Analysis of Additional Degrees in Academic Plastic Surgery Faculty.

Background: As plastic surgery continues to evolve, an increasing number of surgeons are attaining additional degrees (ADs). Prior studies illustrate this trend of increased AD attainment among plastic surgery faculty within the United States. Yet, no such study has documented AD attainment variability and influence within Canadian plastic surgery faculty. Objectives: Our objective was to investigate the relationship between AD attainment and gender, alongside research productivity, and academic rank of Canadian plastic surgery faculty members. Methods: All Canadian academic plastic surgery faculty members were identified and information regarding gender, academic rank, research productivity, timing of AD attainment was recorded. AD was defined as any degree beyond a medical degree or equivalent. Results: A total of 299 faculty members were identified. Of these, 33% (N = 99) attained an AD. A higher percentage of females (40%) obtained ADs compared to males (30%) (P = .0402). When controlling for number of years in practice, there was a significantly larger proportion of females than males with ADs as assistant and associate professor (P = .033). Faculty with ADs were associated with higher research productivity and higher academic rank than those with MDs (P < .05). ADs were commonly obtained post-residency (38%) and most common ADs were MSc (51%) and PhDs (21%). It was found that the Canadian plastic surgeons were less likely to pursue MBAs than US plastic surgeons (P = .002). Conclusion: One-third of Canadian academic plastic surgeons had ADs. Those with ADs present with higher research productivity and academic rank. When segmented by gender, there were significant differences among AD holders. The results of this study will lend support to ongoing endeavors voicing the need for gender equity in academic plastic surgery.

Historique : Tandis que la chirurgie plastique continue d'évoluer, de plus en plus de chirurgiens obtiennent des diplômes supplémentaires (DS). Des études antérieures démontrent cette tendance des professeurs en chirurgie plastique des États-Unis à obtenir des DS. Pourtant aucune étude n'a évalué la variabilité et l'influence des DS chez les professeurs de chirurgie plastique au Canada. Objectifs : Les chercheurs avaient comme objectif d'explorer la relation entre l'obtention de DS et le genre, conjointement avec la productivité de la recherche et le rang universitaire des professeurs de chirurgie plastique canadiens. Méthodologie : Les chercheurs ont répertorié tous les professeurs de chirurgie plastique canadiens et ont consigné l'information relative à leur genre, à leur rang universitaire, à la productivité de leur recherche, au moment de l'obtention des DS. Le DS était défini comme tout diplôme obtenu après un diplôme en médecin ou un diplôme équivalent. Résultats : Au total, 299 professeurs ont été répertoriés. De ce nombre, 33 % (N = 99) ont obtenu un DS. Un plus fort pourcentage de femmes (40 %) que d'hommes (30 %) (P = ,0402) a obtenu des DS. Après avoir tenu compte du nombre d'années d'exercice, une proportion beaucoup plus importante de femmes que d'hommes ayant des DS étaient professeurs adjoints et agrégés (P = 0,033). Les professeurs qui possèdent des DS étaient associés à une plus grande productivité de la recherche et à un rang universitaire plus élevé que ceux qui possédaient un diplôme en médecine (P < 0,05). Les DS étaient souvent obtenus après la résidence (38 %), et les plus courants étaient des maîtrises (51 %) et des doctorats (21 %). Il a été établi que les chirurgiens plasticiens canadiens étaient moins susceptibles de faire un MBA que les chirurgiens des États-Unis (P =0 ,002). Conclusion : Le tiers des chirurgiens plasticiens universitaires canadiens possédaient des DS. Ceux qui en détenaient présentaient une plus grande productivité en recherche et un meilleur rang universitaire. Lorsqu'ils étaient divisés par genre, les détenteurs de DS présentaient des différences importantes. Les résultats de la présente étude appuient les initiatives en cours soulignant la nécessité de respecter l'égalité des genres en chirurgie plastique universitaire.

Ivory tower in MD/PhD programmes: sticky floor, broken ladder and glass ceiling.

