A single-cell atlas of human and mouse white adipose tissue.

White adipose tissue, once regarded as morphologically and functionally bland, is now recognized to be dynamic, plastic and heterogenous, and is involved in a wide array of biological processes including energy homeostasis, glucose and lipid handling, blood pressure control and host defence1. High-fat feeding and other metabolic stressors cause marked changes in adipose morphology, physiology and cellular composition1, and alterations in adiposity are associated with insulin resistance, dyslipidemia and type 2 diabetes2. Here we provide detailed cellular atlases of human and mouse subcutaneous and visceral white fat at single-cell resolution across a range of body weight. We identify subpopulations of adipocytes, adipose stem and progenitor cells, vascular and immune cells and demonstrate commonalities and differences across species and dietary conditions. We link specific cell types to increased risk of metabolic disease and provide an initial blueprint for a comprehensive set of interactions between individual cell types in the adipose niche in leanness and obesity. These data comprise an extensive resource for the exploration of genes, traits and cell types in the function of white adipose tissue across species, depots and nutritional conditions.

Repurposing an endogenous degradation domain for antibody-mediated disposal of cell-surface proteins.

The exquisite specificity of antibodies can be harnessed to effect targeted degradation of membrane proteins. Here, we demonstrate targeted protein removal utilising a protein degradation domain derived from the endogenous human protein Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9). Recombinant antibodies genetically fused to this domain drive the degradation of membrane proteins that undergo constitutive internalisation and recycling, including the transferrin receptor and the human cytomegalovirus latency-associated protein US28. We term this approach PACTAC (PCSK9-Antibody Clearance-Targeting Chimeras).

A large-scale conformational change couples membrane recruitment to cargo binding in the AP2 clathrin adaptor complex.

The AP2 adaptor complex (alpha, beta2, sigma2, and mu2 subunits) crosslinks the endocytic clathrin scaffold to PtdIns4,5P(2)-containing membranes and transmembrane protein cargo. In the "locked" cytosolic form, AP2's binding sites for the two endocytic motifs, YxxPhi on the C-terminal domain of mu2 (C-mu2) and [ED]xxxL[LI] on sigma2, are blocked by parts of beta2. Using protein crystallography, we show that AP2 undergoes a large conformational change in which C-mu2 relocates to an orthogonal face of the complex, simultaneously unblocking both cargo-binding sites; the previously unstructured mu2 linker becomes helical and binds back onto the complex. This structural rearrangement results in AP2's four PtdIns4,5P(2)- and two endocytic motif-binding sites becoming coplanar, facilitating their simultaneous interaction with PtdIns4,5P(2)/cargo-containing membranes. Using a range of biophysical techniques, we show that the endocytic cargo binding of AP2 is driven by its interaction with PtdIns4,5P(2)-containing membranes.

Propulsive colonic contractions are mediated by inhibition-driven poststimulus responses that originate in interstitial cells of Cajal.

The peristaltic reflex is a fundamental behavior of the gastrointestinal (GI) tract in which mucosal stimulation activates propulsive contractions. The reflex occurs by stimulation of intrinsic primary afferent neurons with cell bodies in the myenteric plexus and projections to the lamina propria, distribution of information by interneurons, and activation of muscle motor neurons. The current concept is that excitatory cholinergic motor neurons are activated proximal to and inhibitory neurons are activated distal to the stimulus site. We found that atropine reduced, but did not block, colonic migrating motor complexes (CMMCs) in mouse, monkey, and human colons, suggesting a mechanism other than one activated by cholinergic neurons is involved in the generation/propagation of CMMCs. CMMCs were activated after a period of nerve stimulation in colons of each species, suggesting that the propulsive contractions of CMMCs may be due to the poststimulus excitation that follows inhibitory neural responses. Blocking nitrergic neurotransmission inhibited poststimulus excitation in muscle strips and blocked CMMCs in intact colons. Our data demonstrate that poststimulus excitation is due to increased Ca2+ transients in colonic interstitial cells of Cajal (ICC) following cessation of nitrergic, cyclic guanosine monophosphate (cGMP)-dependent inhibitory responses. The increase in Ca2+ transients after nitrergic responses activates a Ca2+-activated Cl− conductance, encoded by Ano1, in ICC. Antagonists of ANO1 channels inhibit poststimulus depolarizations in colonic muscles and CMMCs in intact colons. The poststimulus excitatory responses in ICC are linked to cGMP-inhibited cyclic adenosine monophosphate (cAMP) phosphodiesterase 3a and cAMP-dependent effects. These data suggest alternative mechanisms for generation and propagation of CMMCs in the colon.

