Students Matriculating into Integrated Plastic Surgery: Are all Medical Schools Equal?

INTRODUCTION: Becoming a craniofacial/pediatric plastic surgeon depends on completing a plastic surgery (PS) residency. As medical school curricula for PS exposure are highly inconsistent, the authors investigated whether there was an association between the presence of PS elective rotations and/or home programs in medical schools with the proportion of students matriculating into integrated PS residency. METHODS: A list of 198 medical schools was compiled from the Association for American Medical Colleges and the American Association of Colleges of Osteopathic Medicine. Plastic surgery residency programs were identified by the American Society of Plastic Surgery and the American Council of Educators in Plastic Surgery. Plastic surgery elective rotation offerings and recent matches (2021-2022) were obtained from school websites. Mean proportions of students matriculating into PS between schools that did versus did not have PS elective rotations and/or home PS residency programs were compared. RESULTS: One hundred fifty-nine medical schools were included. Seventy-seven of 159 (48%) had both PS elective rotations and home program(s), 63/159 (40%) offered PS elective rotations only, and 19/159 (12%) had neither. The mean proportions of students matriculating differed significantly (P<0.001) among schools without PS electives or a home program [0.09%, 95% confidence interval (CI): -0.04% to 0.21%), PS elective only (0.51%, 95% CI: 0.25%-0.77%), and both PS elective and home program(s) (1.14%, 95% CI: 0.92%-1.37%). CONCLUSION: The presence of elective PS rotations and a home PS residency program significantly increase the chances of matriculation into integrated PS residency programs.

Negative Pressure Wound Therapy: Challenges, Novel Techniques, and Future Perspectives.

Significance: Negative pressure wound therapy (NPWT) has been in practice for decades, proving its utility in many applications, ranging from acutely infected wounds to complex combat wounds and skin grafting. It has been routinely demonstrated that NPWT has superior wound healing outcomes compared with previous standard-of-care therapies. However, the technique involves some challenges related to each of the components that comprise the therapy. The purpose of this article is to highlight the challenges, introduce the recent advancements, and discuss about the future directions in NPWT systems. Recent Advances: New techniques and materials have been developed to improve the currently used NPWT systems with promising results when utilized with appropriate indications. Many advancements have been introduced in modes of negative pressure delivery, pumps, interface dressings, adhesive dressings, and tubing technology. Critical Issues: An optimal NPWT system would avoid the common problems such as failure to deliver negative pressure due to loss of an airtight seal or tissue ingrowth into the interface dressing causing painful dressing changes and bleeding. Other challenges include infection control and patient pain and discomfort that may contribute to noncompliance. Future Directions: Many studies have been performed to evaluate the optimal combination of settings and components in various wounds; however, there is still no clear "best" answer for many specific patient-wound scenarios. Novel and emerging tissue engineering and regenerative medicine approaches could potentially be utilized in the future NPWT systems and thus, this review will discuss some novel ideas for future considerations.

"A Fifty-Year Review of Congressional Membership by Healthcare Professionals: Is Surgical Representation Adequate for Informed Legislation?"

SUMMARY: Whereas 100% of Congressional legislators vote on healthcare policy, only a minority have a background in healthcare. A review of the participation of healthcare professionals (HCPs) in Congress, highlighting participation by surgeons, is critical to the future policy-making endeavors in healthcare. This article seeks to better understand the characteristics of HCPs that engage in advocacy and describe the trends in their representation in Congress, with commentary on participation by surgeons and its impact on current health advocacy efforts.A search of Congress.gov and the Biographical Directory of the United States Congress was performed to identify professional healthcare history for each Congressperson, followed by review of official campaign websites for health advocacy work. Statistical analysis was performed using IBM® SPSS® Statistics Software for changes in representation of healthcare professionals, physicians, and surgeons in Congress over time.While there has been increasing representation of HCPs in Congress in the last 25 years, surgeons have the lowest increase in Congressional membership. For healthcare reform to optimally address high costs, variable insurance coverage and reimbursement rates, and equal access to care, more physicians must make healthcare advocacy efforts an integral part of their careers. Incorporation of education in areas of healthcare advocacy and/or reform into undergraduate and graduate medical education curricula may help address deficiencies in knowledge of current healthcare-related events to further encourage involvement in healthcare legislation.

Do Unpaid Children's Hospital Account Balances Correlate with Family Income or Insurance Type?

Background: Current understanding of medical debt among various income ranges and insurance carriers is limited. We analyzed median household incomes, insurance carriers, and medical debt of plastic surgery patients at a major metropolitan children's hospital. Methods: A retrospective chart review for zip codes, insurance carriers, and account balances was conducted for 2018-2021. All patients were seen by members of the Division of Pediatric Plastic Surgery at Ann and Robert H. Lurie Children's Hospital of Chicago. Blue Cross was reported separately among other commercial insurance carriers by the hospital's business analytics department. Median household income by zip code was obtained. IBM SPSS Statistics was used to perform chi-squared tests to study the distribution of unpaid account balances by income ranges and insurance carriers. Results: Of the 6877 patients, 630 had unpaid account balances. Significant differences in unpaid account balances existed among twelve insurance classes (P < 0.001). There were significant differences among unpaid account balances when further examined by median household income ranges for Blue Cross (P < 0.001) and other commercial insurance carriers (P < 0.001). Conclusions: Although patients with insurance policies requiring higher out-of-pocket costs (ie, Blue Cross and other commercial insurance carriers) are generally characterized by higher household incomes, these patients were found to have higher unpaid account balances than patients with public insurance policies. This suggests that income alone is not predictive of unpaid medical debt and provides greater appreciation of lower income families who may make a more consistent effort in repaying their medical debt.

