Changes in Subspecialty Interest of Plastic Surgery Residents With Progression of Training: Impact on Academic Attrition.

BACKGROUND: Plastic surgery residency applicants often express interest in academic subspecialties, but only a small percentage of graduating residents pursue academic careers. Identifying reasons for academic attrition may help training programs address this discrepancy. METHODS: A survey was sent to plastic surgery residents through the American Society of Plastic Surgeons Resident Council to assess interest in 6 plastic surgery subspecialties during junior and senior years of training. If a resident changed their subspecialty interest, the reasons for change were recorded. The importance of different career incentives over time were analyzed with paired t tests. RESULTS: Two hundred seventy-six plastic surgery residents of 593 potential respondents (46.5% response rate) completed the survey. Of 150 senior residents, 60 residents reported changing interests from their junior to senior years. Craniofacial and microsurgery were identified as the specialties with the highest attrition of interest, while interest in esthetic, gender-affirmation, and hand surgery increased. For residents who left craniofacial and microsurgery, the desire for higher compensation, to work in private practice, and the desire for improved job opportunities significantly increased. The desire for improved work/life balance was a prominent reason for subspecialty change among senior residents who changed to esthetic surgery. CONCLUSIONS: Plastic surgery subspecialties associated with academia, such as craniofacial surgery, suffer from resident attrition due to a variety of factors. Increased retention of trainees in craniofacial surgery, microsurgery, and academia could be improved through dedicated mentorship, improved job opportunities, and advocacy for fair reimbursement.

Is Preferred Language Other Than English Associated With Delayed Surgery After ACL Injury in Children and Adolescents?

BACKGROUND: Previous studies have investigated the impact of social determinants of health, such as the type of healthcare insurance and household income, on children and adolescents with ACL tears. However, despite the increasing incidence of ACL injury in young patients and a substantial proportion of families who may prefer languages other than English, the relationship between language and clinical care remains unclear. QUESTIONS/PURPOSES: To investigate the relationship between language and the care of children and adolescents with ACL tears, we asked: (1) Is a preferred language other than English (PLOE) associated with a delay between ACL injury and surgery? (2) Is a PLOE associated with a greater odds of a patient experiencing a meniscal tear and undergoing a meniscectomy than in those who prefer English? METHODS: We treated 591 patients surgically for ACL injuries between 2011 and 2021. Of those, we considered patients aged 18 years or younger who underwent primary ACL reconstruction for this retrospective, comparative study. Five percent (31 of 591) of patients were excluded because the date of injury was not clearly documented, 2% (11 of 591) were revision reconstructions, and 1% (6 of 591) underwent procedures that were intentionally delayed or staged, leaving 92% (543 of 591) for analysis. The mean age was 16 ± 2 years, and 51% (276 of 543) of patients were boys. The family's preferred language was noted, as were demographic data, time between injury and surgery, and intraoperative findings. A language other than English was preferred by 21% (113 of 543) of patients. Of these, 94% (106 of 113) preferred Spanish. In a univariate analysis, we used independent-samples t-tests, Mann-Whitney U-tests, and Fisher exact tests, as appropriate. Purposeful-entry multivariable regression analyses were used to determine whether PLOE was associated with increased time to surgery, concomitant meniscus injury, or performance of meniscectomy while adjusting for confounding variables. Variables were included in multivariable models if they met the threshold for statistical significance in univariate testing (p < 0.05). RESULTS: The median time between injury and ACL reconstruction was shorter in families who preferred English compared with those with a PLOE (69 days [IQR 80] versus 103 days [IQR 107)]; p < 0.001). After controlling for potentially confounding variables like insurance and age, we found that patients whose families had a PLOE had greater odds of undergoing surgery more than 60 days after injury (OR 2.2 [95% CI 1.3 to 3.8]; p = 0.005) and more than 90 days after injury (OR 1.8 [95% CI 1.1 to 2.8]; p = 0.02). After controlling for insurance, age, and other factors, PLOE was not associated with surgical delay beyond 180 days, concomitant meniscal tears, or performance of meniscectomy. CONCLUSION: In this study of children and adolescents undergoing primary ACL reconstruction, patients whose families prefer a language other than English experienced a longer delay between injury and surgery. In areas with a large proportion of families with a PLOE, partnerships with primary care clinicians, emergency departments, schools, athletic teams, and community organizations may improve efficiency in the care of children with ACL injuries. Clinicians proficient in other languages, reliable interpreter services, and translated references and resources may also be impactful. Our results suggest a need for further research on the experiences, needs, and long-term outcomes of these patients, as well as the association of preferred language with results after surgery. LEVEL OF EVIDENCE: Level III, therapeutic study.