Harnessing the Peterson Reaction for the Stereospecific Synthesis of Z-Vinyl Ethers.

Vinyl ethers are valuable synthetic intermediates which are also found as natural products, including aflatoxins, rifamycins and plasmalogens. The latter are ubiquitous phospholipids in human cells and contain a vinyl ether moiety with specifically Z configuration. Although numerous methods are available for synthesis of vinyl ethers, there is a lack of methods for obtaining Z isomers of molecules of the type RCH=CHOR' that are applicable to plasmalogens. A variant of the Peterson reaction is described that generates such molecules with very high stereoselectivity (Z/E ratio: 99 : 1). (R,R)/(S,S)-1-alkoxy-2-hydroxyalkylsilanes were synthesized from 1-trimethylsilylalkynes by a sequence of reduction with di-isobutylaluminium hydride to a (Z)-1-trimethylsilylalkene, epoxidation of the alkene to a 2-trimethylsilyl-3-substituted epoxide and regioselective, boron-trifluoride catalyzed ring-opening of the epoxide by reaction with an alcohol. Conversion of the (R,R)/(S,S)-1-alkoxy-2-hydroxyalkylsilanes to vinyl ethers (RCH=CHOR') was achieved under basic conditions as in a standard Peterson reaction. However, near exclusive formation of a Z vinyl ether was only achieved when the reaction was performed using potassium hydride in the non-polar solvent α,α,α-trifluorotoluene, more polar solvents giving increasing amounts of the E isomer. The sequence described embraces a variety of substituents and precursors, proceeds in overall high yield and is readily scalable.

Improving Readability and Automating Content Analysis of Plastic Surgery Webpages With ChatGPT.

INTRODUCTION: The quality and readability of online health information are sometimes suboptimal, reducing their usefulness to patients. Manual evaluation of online medical information is time-consuming and error-prone. This study automates content analysis and readability improvement of private-practice plastic surgery webpages using ChatGPT. METHODS: The first 70 Google search results of "breast implant size factors" and "breast implant size decision" were screened. ChatGPT 3.5 and 4.0 were utilized with two prompts (1: general, 2: specific) to automate content analysis and rewrite webpages with improved readability. ChatGPT content analysis outputs were classified as hallucination (false positive), accurate (true positive or true negative), or omission (false negative) using human-rated scores as a benchmark. Six readability metric scores of original and revised webpage texts were compared. RESULTS: Seventy-five webpages were included. Significant improvements were achieved from baseline in six readability metric scores using a specific-instruction prompt with ChatGPT 3.5 (all P ≤ 0.05). No further improvements in readability scores were achieved with ChatGPT 4.0. Rates of hallucination, accuracy, and omission in ChatGPT content scoring varied widely between decision-making factors. Compared to ChatGPT 3.5, average accuracy rates increased while omission rates decreased with ChatGPT 4.0 content analysis output. CONCLUSIONS: ChatGPT offers an innovative approach to enhancing the quality of online medical information and expanding the capabilities of plastic surgery research and practice. Automation of content analysis is limited by ChatGPT 3.5's high omission rates and ChatGPT 4.0's high hallucination rates. Our results also underscore the importance of iterative prompt design to optimize ChatGPT performance in research tasks.

Three-Dimensional Printing in Surgical Education: An Updated Systematic Review of the Literature.

