A Review of Meta-Analyses in Plastic Surgery: Need for Adequate Assessment of Publication Bias.

INTRODUCTION: Publication bias describes a phenomenon in which significant positive results have a higher likelihood of being published compared to negative or nonsignificant results. Publication bias can confound the estimated therapeutic effect in meta-analyses and needs to be adequately assessed in the surgical literature. METHODS: A review of meta-analyses published in five plastic surgery journals from 2002 to 2022 was conducted. The inclusion criteria for meta-analyses were factors that demonstrated an obligation to assess publication bias, such as interventions with comparable treatment groups and enough power for statistical analysis. Acknowledgment of publication bias risk, quality of bias assessment, methods used in assessment, and individual article factors were analyzed. RESULTS: 318 unique meta-analyses were identified in literature search, and after full-text reviews, 143 met the inclusion criteria for obligation to assess publication bias. 64% of eligible meta-analyses acknowledged the confounding potential of publication bias, and only 46% conducted a formal assessment. Of those who conducted an assessment, 49% used subjective inspection of funnel plots alone, while 47% used any statistical testing in analysis. Overall, only 9/143 (6.3%) assessed publication bias and attempted to correct for its effect. Journals with a higher average impact factor were associated with mention and assessment of publication bias, but more recent publication year and higher number of primary articles analyzed were not. CONCLUSIONS: This review identified low rates of proper publication bias assessment in meta-analyses published in five major plastic surgery journals. Assessment of publication bias using objective statistical testing is necessary to ensure quality literature within surgical disciplines.

Discrepancies in Gender Representation Between Integrated and Independent Plastic Surgery Programs.

PURPOSE: Despite increasing female representation in integrated plastic surgery training programs, independent programs have lower representation and slow improvement in female enrollment. Self-reported resident data were used to investigate trends of female representation in integrated and independent programs. METHODS: Data were collected from Accreditation Council of Graduate Medical Education resources of active residents' characteristics. Self-reported gender data were collected for integrated, independent, and general surgery programs from annual reports since 2009. χ2 analysis was conducted to compare female enrollment of integrated programs, independent programs, general surgery programs, and general surgery programs with matriculation-year adjustment. RESULTS: In 2008, 89 independent programs had nearly identical percentage of female enrollment with 30 integrated programs at 23.8% and 23.1%, respectively. Differences in representation between independent and integrated programs became significant in 2012, with independent programs demonstrating 25.1% female enrollment compared with 30.5% in integrated programs. This trend of higher female representation in integrated programs has persisted since 2012. To correct for preexisting disparity in general surgery programs, we compared female enrollment of independent programs with female enrollment of that class' general surgery matriculation-year 5 years earlier. In all examined years, general surgery still had proportionally higher female enrollment compared with independent programs, even with conservative 5-year matriculation adjustment. CONCLUSIONS: Dramatic differences in female enrollment were found between integrated and independent programs, with representation in integrated programs rising more quickly. Adjustments for previous rates of female enrollment in general surgery did not yield explanation for low independent program enrollment. Increasing female representation in independent training models will continue to create a more diverse workforce.

Surgical Fellowships Demonstrate Variable Improvement in Gender Representation Despite Greater Female Enrollment in General Surgery Residencies.

OBJECTIVE: Despite increasing female representation in General Surgery (GS) residency training programs, proportional improvement of female enrollment in surgical fellowships has yet to be quantified. We aimed to assess if female enrollment in surgical fellowships has improved at an equivalent rate in 7 different surgical fellowship options after GS. DESIGN AND SETTING: Data were collected from Accreditation Council for Graduate Medical Education (ACGME) resources which disclosed active resident and fellow characteristics. Gender identification was self-reported by residents to ACGME. Gender data collected for GS programs and surgical fellowships including Surgical Critical Care, Colon, and Rectal Surgery, Pediatric Surgery, Plastic Surgery, Surgical Oncology, Thoracic Surgery, and Vascular Surgery from annual reports. Pearson Chi-squared analysis was conducted between GS residencies and fellowship programs in their corresponding years using Stata15 software. RESULTS: In all years examined, fellowships in Vascular, Thoracic, and Plastic Surgery had significantly lower female enrollment in proportion to the number of female GS residents (p = <0.02). In all years examined, Surgical Oncology, Pediatric, Colon and Rectal, and Surgical Critical Care had female enrollment that was, at minimum, proportional to female enrollment in GS residency, indicating equitable gender representation. Surgical Oncology (2016), Pediatric (2020) and Surgical Critical Care (2016) fellowships each had 1 year where female enrollment was significantly higher than General Surgery. CONCLUSIONS: The enrollment of female surgeons in Plastic, Vascular, and Thoracic Surgery fellowships has not improved proportionally despite an increase in female GS residents. These results suggest the possibility of persistent factors that deter female enrollment in Vascular, Thoracic and Plastic Surgery fellowships that are not present to the same degree in fields with equitable fellowship female enrollment. Female representation in surgical fellowships is vital to improving gender diversity in all disciplines of surgery, particularly academic surgery.

