Objectives: To present a novel location in which neurosarcoidomatous inflammation is identified and its accompanying presentation. Methods: The authors present a case of bilateral vocal fold paresis associated with non-caseating granulomatous inflammation of the cervical and intra-axial portions of the vagus nerve masquerading as a cranial nerve tumor. Results: Examination revealed bilateral vocal fold paresis and asymmetric palate elevation. MRI demonstrated enhancing bilateral jugular foramen masses, and neck ultrasound demonstrated bilateral thickened appearance of the vagus nerves. Vagus nerve biopsy demonstrated non-caseating granulomas. Conclusions: Neurosarcoidosis may contribute to variable cranial neuropathies. Vocal fold paresis is usually thought to arise from mediastinal compression of the left recurrent laryngeal nerve. Rarely, though, lesions may arise in other parts of the vagus nerve. Failure of response to steroids does not rule out the diagnosis, making tissue diagnosis important in some cases.

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Introduction. Less than 1% of all breast cancers are diagnosed in males. In females, postmastectomy breast reconstruction is associated with increased patient satisfaction. However, there is a paucity of literature describing reconstructive options for postmastectomy deformity in the male chest. The purpose of this systematic review was to evaluate postmastectomy reconstruction outcomes in males with breast cancer. Methods. A systematic review was performed in accordance with PRISMA guidelines. Ovid MEDLINE, Embase, Cochrane, and Web of Science were queried for records pertaining to the study question using medical subject heading (MeSH) terms such as “male breast cancer,” “mastectomy,” and “reconstruction.” No limitations were placed on the year of publication, country of origin, or study size. Study characteristics and patient demographics were collected. Primary outcomes of interest included postoperative complications, recurrence rate, and mortality rate. Results. A total of 11 articles examining 29 male patients with breast cancer who underwent postmastectomy reconstruction were included for analysis. Literature was most commonly available in the form of case reports. The average age was 59.6 +/−11.4 years. Reconstruction methods included fat grafting (n = 1, 3.4%), silicone implants (n = 1, 3.4%), and autologous chest wall reconstruction with local flaps (n = 26, 89.7%). Postoperative complications occurred in two patients (6.8%), including partial nipple necrosis (n = 1) and hypertrophic scarring (n = 1). Of the studies reporting patient satisfaction, all patients were pleased with the aesthetic appearance of their chest. Conclusion. This systematic review revealed the limited availability of research regarding postmastectomy chest reconstruction in males with breast cancer. Nevertheless, the evidence available suggests that reconstruction can restore a patient’s body image and, thus, should be regularly considered and discussed with male patients. Larger studies are warranted to further shed light on this population.

The United States Medical Licensing Examination (USMLE) Step 1 was designed to be a benchmark measure of knowledge and has been used heavily in the residency application process. Step 1 has moved from 3-digit scoring to a pass/fail scoring system, in part to decrease the stress associated with the exam. Emerging literature suggests that this transition has led to other stresses for students. Our study compared student stress levels, both overall and in relation to Step 1, leading up to the exam between a scored cohort and pass/fail cohort. We administered to each cohort a 14-item survey that included demographics, the PSS-4 stress scale, and 6 other potential stressors. Data was analyzed using two-tailed t test for independent means and analysis of variance. We found that while there was no difference in general overall stress between the students who took Step 1 for a score and students who took Step 1 pass/fail, we did see differences in stress related to the Step 1 exam. Step 1 stress was significantly lower for the pass/fail cohort than the score cohort during the second year of medical education leading up to the exam. However, this difference in Step 1 stress between the cohorts disappeared by the dedicated study period immediately before the exam. The change in scoring appears to have decreased stress specifically related to Step 1, but this reduction was not sustained as students entered their study period to prepare for Step 1.

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Objective: To evaluate the impact of the Affordable Care Act's Medicaid expansion on patient safety metrics at the hospital level by expansion status, across varying levels of safety-net burden, and over time. Summary Background Data: Medicaid expansion has raised concerns over the influx of additional medically and socially complex populations on hospital systems. Whether increases in Medicaid and uninsured payor mix impact hospital performance metrics remains largely unknown. We sought to evaluate the effects of expansion on Centers for Medicare and Medicaid Services-endorsed Patient Safety Indicators (PSI-90). Methods: Three hundred fifty-eight hospitals were identified using State Inpatient Databases (2012–2015) from 3 expansions (KY, MD, NJ) and 2 nonexpansion (FL, NC) states. PSI-90 scores were calculated using Agency for Healthcare Research and Quality modules. Hospital Medicaid and uninsured patients were categorized into safety-net burden (SNB) quartiles. Hospital-level, multivariate linear regression was performed to measure the effects of expansion and change in SNB on PSI-90. Results: PSI-90 decreased (safety improved) over time across all hospitals (−5.2%), with comparable reductions in expansion versus nonexpansion states (−5.9% vs −4.7%, respectively; P = 0.441) and across high SNB hospitals within expansion versus nonexpansion states (−3.9% vs −5.2%, P = 0.639). Pre-ACA SNB quartile did not predict changes in PSI-90 post-ACA. However, when hospitals increased their SNB by 5%, they incurred significantly more safety events in expansion relative to nonexpansion states (+1.87% vs −14.0%, P = 0.013). Conclusions: Despite overall improvement in patient safety, increased SNB was associated with increased safety events in expansion states. Accordingly, Centers for Medicare and Medicaid Services measures may unintentionally penalize hospitals with increased SNB following Medicaid expansion.