INTRODUCTION: Three-dimensional printing (3DP) is being integrated into surgical practice at a significant pace, from preprocedural planning to procedure simulation. 3DP is especially useful in surgical education, where printed models are highly accurate and customizable. The aim of this study was to evaluate how 3DP is being integrated most recently into surgical residency training. METHODS: We performed a structured literature search of the OVID/MEDLINE, EMBASE, and PUBMED databases following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Articles published from 2016 to 2023 that met predefined inclusion and exclusion criteria were included. Data extracted included surgical subspecialty using 3DP, application of 3DP, and any reported satisfaction measures of trainees. A thorough analysis of pooled data was performed to evaluate satisfaction rates among studies. RESULTS: A total of 85 studies were included. The median number of participants was 18 (interquartile range 10-27). Fourteen surgical disciplines were represented, with ear, nose, and throat/otolaryngology having the highest recorded utilization of 3DP models among residents and medical students (22.0%), followed by neurosurgery (14.0%) and urology (12.0%). 3DP models were created most frequently to model soft tissue (35.3%), bone (24.7%), vessel (14.1%), mixed (16.4%), or whole organs (6.66%) (Fig.1). Feedback from trainees was overwhelmingly positive regarding the fidelity of the models and their support for integration into their training programs. Among trainees, the combined satisfaction rate with their use in the curriculum was 95% (95% confidence interval, 0.92-0.97), and the satisfaction rate with the model fidelity was 90% (95% confidence interval, 0.86-0.94). CONCLUSIONS: There is wide variation in the surgical specialties utilizing 3DP models in training. These models are effective in increasing trainee comfort with both common and rare scenarios and are associated with a high degree of resident support and satisfaction. Plastic surgery programs may benefit from the integration of this technology, potentially strengthening future surgical curricula. Objective evaluations of their pedagogic effects on residents are areas of future research.

Association of Metabolic Derangement and Postoperative Outcomes in Hernia Repair With Component Separation: A Propensity Score-matched Nationwide Analysis.

INTRODUCTION: Metabolic syndrome (MetS) is characterized by cardiometabolic abnormalities such as hypertension, obesity, diabetes, or dyslipidemia. This study aims to evaluate the association of MetS on the postoperative outcomes of ventral, umbilical, and epigastric hernia repair using component separation. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent ventral, umbilical, and epigastric hernia repair with component separation between 2015 and 2021. MetS status was defined as patients receiving medical treatment for diabetes mellitus and hypertension, with a body mass index greater than 30 kg/m2. Propensity matching was performed to generate two balanced cohorts with and without MetS. T-tests and Fisher's Exact tests assessed group differences. Logistic regression models evaluated complications between the groups. RESULTS: After propensity score matching, 3930 patients were included in the analysis, with 1965 in each group (MetS versus non-MetS). Significant differences were observed in the severity and clinical presentation of hernias between the groups. The MetS cohort had higher rates of incarcerated hernia (39.1% versus 33.2%; P < 0.001), and recurrent ventral hernia (42.7% versus 36.5%; P < 0.001) compared to the non-MetS cohort. The MetS group demonstrated significantly increased rates of renal insufficiency (P = 0.026), unplanned intubation (P = 0.003), cardiac arrest (P = 0.005), and reoperation rates (P = 0.002) than the non-MetS cohort. Logistic regression models demonstrated higher likelihood of postoperative complications in the MetS group, including mild systemic complications (OR 1.25; 95%CI 1.030-1.518; P = 0.024), severe systemic complications (OR 1.63; 95%CI 1.248-2.120; P < 0.001), and reoperation (OR 1.47; 95%CI 1.158-1.866; P = 0.002). There were no significant differences in the rates of 30-d wound complications between groups. CONCLUSIONS: The presence of metabolic derangement appears to be associated with adverse postoperative medical outcomes and increased reoperation rates after hernia repair with component separation. These findings highlight the importance of optimizing preoperative comorbidities as surgeons counsel patients with MetS.

The Impact of Health Literacy on Trust in Online Plastic Surgery Content: A Nationwide Analysis.

INTRODUCTION: On most online platforms, just about anyone can disseminate plastic surgery (PS) content regardless of their educational or professional background. This study examines the general public's perceptions of the accuracy of online PS content and the factors that contribute to the discernment of credible information. METHODS: The Amazon Mechanical Turk crowdsourcing platform was used to survey adults in the United States. The survey assessed respondent demographics, health literacy (HL), and perceptions of online PS content accuracy. T-tests, Chi-square tests, and post hoc analyses with Bonferroni corrections assessed differences between HL groups. Multivariate linear regressions assessed associations between sociodemographic variables and perceptions of online content. RESULTS: In total, 428 (92.0%) of 465 complete responses were analyzed. The median age of respondents was 32 y (interquartile range: 29-40). Online sources were predominantly perceived to have a high degree of accuracy, with mean scores of various platforms ranging from 3.8 to 4.5 (1 = not accurate at all; 5 = extremely accurate). The low HL group perceived social media sites and review sites to be more accurate than the high HL respondents, particularly for Reddit (P = 0.004), Pinterest (P = 0.040), and Snapchat (P = 0.002). CONCLUSIONS: There is a concerning relationship between low HL and the perceptions of the accuracy of online PS sources. This study underscores the need for education campaigns, the development of trustworthy online resources, and initiatives to improve HL. By fostering a more informed public, individuals seeking PS can make better informed decisions.