Beyond Strong Enforcement: Understanding the Factors Related to Retailer Compliance With Tobacco 21.

INTRODUCTION: Tobacco 21 (T21), which sets the minimum legal sales age for tobacco to age 21, is now a national law in the United States. Although T21 is expected to help curb youth tobacco use, its impact may be dampened due to poor retailer compliance. Even within environments where enforcement is strong (ie, compliance checks are conducted with tough sanctions for violations), compliance might vary due to other factors. AIMS AND METHODS: Three studies were conducted in Columbus, OH, where T21 became strongly enforced in 2018. These studies examined how retailer compliance related to features of the neighborhood in which a retailer was located (Study 1), features of the retailer (Study 2), and features of the retail cashier (Study 3). RESULTS: Study 1 found that, after controlling for race- and age-based factors, retailers located in high (vs. low)-poverty neighborhoods had a lower likelihood of conducting identification (ID) checks. Study 2 found that ID checks were related to whether retailers displayed signage about T21, as required by the city law. Study 3 found that, among cashiers, T21 awareness (which was high) and perceptions about T21 (which were moderate) were not generally related to their retailer's compliance; having (vs. not having) scanners for ID checks was related to a higher likelihood of compliance. CONCLUSIONS: These studies emphasize the many, multilevel factors influencing T21 outcomes. Findings also indicate the potential for T21 to widen disparities in tobacco use, indicating the need for strategies to equitably improve T21 compliance. IMPLICATIONS: T21, which sets the minimum legal sales age for all tobacco products to age 21, is now a national law in the United States. Despite optimistic projections about what T21 could achieve, the ultimate impact may be dampened when it is applied in real-world settings. Our project revealed the many, multilevel factors influencing T21 compliance. Findings also indicate the potential for T21 to widen disparities in tobacco use if gaps in compliance persist. Strategies for equitably improving T21 compliance are discussed. This article is of relevance to areas interested in implementing or improving their local T21 enforcement.

Intentions and Motivations for Exiting the Emergency Medical Services Profession Differ Between Emergency Medical Technicians and Paramedics.

BACKGROUND: Retention in emergency medical services (EMS) is a concern. To evaluate workforce stability within EMS, it is critical to understand factors that may lead an emergency medical technician (EMT) or paramedic to leave the profession. OBJECTIVE: We compared the most important factors influencing an EMT or paramedic's decision to leave EMS and determined whether these factors differed between the two certification levels. METHODS: We performed a cross-sectional analysis of an electronic questionnaire deployed to EMTs and paramedics who did not renew National EMS Certification in 2017 and were no longer working in EMS. Chi-squared tests with Bonferroni adjustment were used to compare factors between the two groups. RESULTS: Of the 5,093 responses, 53.1% (n=2,703) were no longer practicing in EMS and were included in the analyses. The most important factor for leaving EMS was pursuing education for EMTs (20.6%) and seeking better pay/benefits for paramedics (19.6%). Excluding those considering retirement, 32.4% of EMTs and 16.4% of paramedics (p<0.001) stated an intention to return to EMS. CONCLUSION: EMTs and paramedics leave EMS for different reasons, and fewer paramedics reported an intention to return. The need for better pay and benefits and lack of career advancement opportunity were common themes.

PPARγ is critical for Mycobacterium tuberculosis induction of Mcl-1 and limitation of human macrophage apoptosis.

Peroxisome proliferator-activated receptor (PPAR)γ is a global transcriptional regulator associated with anti-inflammatory actions. It is highly expressed in alveolar macrophages (AMs), which are unable to clear the intracellular pathogen Mycobacterium tuberculosis (M.tb). Although M.tb infection induces PPARγ in human macrophages, which contributes to M.tb growth, the mechanisms underlying this are largely unknown. We undertook NanoString gene expression analysis to identify novel PPARγ effectors that condition macrophages to be more susceptible to M.tb infection. This revealed several genes that are differentially regulated in response to PPARγ silencing during M.tb infection, including the Bcl-2 family members Bax (pro-apoptotic) and Mcl-1 (pro-survival). Apoptosis is an important defense mechanism that prevents the growth of intracellular microbes, including M.tb, but is limited by virulent M.tb. This suggested that M.tb differentially regulates Mcl-1 and Bax expression through PPARγ to limit apoptosis. In support of this, gene and protein expression analysis revealed that Mcl-1 expression is driven by PPARγ during M.tb infection in human macrophages. Further, 15-lipoxygenase (15-LOX) is critical for PPARγ activity and Mcl-1 expression. We also determined that PPARγ and 15-LOX regulate macrophage apoptosis during M.tb infection, and that pre-clinical therapeutics that inhibit Mcl-1 activity significantly limit M.tb intracellular growth in both human macrophages and an in vitro TB granuloma model. In conclusion, identification of the novel PPARγ effector Mcl-1 has determined PPARγ and 15-LOX are critical regulators of apoptosis during M.tb infection and new potential targets for host-directed therapy for M.tb.