OBJECTIVE: Achieving gender equity in academic medicine is not only a matter of social justice but also necessary in promoting an innovative and productive academic community. The purpose of this study was to assess gender distribution in dual MD/PhD academic programme faculty members across North America. METHODS: Academic metrics were analysed to quantify the relative career success of academic faculty members in MD/PhD programmes. Measured parameters included academic and leadership ranks along with nominal research factors such as peer-reviewed research publications, H-index, citation number and years of active research. RESULTS: Χ² analysis revealed a statistically significant (p<0.0001, χ²=114.5) difference in the gender distribution of faculty and leadership across North American MD/PhD programmes. Men held 74.2% of full professor positions, 64% of associate professor positions, 59.4% of assistant professor positions and 62.8% of lecturer positions. Moreover, men occupied a larger share of faculty leadership roles with a statistically significant disparity across all ranks (p<0.001, χ²=20.4). A higher proportion of men held positions as department chairs (79.6%), vice chairs (69.1%) and programme leads (69.4%). CONCLUSION: Gender disparity was prevalent in the MD/PhD programmes throughout North America with women achieving a lower degree of professional stature than men. Ultimately, steps must be taken to support women faculty to afford them better opportunities for academic and professional advancement.

Gender and race in radiology: An intersectional analysis of the American Association of Medical Colleges (AAMC) database from 1966 to 2021.

PURPOSE: To describe trends in gender and racial representation within academic radiology in the United States over a 55-year period from 1966 to 2021. METHODS: A retrospective analysis of the American Association of Medical Colleges database of radiology faculty members from 1966 to 2021 was conducted. Trends in academic rank and tenure status for five different ethnoracial groups (White, Asian, Black, Hispanic, and Native American) each subdivided into two gender identities (men and women) were analyzed. The proportional change over time of each demographic group per outcome was analyzed with linear regression models. RESULTS: Between 1966 and 2021, White men comprised the largest demographic in academic radiology each year. A significant decrease in both White individuals (-0.51 % per year) and men (-0.30 % per year) were observed over the study period. Additionally, the only demographic groups with meaningful changes in representation were White women (+0.20 % per year) and Asian men (+0.23 % per year), followed by Asian women in later years. Underrepresented minority groups (Black, Hispanic and Native American) collectively comprised less than 5 % of all academic radiologists. Finally, within each demographic group, the representation of women consistently lagged behind men. Despite these relative increases, in 2021, the majority of US academic radiologists were White (59.1 %) and male (70.1 %). CONCLUSION: Historically underrepresented minorities, especially women within these groups, continue to face discrimination and are consistently the least represented in radiology. Initiatives that incorporate the intersectionality framework are imperative to break this cycle.

Assessing sex and gender equity in submission guidelines of radiology journals: A cross-sectional study.

PURPOSE: Our study aimed to determine the current percentage of gender and sex equity promoting (GSEP) radiology journals, defined as satisfying at least one criterion of the Sex and Gender Equity in Research (SAGER) checklist, published by the European Association of Science Editors (EASE). A secondary objective was to compare characteristics of GSEP and non-GSEP journals. METHODS: A cross-sectional analysis between June 24 and July 3, 2023, was conducted. The author submission guidelines of radiology journals with a 2021 Journal Impact Factor (JIF) were assessed according to the SAGER checklist. GSEP journals were defined as satisfying one or more SAGER checklist criteria in their research instructions. Bibliometric data and journal information were collected from the Journal Citation Reports and National Library of Medicine catalogue. RESULTS: Only 39.7 % (52) of 132 journals satisfied at least one SAGER checklist criterion. Median 2021 JIFs were higher in GSEP journals (4.62, IQR: 3.73 - 5.21) than non-GSEP journals (2.70, IQR: 2.32) (p = 0.00). Median 2021 Journal Citation Index (JCI) scores were higher in GSEP (0.64, 0.56 - 0.73) than non-GSEP journals (0.97, 0.83 - 1.10) (p = 0.00). Cited half-life was shorter for GSEP (5.40, 4.80 - 6.50) than non-GSEP journals (6.70, 5.70 - 7.40) (p = 0.05). Elsevier published 33 of 52 of GSEP journals. CONCLUSION: 60.3% of radiology journals with a 2021 JIF do not meet a single SAGER checklist criterion in their author submission guidelines. GSEP journals had higher impact and source metrics and a shorter cited half-life. Publishers may play a significant role in promoting endorsement of the SAGER checklist in the author submission guidelines of radiology journals.

Gender, Race, and Ethnicity of US Academic Ophthalmology Faculty and Department Chairs From 1966 to 2021.

