The brachial vein transposition, when done as a one-stage procedure, is associated with inferior patency rates when compared to the basilic vein transposition AVF and AVG. Therefore, in the setting of inadequate cephalic and basilic vein, a prosthetic graft is superior to a brachial vein transposition. A two-stage procedure, as suggested by others, may improve the results of this technique.

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IntroductionThe process of applying to residency can be expensive for medical students, and the approach to financing this expense varies considerably from student to student. The process may become more burdensome as the match becomes increasingly competitive with recent advising strategies focusing on application to an increasing number of programs or on parallel application to alternative programs. The role of finances in students' decision-making during the residency application process is unclear though of critical interest due to the implications it has for our community. In addition to medical student debt burden, a financially driven application process may have implications on specialty demographics and diversity in medicine. In order for us to begin to understand and ultimately proactively address these long-term implications, the Organization of Student Representatives (OSR) has initiated periodic distribution of a questionnaire to assess and track the financial burden that applying to residency has on medical students and how students defray these costs. ImplementationIn March 2015, the OSR distributed a questionnaire concerning the cost of applying to residency in the 2014-2015 application cycle through the OSR listserve, requesting that OSR representatives disseminate it to fourth year students at their institutions. There were 959 partial or complete responses to the questionnaire. It is important to note that the questionnaire assessed expense related to interviewing (lodging and travel); the figures discussed throughout do not represent total cost to applicants over the interview season (e.g., additional costs associated with ERAS fees), but rather a key portion of the costs that are not usually traceable by other means. The results of the questionnaire presented in this report represent a small sample of medical students from institutions across the country. The self-reported and unverified data represent crude estimates and we are unable to assess the sampling bias associated with this questionnaire. The results should be interpreted with these limitations in mind. DemographicsDemographic information about the respondent's institution and specialty choices were collected. Figure 1. Out of 953 responses, 431 (45%) respondents identified their institution as private and 522 (55%) as public.Figure 2. Out of 953 responses, 670 (70%) of respondents identified attending medical school in an urban environment, 227 (24%) in a suburban environment, and 56 (6%) in a rural environment. Private 45% Public 55% n = 953 Rural 6% Suburban 24% Urban 70% n = 953 Figure 3. Out of 953 responses, 313 (33%) of respondents identified attending medical school in the Central Region, 287 (30%) in the Southern Region, 238 (25%) in the Northeast Region, and 115 (12%) in the Western Region.Figure 4.Out of 958 responses, 814 respondents (85%) applied to one specialty (inclusive of applicants who additionally applied to preliminary positions in medicine, surgery, or transitional programs), 68 (7%) applied to two distinct spe...

Numerous techniques have been described for the correction of inverted nipples; their diversity supports the lack of a consistently reliable method. Dermoglandular flaps, open suture, and suction techniques have all been described to combat the "corrected" nipple's propensity to collapse. We present a minimally invasive parenchymal release and percutaneous suture technique that provides sustainable long-term correction of inverted nipples. Thirty-one patients with 58 inverted nipples were treated. The technique, performed under local anesthesia, employs lysis of the foreshortened subareolar fibro-ductal tissue to achieve resting eversion of the nipple using an 18-gauge needle. Through the same needle-access site, a purse-string suture is then placed, exiting the areolar skin and re-entering through the same stitch point every 3 to 5 mm around the circumference of the new nipple-base. An absorbable suture closes the access site over the knot, and 2 crossed absorbable mattress sutures are placed beneath the nipple to complete the correction. Of 27 patients with bilateral and 4 with unilateral, nipple inversion, durable correction was achieved in 1 procedure in 45 of 58 nipples (78%). There were 13 recurrences, of which 11 (19%) were successfully treated under local anesthesia with a second purse-string suture, and 2 (3%) required a third procedure under local anesthesia. There were no late reinversions. There were no cases of infection, nipple ischemia, or other complications. Occasional recurrences are corrected very simply under local anesthesia. Percutaneous release of nipple inversion followed by purse-string suture support performed through "needle-only" access points is a simple, safe, and reliable technique, and should be considered for the correction of inverted nipples.