Beyond Accreditation Council for Graduate Medical Education Required Scholarship: The Academic Journey of Plastic Surgery Residents.

INTRODUCTION: Research productivity is an important part of required Accreditation Council for Graduate Medical Education scholarship during residency training and critical to trainees who intend to pursue careers in academia. This study aims to determine plastic surgery residents' experiences with and attitudes toward research. METHODS: Accredited independent (52) and integrated (86) plastic surgery program websites were manually searched for currently active residents' names and email addresses. Identified residents were emailed a survey consisting of 25 questions through Research Electronic Data Capture. RESULTS: A total of 45 plastic surgery residents responded to the survey request (14.6% response rate). Respondents were 57% female and 43% male, with an average age of 30.7 y. At the time of survey participation, 95% of surgery residents were involved in research endeavors, voluntarily or as part of their residency training. Of the respondents, 13 (32%) previously participated in a research fellowship compared to 28 (68%) respondents who did not. Interestingly, respondents who completed fellowships were 2.84 times (95% confidence interval: 0.52-15.38, P = 0.2269) more likely to intend continuing research endeavors after residency. Participants were most in agreement with statements suggesting their research fellowship benefitted their application in the plastic surgery match process (4 [interquartile range (IQR): 4, 4]), improved their ability to conduct research (4 [IQR: 4, 4]), and helped to better understand medical literature (4 [IQR: 3, 4]). CONCLUSIONS: Plastic surgery programs' robust research emphasis has a favorable translation into residents' self-perceived understanding of medical literature and clinical knowledge.

Pan-African evolution of within- and between-country COVID-19 dynamics.

The coronavirus disease 2019 (COVID-19) pandemic is heterogeneous throughout Africa and threatening millions of lives. Surveillance and short-term modeling forecasts are critical to provide timely information for decisions on control strategies. We created a strategy that helps predict the country-level case occurrences based on cases within or external to a country throughout the entire African continent, parameterized by socioeconomic and geoeconomic variations and the lagged effects of social policy and meteorological history. We observed the effect of the Human Development Index, containment policies, testing capacity, specific humidity, temperature, and landlocked status of countries on the local within-country and external between-country transmission. One-week forecasts of case numbers from the model were driven by the quality of the reported data. Seeking equitable behavioral and social interventions, balanced with coordinated country-specific strategies in infection suppression, should be a continental priority to control the COVID-19 pandemic in Africa.

Gender Diversity Among Reconstructive Microsurgery Studies Based on the Relative Citation Ratio: An 18-Year Analysis.

BACKGROUND: Gender disparities in plastic surgery authorship have been previously described in the literature. The relative citation ratio (RCR) index is a new metric that normalizes citation rates for field and time, which can be utilized to compare authors. This study aims to evaluate differences in gender authorship in reconstructive microsurgery (RM) papers, as well as the impact of gender on the RCR index. METHODS: A PubMed query isolated RM studies between 2002 and 2020 across the 3 highest impact PS journals. Author names and RCR information were collected from NIH iCite. The likely gender was adjudicated by using NamSor-Software. Unpaired Wilcoxon rank-sum and chi-square tests were used to assess differences between groups. RESULTS: Of 1146 articles (2172 authors), there was a significant difference between the proportion of females as senior authors compared to first authors (P < 0.001). Overall, females represented 15.4% of all authors, 19.7% of first authors, and 11.3% of senior authors. Males had a significantly higher weighted RCR (P < 0.0001) and number of publications (P < 0.0001), which remained significant when stratified by first and senior author. Female authors collectively had a higher mean RCR (P = 0.008) and among first authors (P < 0.0001), with no significant difference among senior authors (P = 0.47). CONCLUSION: A considerably greater number of males are publishing in reconstructive microsurgery compared to females, with significantly more males being senior authors compared to first authors. Males had higher weighted RCR scores and publications compared to females. This study suggests that equity in gender authorship within the field is yet to be achieved.