Importance: Workforce diversity is integral to optimal function within health care teams. Objective: To analyze gender, race, and ethnicity trends in rank and leadership among US full-time academic ophthalmology faculty and department chairs between 1966 and 2021. Design, Setting, and Participants: This cohort study included full-time US academic ophthalmology faculty and department chairs registered in the Association of American Medical Colleges. Study data were analyzed in September 2023. Exposure: Identifying with an underrepresented in medicine (URiM) group. Main Outcomes and Measures: The main outcome measures were demographic (ie, gender, race, and ethnicity) changes among academic faculty and department chairs, assessed in 5-year intervals. The term minoritized race refers to any racial group other than White race. Results: There were 221 academic physicians in 1966 (27 women [12.2%]; 38 minoritized race [17.2%]; 8 Hispanic, Latino, or Spanish [3.6%]) and 3158 academic faculty by 2021 (1320 women [41.8%]; 1298 minoritized race [41.1%]; 147 Hispanic, Latino, or Spanish ethnicity [4.7%]). The annual proportional change for women, minoritized race, and Hispanic, Latino, or Spanish ethnicity was +0.63% per year (95% CI, 0.53%-0.72%), +0.54% per year (95% CI, 0.72%-0.36%), and -0.01% (95% CI, -0.03% to 0%), respectively. Women were underrepresented across academic ranks and increasingly so at higher echelons, ranging from nonprofessor/instructor roles (period-averaged mean difference [PA-MD], 19.88%; 95% CI, 16.82%-22.94%) to professor (PA-MD, 81.33%; 95% CI, 78.80%-83.86%). The corpus of department chairs grew from 77 in 1977 (0 women; 7 minoritized race [9.09%]; 2 Hispanic, Latino, or Spanish ethnicity [2.60%]) to 104 by 2021 (17 women [16.35%]; 22 minoritized race [21.15%]; 4 Hispanic, Latino, or Spanish ethnicity [3.85%]). For department chairs, the annual rate of change in the proportion of women, minoritized race, and Hispanic, Latino, or Spanish ethnicity was +0.32% per year (95% CI, 0.20%-0.44%), +0.34% per year (95% CI, 0.19%-0.49%), and +0.05% per year (95% CI, 0.02%-0.08%), respectively. In both faculty and department chairs, the proportion of URiM groups (American Indian or Alaska Native, Black or African American, Hispanic, and Native Hawaiian or Other Pacific Islander) grew the least. Intersectionality analysis suggested that men and non-URiM status were associated with greater representation across ophthalmology faculty and department chairs. However, among ophthalmology faculty, URiM women and men did not significantly differ across strata of academic ranks, whereas for department chairs, no difference was observed in representation between URiM men and non-URiM women. Conclusion & Relevance: Results of this cohort study revealed that since 1966, workforce diversity progressed slowly and was limited to lower academic ranks and leadership positions. Intersectionality of URiM status and gender persisted in representation trends. These findings suggest further advocacy and intervention are needed to increase workforce diversity.

Triclosan administration to humanized UDP-glucuronosyltransferase 1 neonatal mice induces UGT1A1 through a dependence on PPARα and ATF4.

Triclosan (TCS) is an antimicrobial toxicant found in a myriad of consumer products and has been detected in human tissues, including breastmilk. We have evaluated the impact of lactational TCS on UDP-glucuronosyltransferase 1A1 (UGT1A1) expression and bilirubin metabolism in humanized UGT1 (hUGT1) neonatal mice. In hUGT1 mice, expression of the hepatic UGT1A1 gene is developmentally delayed resulting in elevated total serum bilirubin (TSB) levels. We found that newborn hUGT1 mice breastfed or orally treated with TCS presented lower TSB levels along with induction of hepatic UGT1A1. Lactational and oral treatment by gavage with TCS leads to the activation of hepatic nuclear receptors constitutive androstane receptor (CAR), peroxisome proliferator-activated receptor alpha (PPARα), and stress sensor, activating transcription factor 4 (ATF4). When CAR-deficient hUGT1 mice (hUGT1/Car-/-) were treated with TCS, TSB levels were reduced with a robust induction of hepatic UGT1A1, leaving us to conclude that CAR is not tied to UGT1A1 induction. Alternatively, when PPARα-deficient hUGT1 mice (hUGT1/Pparα-/-) were treated with TCS, hepatic UGT1A1 was not induced. Additionally, we had previously demonstrated that TCS is a potent inducer of ATF4, a transcriptional factor linked to the integrated stress response. When ATF4 was deleted in liver of hUGT1 mice (hUGT1/Atf4ΔHep) and these mice treated with TCS, we observed superinduction of hepatic UGT1A1. Oxidative stress genes in livers of hUGT1/Atf4ΔHep treated with TCS were increased, suggesting that ATF4 protects liver from excessive oxidative stress. The increase oxidative stress may be associated with superinduction of UGT1A1. The expression of ATF4 in neonatal hUGT1 hepatic tissue may play a role in the developmental repression of UGT1A1.