Wavefront-guided PRK treatment of myopia using a refractive aberrometer.

PURPOSE: To evaluate the safety, effectiveness, and patient-reported outcomes of wavefront-guided photorefractive keratectomy (PRK) for the correction of myopic refractive errors with and without astigmatism. SETTING: U.S. multicenter study. DESIGN: Prospective, nonrandomized clinical investigation. METHODS: 334 eyes (167 patients) underwent wavefront-guided PRK with the STAR S4 IR Excimer Laser System. Patients had preoperative myopic refractive errors with sphere up to -8.00 diopters (D) and cylinder up to -4.00 D with a maximum spherical equivalent (SE) of -10.00 D. All eyes were targeted for emmetropia, and treatment plans were derived from the iDESIGN system wavefront measurements. RESULTS: At 6 months, the point of refractive stability, 99.4% of eyes achieved 20/20 or better uncorrected distance visual acuity (UDVA), 92% of eyes achieved 20/16 or better UDVA, 85.5% of eyes achieved manifest refraction SE (MRSE) within 0.50 D of target, mean SE was -0.06, and less than 1% of eyes lost more than 2 lines of corrected distance visual acuity. Glare and halos occurred with similar or lower frequencies at 6 months vs preoperative. Results from the National Eye Institute Refractive Error Quality of life questionnaire showed statistically significant improvements at 6 months vs preoperative across most measures of vision-related functioning and well-being. Approximately 98% of patients reported high satisfaction with their overall vision at 6 months. CONCLUSIONS: Wavefront-guided PRK with the iDESIGN aberrometer was safe, effective, and predictable for the correction of low to moderate myopia with and without astigmatism and led to high patient satisfaction.

Garcinia cambogia-A Supplement-Related Liver Injury.

Drug-induced liver injury, and specifically supplement-related liver injury, accounts for an increasing proportion of acute liver injury cases. We present the case of acute liver injury due to a Garcinia cambogia-containing weight-loss supplement not previously associated with liver injury. Identifying supplements as a potential cause is a key to managing acute liver injury of uncertain etiology.

Censoring of self-reactive B cells by follicular dendritic cell-displayed self-antigen.

In the secondary lymphoid organs, intimate contact with follicular dendritic cells (FDCs) is required for B cell retention and Ag-driven selection during the germinal center response. However, selection of self-reactive B cells by Ag on FDCs has not been addressed. To this end, we generated a mouse model to conditionally express a membrane-bound self-antigen on FDCs and to monitor the fate of developing self-reactive B cells. In this article, we show that self-antigen displayed on FDCs mediates effective elimination of self-reactive B cells at the transitional stage. Notwithstanding, some self-reactive B cells persist beyond this checkpoint, showing evidence of Ag experience and intact proximal BCR signaling, but they are short-lived and unable to elicit T cell help. These results implicate FDCs as an important component of peripheral B cell tolerance that prevents the emergence of naive B cells capable of responding to sequestered self-antigens.

Magnetic-based purification of untouched mouse germinal center B cells for ex vivo manipulation and biochemical analysis.

Detailed biochemical analysis of unmanipulated germinal center (GC) B cells has not been achieved. Previously, we designed and used a simple, economical and new magnetic bead separation scheme for the purification of 'untouched' mature GC and non-GC B cells from the spleens of immunized mice and reported the first biochemical assessment of the signaling cascades that contribute to cyclin D stability and GC B cell proliferation. Here we provide a detailed protocol for the method we used, which involves preparing single-cell suspension from the spleens of immunized mice, followed by labeling of nontarget cells with biotinylated antibodies specific for CD43, CD11c and IgD (for GC enrichment) or GL7 (for non-GC enrichment); these steps are followed by cell depletion using standard magnetic bead technology. This protocol can yield GC and non-GC B cells with purities exceeding 90%. The sorting process can be carried out in ∼1 h and provides a population of GC B cells of sufficient purity and quantity to allow ex vivo manipulation, including biochemical and genetic analysis as well as cell culture.

Cyclin D3 is selectively required for proliferative expansion of germinal center B cells.

The generation of robust T-cell-dependent humoral immune responses requires the formation and expansion of germinal center structures within the follicular regions of the secondary lymphoid tissues. B-cell proliferation in the germinal center drives ongoing antigen-dependent selection and the generation of high-affinity class-switched plasma and memory B cells. However, the mechanisms regulating B-cell proliferation within this microenvironment are largely unknown. Here, we report that cyclin D3 is uniquely required for germinal center progression. Ccnd3(-/-) mice exhibit a B-cell-intrinsic defect in germinal center maturation and fail to generate an affinity-matured IgG response. We determined that the defect resulted from failed proliferative expansion of GL7(+) IgD(-) PNA(+) B cells. Mechanistically, sustained expression of cyclin D3 was found to be regulated at the level of protein stability and controlled by glycogen synthase kinase 3 in a cyclic AMP-protein kinase A-dependent manner. The specific defect in proliferative expansion of GL7(+) IgD(-) PNA(+) B cells in Ccnd3(-/-) mice defines an underappreciated step in germinal center progression and solidifies a role for cyclin D3 in the immune response, and as a potential therapeutic target for germinal center-derived B-cell malignancies.