Representation of Racial Diversity on US Plastic Surgery Websites: A Cross-sectional Study: Racial Diversity on Plastic Surgery Websites.

BACKGROUND: The racial diversity portrayed in plastic and reconstructive surgery (PRS) media is an important indicator of an inclusive environment for potential patients. To evaluate the degree to which PRS websites demonstrate inclusivity, we assessed the racial composition of both patients and plastic surgeons depicted on the most visited academic and private PRS websites to determine the extent to which racial diversity is represented. METHODS: A cross-sectional study was conducted in September 2023. The 10 most visited websites in each state were identified. Sociodemographic characteristics including race and sex of patients and plastic surgeons, as well as the type of practice, were collected. Race was classified according to individuals' Fitzpatrick Phototypes into White and non-White. Differences in patient and surgeon representation were compared to the 2020 US Census and the 2020 ASPS demographics using χ2 tests. Subgroup analyses were conducted to identify differences by type of practice and region. RESULTS: We analyzed a total of 2,752 patients from 462 websites belonging to 930 plastic surgeons. PRS websites were predominantly from private practices (93%). Regarding patient representation, 92.6% were female, 7.4% were male, 87.6% were White, and 12.4% were non-White. The surgeon population on the studied webpages was 75.1% male, 92.1% White, and 7.8% non-White. Statistically significant differences were found in the patient population when compared to the 2020 national (P < 0.001) and regional (P < 0.001) US Census demographics and the 2020 ASPS Statistics Report (P < 0.001). Although minority representation was significantly higher on academic websites compared to private practice (22.9% vs. 12.1%; P = 0.007), both were significantly lower than the percentage of minority patients undergoing PRS. CONCLUSIONS: This study illuminates racial disparities in the representation of racial groups among patients and plastic surgeons in the most frequented plastic surgery websites. Moreover, it underscores the imperative to bolster racial diversity within the digital content of both private and academic PRS websites. Greater racial representation can foster a more inclusive perception of the plastic surgery field, which may potentially broaden access to care and enrich the professional landscape.

Development of "Explore Plastic Surgery": An Educational Program for Medical Students Without Home Residency Programs.

BACKGROUND: Medical students who attend institutions without plastic surgery residency programs are at a disadvantage in the plastic surgery match. We developed an educational program for medical students without home programs called Explore Plastic Surgery to provide an overview of the steps toward a career in plastic surgery. The purpose of this study was to assess the impact, utility, and success of the novel program. METHODS: Pre- and postevent surveys were distributed to participants. Survey data were analyzed including participant demographics, perceptions of barriers unique to those without home programs, and the overall event utility. RESULTS: Two hundred seventeen students registered for the program. Ninety-five participants completed the pre-event survey (44%), and of those, 57 participants completed the post-event survey (60%). There was an increase in understanding of the steps toward a career in plastic surgery ( P < 0.001), confidence in overcoming barriers ( P = 0.005), and level of comfort in reaching out to faculty for opportunities ( P = 0.01). There was a decrease in the perceived negative impact that attending medical schools without a home program will have on their abilities to pursue careers in plastic surgery ( P = 0.006). CONCLUSIONS: After the event, participants demonstrated an increase in their confidence in overcoming barriers and a decrease in their perceptions that attending an institution without a home program would negatively impact their ability to pursue plastic surgery. Initiatives focused on early exposure and recruitment of medical students may be important to promote accessibility and diversity within plastic surgery.

Geographic Variability of Genital Gender-Affirming Surgery Centers and Costs of Hospitalization.