Advancing Diversity in Microbiology: A 55-Year Retrospective Analysis.

Background For over 50 years, affirmative action helped advance equity, diversity and inclusion (EDI) in educational institutions in the United States (U.S.). However, the recent U.S. Supreme Court decision to end affirmative action in college admissions threatens the progress toward EDI. Objective This study aimed to assess the progress in promoting gender and racial diversity within the discipline of microbiology over a 55-year period. We sought to analyze the representation of women and minority groups in faculty ranks, tenure positions, and leadership to identify disparities and trends and determine who will likely be impacted most with the end of affirmative action. Materials and methods This longitudinal retrospective study utilized publicly available and non-identifiable Association of American Medical Colleges (AAMC) data on full-time microbiology faculty from 1967 to 2021. Faculty members were categorized based on academic ranks and tenure status, while gender and racial data were also considered. Results The analysis revealed a consistent dominance of white faculty, with over 60% representation across all academic ranks throughout the study period. The Asian and female faculty representation decreased in senior academic ranks. We observed a positive trend in the annual increase of women in faculty positions, academic ranks, chairs, and tenure positions. Furthermore, Asian faculty demonstrated the most robust surge in representation. However, disparities persisted for black, Hispanic, and Native American faculty members, reflecting broader challenges in their representation. Discussion Although efforts to enhance diversity within microbiology have yielded positive results, underrepresented minority groups still face obstacles in attaining leadership positions and senior academic ranks. The diminishing proportion of women at higher academic ranks raises concerns about potential attrition or lack of promotion opportunities. The end of affirmative action poses a risk of perpetuating this trend, leading to a decline in diversity among microbiology faculty.

End of Affirmative Action-Who Is Impacted Most? Analysis of Race and Sex Among US Internal Medicine Faculty.

BACKGROUND: For over 50 years, the United States (US) used affirmative action as one strategy to increase diversity in higher education including medical programs, citing benefits including training future public and private sector leaders. However, the recent US Supreme Court ending affirmative action in college admissions threatens advancements in the diversity of medical college faculty. OBJECTIVE: Our study evaluated the demographic trends in Internal Medicine (IM) faculty in the US by assessing sex and race/ethnicity diversity to investigate who is likely to be impacted most with the end of affirmative action. DESIGN: Longitudinal retrospective analysis SUBJECTS: IM faculty from the Association of American Medical Colleges faculty roster from 1966 to 2021 who self-reported sex and ethnicity MAIN OUTCOMES: The primary study measurement was the annual proportion of women and racial/ethnic groups among IM faculty based on academic rank and department chairs. RESULTS: Although racial/ethnic diversity increased throughout the era of affirmative action, African American, Hispanic, and American Indian populations remain underrepresented. White physicians occupied > 50% of faculty positions across academic ranks and department chairs. Among the non-White professors, Asian faculty had the most significant increase in proportion from 1966 to 2021 (0.6 to 16.6%). The percentage of women increased in the ranks of professor, associate professor, assistant professor, and instructor by 19.5%, 27.8%, 25.6%, and 26.9%, respectively. However, the proportion of women and racial/ethnic minority faculty decreased as academic rank increased. CONCLUSION: Despite an increase in the representation of women and racial/ethnic minority IM faculty, there continues to be a predominance of White and men physicians in higher academic ranks. With the end of affirmative action, this trend has the danger of being perpetuated, resulting in decreasing diversity among IM faculty, potentially impacting patient access and health outcomes.

Organizational Leadership Gender Differences in Medical Schools and Affiliated Universities.