The Palpable Nodule after Autologous Fat Grafting: Distinguishing Benign versus Malignant Lesions in Breast Reconstruction.

BACKGROUND: Nodule formation after autologous fat grafting to the breast is the most common complication. In the reconstructive population, this generates significant patient anxiety and presents a diagnostic challenge. The authors characterized palpable nodule occurrence after autologous fat grafting in breast reconstruction and compared benign versus malignant nodule characteristics. METHODS: Chart review of the senior author's experience with breast fat grafting was performed. Data extracted included demographics, intraoperative details, nodule data, radiographic characteristics, and biopsy results. Logistic regression identified risk factors for nodule formation. Unpaired t tests and Fisher exact tests compared characteristics of benign versus malignant nodules. RESULTS: In total, 775 breasts were identified that underwent 1158 fat grafting procedures, of which 67 (8.6 percent) developed palpable nodules. Sonographic characterization of nodules included presumed fat necrosis (38.2 percent), benign lesions (27.6 percent), presumed oil cysts (17.1 percent), indeterminate (8.9 percent), and concerning for malignancy (8.1 percent). Lesions concerning for malignancy were more often irregular (10.0 percent versus 0 to 2.9 percent of benign nodules) and more often larger than 0.8 cm in greatest dimension (80 percent versus 42.9 to 61.8 percent of benign nodules). Six patients developed a palpable local recurrence. Malignant nodules tended to be larger (1.45 cm versus 0.70 cm; p = 0.03), were more often vascular (50 percent versus 3.8 percent; p = 0.03), and tended to occur later (17.5 months versus 10.0 months; p = 0.60). Benign nodules occurred in the setting of larger fat graft volumes (64.2 cc versus 40.0 cc; p = 0.008). CONCLUSION: This study provides the first comparison of radiographic and clinical characteristics between benign and malignant palpable nodules after autologous fat grafting in breast reconstruction. CLINICAL QUESTION/LEVEL OE EVIDENCE: Risk, III.

Do Dedicated Research Years during Medical School Predict Academic Productivity during Residency?

BACKGROUND: Evidence regarding whether medical school research portends resident research is limited. This information will provide program directors with data that may be useful for selecting applicants with a commitment to continued academic productivity. METHODS: A questionnaire distributed via the American Society of Plastic Surgeons Resident Council to residents in 44 plastic surgery training programs in May 2020 assessed participation in dedicated research years during medical school, the number of publications completed before residency, and the total number of publications by each resident at the time of the survey. One-way ANOVA and post hoc analysis determined significant associations between publication count and number of research years. RESULTS: Of the 256 included respondents, 203 did not complete a research year during medical school, 44 completed 1 research year, and nine completed 2 research years. Mean publications before residency were higher for participants who took 1 or 2 research years (9.88 and 27.60, respectively) compared with those who did not (4.83, P < 0.001). A comparison of total publications during residency similarly revealed increased productivity by individuals who took 1 or more research years; however, there was no difference between the number of publications completed during residency for individuals who took 1 versus 2 years (P = 0.23). CONCLUSIONS: Residents with research experience during medical school continue to produce an increased number of publications during residency compared with those without, suggesting dedicated research years taken during medical school serve as a predictor of academic productivity in plastic surgery residents.

Maintenance treatment of transcranial magnetic stimulation (TMS) for treatment-resistant depression patients responding to acute TMS treatment.

A growing body of studies has demonstrated that acute transcranial magnetic stimulation (TMS) therapy for treatment-resistant major depressive disorder (MDD) has achieved significant antidepressant effects and can alleviate other related symptoms. However, MDD has a high relapse rate, and patients with depressive symptoms can relapse weeks or months after acute TMS treatment. The lack of necessary TMS maintenance protocols after completing acute TMS treatment with full remission might be one of the reasons for the high relapse rates in MDD patients. Thus, investigating post-TMS treatment maintenance guidelines is important for decreasing relapse in treatment-resistant depression patients who had initially responded to acute TMS therapy. Therefore, we recommend a scientific approach to decrease relapse in treatment-resistant depression patients who had initially responded to acute TMS treatment.