PURPOSE: The cost of gender-affirming surgery (GAS) is an important component of healthcare accessibility for transgender patients. However, GAS is often prohibitively expensive, particularly as there are inconsistencies in insurance coverages. Variability in hospital costs has been documented for other types of nonplastic surgery procedures; however, this analysis has not been done for GAS. To better understand the financial barriers impairing access to equitable transgender care, this study analyzes the distribution of hospitals that perform genital GAS and the associated costs of inpatient genital GAS. METHODS: This is a study of the 2016-2019 National Inpatient Sample database. Transgender patients undergoing genital GAS were identified using International Classification of Diseases, Tenth Revision, diagnosis and procedure codes, and patients undergoing concurrent chest wall GAS were excluded. Descriptive statistics were done on patient sociodemographic variables, hospital characteristics, and hospitalization costs. χ2 test was used to assess for differences between categorical variables and Mood's median test was used to assess for differences between continuous variable medians. RESULTS: A total of 3590 weighted genital GAS encounters were identified. The Western region (50.8%) and Northeast (32.3%) performed the greatest proportion of GAS, compared with the Midwest (9.1%) and the South (8.0%) (P < 0.0001). The most common payment source was private insurance (62.8%), followed by public insurance (27.3%). There were significant differences in the variability of median hospital costs across regions (P < 0.0001). The South and Midwest had the greatest median cost for vaginoplasty ($19,935; interquartile range [IQR], $16,162-$23,561; P = 0.0009), while the West had the greatest median cost for phalloplasty ($26,799; IQR, $19,667-$30,826; P = 0.0152). Across both procedures, the Northeast had the lowest median cost ($11,421; IQR, $9155-$13,165 and $10,055; IQR, $9,013-$10,377, respectively). CONCLUSIONS: There is significant regional variability in the number of GAS procedures performed and their associated hospitalization costs. The identified disparities in insurance coverage present an area of possible future improvement to alleviate the financial burden GAS presents to gender-discordant individuals. The variability in cost suggests a need to evaluate variations in care, leading to cost standardization.

Women in Plastic Surgery Innovation: A 10-Year Review of Gender Representation in Mammary Device Patents.

BACKGROUND: This study aims to pioneer in evaluating women's representation in plastic surgery innovations, focusing on mammary prosthesis devices' inventorship. Despite growing gender parity in the field, women's involvement in innovation remains underexplored. This is especially crucial, as the predominant recipients of these innovative technologies are women, urging a necessity for broader female engagement in pioneering surgical advancements. METHOD: Patents under the "A61F2/12: Mammary prostheses and implants" classification between the dates January 1, 2011, to December 31, 2020, were identified using Google Patents Advanced. Inclusion criteria included patents (not designs) in English and applications (not grants), with no litigation limitations. Data collected included ID, title, assignee (categorized as industry, academic, private, individual), inventors, and dates (priority, filing, and publication). Sex of inventors was identified with the literature validated gender API, with manual resolution of unresolved genders or with ga_accuracy scores of less than 75%. Data were analyzed using 2-tailed Student t tests, χ2 analysis, and Pearson correlation coefficient (significance set at P ≤ 0.05). RESULTS: Of the more than 130,000 plastic surgery patents in English identified between the 10-year period, 1355 were classified as A61F2/12. A total of 374 unique patents were included for analysis (841 duplicates were removed, and 140 patents were excluded because of non-English character author names). There was a significant increase in patents over the decade (from 15 in 2011 to 88 in 2020, R2 = 0.74, P < 0.05), with a decrease in number of inventors per patent (R2 = 0.12, P < 0.05). Of the 1102 total inventors, 138 were female (11.2%), with a 4-fold increase in representation over the decade (R2 = 0.58, P < 0.05), including increase in patents filed with a woman first inventor (0%-14.8%). Women were equally likely to be first 3 inventors versus middle to last inventors (12.8% vs 11.1%, respectively). CONCLUSIONS: Over a decade, mammary device innovations rose significantly. Although women inventors' representation improved, it remains disproportionate compared with women in residency/practice. Hence, interventions should aim to align inventor representation with training ratios, through institutional optimization, reducing gender segmentation, and enhancing funding opportunities.

Continuing Insurance Coverage for Flap-Based Breast Reconstruction: Is There a Reservation Cost Related to a Woman's Abdominal Flap Choice?