Objective: To compare gender compositions in the leadership of the top 25 medical schools in North America with the leadership of their affiliated university senior leadership and other faculties. Materials and Methods: This retrospective cross-sectional observational study used publicly available gender data from 2018 to 2019 of universities drawn from the U.S. News Best Global Universities for Clinical Medicine Ranking report. Gender compositions in eight leadership tiers from senior leadership to medical school department directors were analyzed. Data analysis included gender compositions by leadership tier and faculty. Results: Male representation is greater at higher leadership tiers, with the largest imbalance being at the level of medical school department heads. The faculty of medicine has more men in leadership positions than the average of the other faculties (p = 0.02), though similar to schools of engineering, business, dentistry, and pharmacy. Across the eight leadership tiers, a significant trend exists between tier and proportions, indicating that male representation was greater at higher tiers (p < 0.001). No correlation was found between a university's leadership gender composition and its ranking. Conclusion: The under-representation of women is greater in medical school leadership than the leadership of their affiliated universities. The faculty of medicine has greater male over-representation than the average of the other faculties.

Entering the Misinformation Age: Quality and Reliability of YouTube for Patient Information on Liposuction.

Background: YouTube is currently the most popular online platform and is increasingly being utilized by patients as a resource on aesthetic surgery. Yet, its content is largely unregulated and this may result in dissemination of unreliable and inaccurate information. The objective of this study was to evaluate the quality and reliability of YouTube liposuction content available to potential patients. Methods: YouTube was screened using the keywords: "liposuction," "lipoplasty," and "body sculpting." The top 50 results for each term were screened for relevance. Videos which met the inclusion criteria were scored using the Global Quality Score (GQS) for educational value and the Journal of the American Medical Association (JAMA) criteria for video reliability. Educational value, reliability, video views, likes, dislikes, duration and publishing date were compared between authorship groups, high/low reliability, and high/low educational value. Results: A total of 150 videos were screened, of which 89 videos met the inclusion criteria. Overall, the videos had low reliability (mean JAMA score = 2.78, SD = 1.15) and low educational value (mean GQS score = 3.55, SD = 1.31). Videos uploaded by physicians accounted for 83.1% percent of included videos and had a higher mean educational value and reliability score than those by patients. Video views, likes, dislikes, comments, popularity, and length were significantly greater in videos with high reliability. Conclusions: To ensure liposuction-seeking patients are appropriately educated and informed, surgeons and their patients may benefit from an analysis of educational quality and reliability of such online content. Surgeons may wish to discuss online sources of information with patients.

Historique : YouTube est actuellement la plateforme la plus populaire en ligne. Les patients l'utilisent de plus en plus comme ressource en chirurgie plastique. Pourtant, son contenu est en grande partie non réglementé, ce qui peut entraîner la diffusion d'information peu fiable et inexacte. La présente étude vise à évaluer la qualité et la fiabilité du contenu de YouTube sur la liposuccion à la disposition de patients éventuels. Méthodologie : Les chercheurs ont fait une recherche dans YouTube à l'aide des mots-clés liposuction, lipoplasty et body sculpting. Ils ont examiné les 50 premiers résultats de chaque terme pour en déterminer la pertinence. Ils ont classé les vidéos qui respectaient les critères d'inclusion d'après le score de qualité globale (SGQ) pour leur valeur éducative et les critères du Journal of the American Medical Association (JAMA) pour la fiabilité des vidéos. Ils ont comparé la valeur éducative, leur fiabilité, le nombre de visionnements, les « J'aime ¼, les « Je n'aime pas ¼, la durée et la date de publication entre groupes d'auteur, la forte et la faible fiabilité et la valeur éducative élevée ou basse. Résultats : Les chercheurs ont visionné 150 vidéos, dont 89 respectaient les critères d'inclusion. Dans l'ensemble, elles avaient une faible fiabilité (score JAMA moyen = 2.78, ÉT = 1.15) et une faible valeur éducative (SQG moyen = 3.55, ÉT = 1.31). Les vidéos téléversées par des médecins formaient 83,1% du contenu et présentaient une valeur éducative moyenne et un score de fiabilité plus élevés que celles des patients. Les visionnements, les « J'aime ¼, les « Je n'aime pas ¼, les commentaires, la popularité et la durée étaient beaucoup plus élevés lorsque les vidéos avaient une forte viabilité. Conclusions : Pour que les patients qui veulent subir une liposuccion reçoivent la bonne information, les chercheurs et leurs patients peuvent profiter d'une analyse de la qualité et de la fiabilité du contenu en ligne. Les chirurgiens pourraient souhaiter parler des sources d'information en ligne avec leurs patients.