Histidine Residues Are Responsible for Bidirectional Effects of Zinc on Acid-Sensing Ion Channel 1a/3 Heteromeric Channels.

Acid-sensing ion channel (ASIC) subunits 1a and 3 are highly expressed in central and peripheral sensory neurons, respectively. Endogenous biomolecule zinc plays a critical role in physiological and pathophysiological conditions. Here, we found that currents recorded from heterologously expressed ASIC1a/3 channels using the whole-cell patch-clamp technique were regulated by zinc with dual effects. Co-application of zinc dose-dependently potentiated both peak amplitude and the sustained component of heteromeric ASIC1a/3 currents; pretreatment with zinc between 3 to 100 µM exerted the same potentiation as co-application. However, pretreatment with zinc induced a significant inhibition of heteromeric ASIC1a/3 channels when zinc concentrations were over 250 µM. The potentiation of heteromeric ASIC1a/3 channels by zinc was pH dependent, as zinc shifted the pH dependence of ASIC1a/3 currents from a pH50 of 6.54 to 6.77; whereas the inhibition of ASIC1a/3 currents by zinc was also pH dependent. Furthermore, we systematically mutated histidine residues in the extracellular domain of ASIC1a or ASIC3 and found that histidine residues 72 and 73 in both ASIC1a and ASIC3, and histidine residue 83 in the ASIC3 were responsible for bidirectional effects on heteromeric ASIC1a/3 channels by zinc. These findings suggest that histidine residues in the extracellular domain of heteromeric ASIC1a/3 channels are critical for zinc-mediated effects.

Dynamic Evaluation Indices in Spatial Learning and Memory of Rat Vascular Dementia in the Morris Water Maze.

The Morris water maze (MWM) is widely used to evaluate rodent spatial learning and memory. However, current evaluation measures are not comprehensive because there is a wide distribution in the measured response. Utilizing the graph cognition hypothesis, we proposed four new deviation indices to evaluate cognitive function in the MWM that compared the optimal swim track to the actual track taken. These include the sum of the lateral deviation vectors, the sum of the offset angles, the sum of the correction vectors, and the sum of the lateral deviation vectors to the initial optimal route. We compared the four new deviation indices to the classically used escape latency measures in a vascular dementia model and demonstrated a higher consistency in the normal distribution between the vascular dementia group and the control rats. Further, the new measures displayed higher sensitivity and specificity compared to what escape latency displayed in the Monte Carlo simulation. From the receiver operating characteristic curve, the diagnostic values of the new deviation indices are higher than those of escape latency. Therefore, including these new evaluation indices in MWM experiments provided a more effective analysis of cognitive function compared to using escape latency.

Acid-sensing ion channels are expressed in the ventrolateral medulla and contribute to central chemoreception.

The role of acid-sensing ion channels (ASICs) in the ventrolateral medulla (VLM) remains uncertain. Here, we found that ASIC1a and ASIC2 are widely expressed in rat medulla, and the expression level is higher at neonatal stage as compared to adult stage. The two ASIC subunits co-localized in medualla neurons. Furthermore, pH reduction triggered typical ASIC-type currents in the medulla, including the VLM. These currents showed a pH50 value of 6.6 and were blocked by amiloride. Based on their sensitivity to psalmotoxin 1 (PcTx1) and zinc, homomeric ASIC1a and heteromeric ASIC1a/2 channels were likely responsible for acid-mediated currents in the mouse medulla. ASIC currents triggered by pH 5 disappeared in the VLM neurons from ASIC1-/-, but not ASIC2-/- mice. Activation of ASICs in the medulla also triggered neuronal excitation. Moreover, microinjection of artificial cerebrospinal fluid at a pH of 6.5 into the VLM increased integrated phrenic nerve discharge, inspiratory time and respiratory drive in rats. Both amiloride and PcTx1 inhibited the acid-induced stimulating effect on respiration. Collectively, our data suggest that ASICs are highly expressed in the medulla including the VLM, and activation of ASICs in the VLM contributes to central chemoreception.