BACKGROUND: The recent proposed alterations to the Centers for Medicare and Medicaid Services regulations, although subsequently reversed on August 21, 2023, have engendered persistent concerns regarding the impact of insurance policies on breast reconstruction procedures coverage. This study aimed to identify factors that would influence women's preferences regarding autologous breast reconstruction to better understand the possible consequences of these coverage changes. METHODS: A survey of adult women in the United States was conducted via Amazon Mechanical Turk to assess patient preferences for breast reconstruction options, specifically deep inferior epigastric perforator (DIEP) and transverse rectus abdominis myocutaneous (TRAM) flap surgery. The Cochrane-Armitage test evaluated trends in flap preferences concerning incremental out-of-pocket payment increases. RESULTS: Of 500 total responses, 485 were completed and correctly answered a verification question to ensure adequate attention to the survey, with respondents having a median (interquartile range) age of 26 (25-39) years. When presented with the advantages and disadvantages of DIEP versus TRAM flaps, 78% of respondents preferred DIEP; however, as DIEP's out-of-pocket price incrementally rose, more respondents favored the cheaper TRAM option, with $3804 being the "indifference point" where preferences for both procedures converged (P < 0.001). Notably, respondents with a personal history of breast reconstruction showed a higher preference for DIEP, even at a $10,000 out-of-pocket cost (P = 0.04). CONCLUSIONS: Out-of-pocket cost can significantly influence women's choices for breast reconstruction. These findings encourage a reevaluation of emergent insurance practices that could potentially increase out-of-pocket costs associated with DIEP flaps, to prevent cost from decreasing equitable patient access to most current reconstructive options.

Diversifying laboratory assessment modes broadens engagement with practical competencies in life science students.

Laboratory practicals in life science subjects are traditionally assessed by written reports that reflect disciplinary norms for documenting experimental activities. However, the exclusive application of this assessment has the potential to engage only a narrow range of competencies. In this study, we explored how multiple modes of laboratory assessment might affect student perceptions of learned skills in a life science module. We hypothesized that while a mixture of assessments may not impact student summative performance, it might positively influence student perceptions of different skills that varied assessments allowed them to practice. This was informed by universal design for learning and teaching for understanding frameworks. In our study, in a third-year Bioscience program, written reports were complemented with group presentations and online quizzes via Moodle. Anonymous surveys evaluated whether this expanded portfolio of assessments promoted awareness of, and engagement with, a broader range of practical competencies. Aspects that influenced student preferences in assessment mode included time limitations, time investment, ability to practice new skills, links with lecture material, and experience of assessment anxiety. In particular, presentations were highlighted as promoting collaboration and communication and the quiz as an effective means of diversifying assessment schedules. A key takeaway from students was that while reports were important, an overreliance on them was detrimental. This study suggests that undergraduate life science students can benefit significantly from a holistic assessment strategy that complements reports with performance-based approaches that incorporate broader competencies and allow for greater student engagement and expression in undergraduate modules.NEW & NOTEWORTHY This study suggests that undergraduate life science students can benefit significantly from a holistic assessment strategy that complements reports with performance-based approaches that incorporate broader competencies and allow for greater student engagement and expression in undergraduate modules.

Outcomes of patients in rural communities undergoing autologous breast reconstruction: A comparison of cost and patient demographics with implications for rural health policy.

BACKGROUND: Patients with breast cancer living in rural areas are less likely to undergo breast reconstruction. Further, given the additional training and resources required for autologous reconstruction, it is likely that rural patients face barriers to accessing these surgical options. Therefore, the purpose of this study is to determine if there are disparities in autologous breast reconstruction care among rural patients on the national level. METHODS: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample Database was queried from 2012 to 2019 using ICD9/10 codes for breast cancer diagnoses and autologous breast reconstruction. The resulting data set was analyzed for patient, hospital, and complication-specific information with counties comprised of less than 10,000 inhabitants classified as rural. RESULTS: From 2012 to 2019, 89,700 weighted encounters for autologous breast reconstruction involved patients who lived in non-rural areas, while 3605 involved patients from rural counties. The majority of rural patients underwent reconstruction at urban teaching hospitals. However, rural patients were more likely than non-rural patients to have their surgery at a rural hospital (6.8% vs. 0.7%). Rural-county residing patients had lower odds of receiving a deep inferior epigastric perforator (DIEP) flap compared to non-rural-county residing patients (OR 0.51 CI: 0.48-0.55, p < .0001). Further, rural patients were more likely to experience infection and wound disruption than urban patients (p < .05), regardless of where they underwent surgery. Complication rates were similar among rural patients who received care at rural hospitals versus urban hospitals (p > .05). Meanwhile, the cost of autologous breast reconstruction was higher (p = .011) for rural patients at an urban hospital ($30,066.2, SD19,965.5) than at a rural hospital ($25,049.5, SD12,397.2). CONCLUSION: Patients living in rural areas face disparities in health care, including lower odds of being potentially offered gold-standard breast reconstruction treatments. Increased microsurgical option availability and patient education in rural areas may help alleviate current disparities in breast reconstruction.