The Genetic Evaluation of Dilated Cardiomyopathy.

Dilated cardiomyopathy (DCM) is a common cause of heart failure and is the primary indication for heart transplantation. A genetic etiology can be found in 20-35% of patients with DCM, especially in those with a family history of cardiomyopathy or sudden cardiac death at an early age. With advancements in genome sequencing, the understanding of genotype-phenotype relationships in DCM has expanded with over 60 genes implicated in the disease. Subsequently, these findings have increased adoption of genetic testing in the management of DCM, which has allowed for improved risk stratification and identification of at risk family members. In this review, we discuss the genetic evaluation of DCM with a focus on practical genetic testing considerations, genotype-phenotype associations, and insights into upcoming personalized therapies.

Gene therapy for heart failure and cardiomyopathies.

Gene therapy strategies encompass a range of approaches, including gene replacement and gene editing. Gene replacement involves providing a functional copy of a modified gene, while gene editing allows for the correction of existing genetic mutations. Gene therapy has already received approval for treating genetic disorders like Leber's congenital amaurosis and spinal muscular atrophy. Currently, research is being conducted to explore its potential use in cardiology. This review aims to summarize the mechanisms behind different gene therapy strategies, the available delivery systems, the primary risks associated with gene therapy, ongoing clinical trials, and future targets, with a particular emphasis on cardiomyopathies.

American Society of Emergency Radiology (ASER) social media committee workgroup: best practices for the use of social media in emergency radiology.

Social media has become integrated within the profession of medicine, and emergency radiology has inevitably felt the impact of its presence. Emergency radiologists are encouraged to consider the advantages of embracing the digital era and the benefits it may bring to our careers. We aim to present the best practice guidelines for emergency radiologists and radiology departments. This paper is a product of the American Society of Emergency Radiology Social Media (ASER) Committee workgroup and represents the best practices of the society.

Lactational delivery of Triclosan promotes non-alcoholic fatty liver disease in newborn mice.

Here we show that Triclosan (TCS), a high-volume antimicrobial additive that has been detected in human breastmilk, can be efficiently transferred by lactation to newborn mice, causing significant fatty liver (FL) during the suckling period. These findings are relevant since pediatric non-alcoholic fatty liver disease (NAFLD) is escalating in the United States, with a limited mechanistic understanding. Lactational delivery stimulated hepatosteatosis, triglyceride accumulation, endoplasmic reticulum (ER) stress, signs of inflammation, and liver fibrosis. De novo lipogenesis (DNL) induced by lactational TCS exposure is shown to be mediated in a PERK-eIF2α-ATF4-PPARα cascade. The administration of obeticholic acid (OCA), a potent FXR agonist, as well as activation of intestinal mucosal-regenerative gp130 signaling, led to reduced liver ATF4 expression, PPARα signaling, and DNL when neonates were exposed to TCS. It is yet to be investigated but mother to child transmission of TCS or similar toxicants may underlie the recent increases in pediatric NAFLD.

Subscription-based and open access dermatology journals: the publication model dilemma.

Medical journalism and the dissemination of peer-reviewed research serve to promote and protect the integrity of scholarship. We evaluated the publication models of dermatology journals to provide a snapshot of the current state of publishing. A total of 106 actively-publishing dermatology journals were identified using the SCImago Journal Rankings (SJR) citation database. Journals were classified by publication model (subscription-based and open-access), publishing company, publisher type (commercial, professional society, and university), MEDLINE-indexing status, and SJR indicator. Of these, 65 (61.32%) dermatology journals were subscription-based and 41 (38.68%) were open-access. In addition, 59 (55.66%) journals were indexed in MEDLINE and most were subscription-based (N=51) and published by commercial entities (N=54). MEDLINE-indexing status was significantly different across publisher types (P<0.001), access-types (P<0.001), and the top four publishers (P=0.016). Distribution of SJR indicator was significantly different across publisher types (P<0.001) and access-types (all journals, P=0.001; indexed journals only, P=0.046). More than 91% of MEDLINE-indexed titles were published by commercial entities, and among them, four companies controlled the vast majority. Discontinuation of access to any one of the top publishers in dermatology can significantly and disproportionately impact education and scholarship.