Impact of the Virtual Format on Plastic Surgery Residency and Fellowship Interviews: A National Cross-Sectional Study.

BACKGROUND: The 2020 to 2021 residency and fellowship application cycles were profoundly affected by the introduction of virtual interviews. The authors investigated the impact the virtual format had on plastic surgery residency and fellowship interviews from the perspectives of program directors. METHODS: Surveys were sent to program directors of integrated plastic surgery residency and fellowship programs to ascertain their perspectives regarding the virtual format's impact on residency and fellowship interviews. Program directors were stratified into residency and fellowship cohorts, and comparative analysis was performed. RESULTS: Ninety-two program directors, 28 from integrated plastic surgery residency programs and 64 from fellowship programs, completed our survey (35 percent). Compared to in-person interviews, virtual interviews were reported to be more economical and time efficient by program directors of residency (100 percent and 46 percent, respectively) and fellowship programs (97 percent and 48 percent, respectively). Consequentially, 36 percent and 47 percent of residency and fellowship programs were able to interview more applicants, respectively. Program directors of residency and fellowship programs reported that virtual interviews hindered their ability to assess applicants' fit with the program (75 percent and 63 percent, respectively), personality and communication skills (75 percent and 64 percent, respectively), and commitment to the field, along with their ability to function as a trainee (57 percent and 50 percent, respectively). Overall, 71 percent of program directors of residency and 58 percent of program directors of fellowship programs preferred in-person interviews. The majority of residency (71 percent) and fellowship (56 percent) program directors intend to conduct both in-person and virtual interviews in future application cycles ( p = 0.12). CONCLUSIONS: Despite preferring in-person interviews, program directors intend to host both in-person and virtual interviews in future application cycles. It remains to be seen how virtual interviews will be used moving forward.

Cost-effectiveness of Multidisciplinary Care in Plastic Surgery: A Systematic Review.

BACKGROUND: Multidisciplinary care has been previously shown to improve outcomes for patients and providers alike, fostering interprofessional collaboration and communication. Many studies have demonstrated the beneficial health care outcomes of interdisciplinary care. However, there has been minimal focus on the cost-effectiveness of such care, particularly in the realm of plastic surgery. This is the first systematic review to examine cost savings attributable to plastic surgery involvement in multidisciplinary care. METHODS: A comprehensive literature review of articles published on cost outcomes associated with multidisciplinary teams including a plastic surgeon was performed. Included articles reported on cost outcomes directly or indirectly attributable to a collaborative intervention. Explicitly reported cost savings were totaled on a per-patient basis. Each article was also reviewed to determine whether the authors ultimately recommended the team-based intervention described. RESULTS: A total of 604 articles were identified in the initial query, of which 8 met the inclusion criteria. Three studies reported explicit cost savings from multidisciplinary care, with cost savings ranging from $707 to $26,098 per patient, and 5 studies reported changes in secondary factors such as complication rates and length of stay. All studies ultimately recommended multidisciplinary care, regardless of whether cost savings were achieved. CONCLUSIONS: This systematic review of the cost-effectiveness of multidisciplinary plastic surgery care examined both primary cost savings and associated quality outcomes, such as length of stay, complication rate, and resource consumption. Our findings indicate that the inclusion of plastic surgery in team-based care provides both direct and indirect cost savings to all involved parties.

Perforated duodenal ulcer: An unusual manifestation of allergic eosinophilic gastroenteritis.

Spontaneous perforation of a duodenal ulcer secondary to allergic eosinophilic gastroenteritis (EGE) has not been previously reported. We present such a case in a teenager who presented with peritonitis. After exploration and operative repair of his ulcer, he continued to experience intermittent abdominal pain, and further evaluation revealed eosinophilic gastroenteritis in the setting of multiple food allergies. His EGE resolved after adhering to a restrictive diet. Both duodenal ulcers and EGE are very rarely seen in pediatric patients. EGE has a variable presentation depending on the layer(s) of bowel wall affected and the segment of the gastrointestinal tract that is involved. Once diagnosed, it may respond to dietary changes in patients with recognized food allergies, or to steroids in patients in whom an underlying cause is not identified. Our case highlights the need to keep EGE in the differential diagnosis when treating pediatric patients with duodenal ulcers. The epidemiology, pathophysiology, and treatment of EGE are also discussed, along with a review of the current literature.

Androgen receptor immunohistochemistry in genitourinary neoplasms.

PURPOSE: Androgen receptor (AR) is a recognized immunohistochemical marker of prostate cancer. However, the sensitivity and specificity of AR for prostate cancer in the setting of other genitourinary neoplasms has not been rigorously studied. METHODS: We employed tissue microarrays containing prostate carcinomas, urothelial carcinomas, renal cell carcinomas, and testicular neoplasms. Slides were stained immunohistochemically for AR. RESULTS: Androgen receptor was positive in 95% of prostate carcinomas (n=230), but 19% of invasive urothelial carcinomas of the bladder (n=190) and 33% of non-invasive bladder urothelial carcinomas were also AR positive (N=107). Furthermore, 16% of renal pelvis urothelial carcinomas (n=43) were positive. Of primary renal cell carcinomas, 19% were AR positive (n=307). From a metastatic renal cell carcinoma cohort, 28% of metastases were AR positive (N=126). Six percent of non-teratomatous testicular germ cell tumors stained for AR (n=103). CONCLUSIONS: Our data show that the sensitivity of AR immunohistochemistry for prostate cancer is 94.8%. However, the specificity of AR is only 81.4%, among our cohort of invasive genitourinary tumors. Thus, we find the specificity of AR suboptimal, yet AR may remain useful as a component of an immunostain panel.

Utility of immunohistochemical markers in irradiated breast tissue: an analysis of the role of myoepithelial markers, p53, and Ki-67.

Radiation therapy is an important adjunct to breast-conserving surgery, but the diagnosis of recurrent/de novo carcinoma in a background of radiation atypia can be difficult, especially on small biopsies. Immunostaining for myoepithelial cell proteins is often used to assess invasion in nonirradiated breast tissue, yet these stains have not been investigated specifically in irradiated breast. We studied 29 irradiated breast resection specimens, some with carcinoma in situ (CIS, n=13) and/or invasive carcinoma (n=13). Representative blocks were stained for the myoepithelial proteins p63, smooth muscle myosin heavy chain (SMM), calponin, CK5/6, the proliferative marker Ki-67, and the tumor-suppressor p53. Nonirradiated control tissue was also stained with Ki-67 and p53 (CIS, normal, contralateral). Areas of radiation atypia/atrophy and nearly all CIS in irradiated breast tissue had abundant myoepithelial cells as evidenced by SMM, calponin, and p63 stains, with focal staining attenuation or gaps with SMM and calponin and frequently absent CK5/6 staining. As predicted, myoepithelial cell staining was absent in invasive carcinoma. p63 staining revealed postradiation myoepithelial nuclear morphologic changes. p53 staining was increased, although weak, in irradiated non-neoplastic breast (12% irradiated; 4% nonirradiated); however, irradiated CIS had less p53 staining when compared with control CIS (3% irradiated; 38% nonirradiated). As expected, Ki-67 was increased in carcinoma as compared with non-neoplastic irradiated tissue. Thus, myoepithelial immunostaining is a useful diagnostic adjunct in irradiated breast, with caveats similar to nonirradiated breast. Ki-67 may be helpful in some postradiation specimens; however, p53 staining is not reliable in this setting.

High-energy particle-induced tumorigenesis throughout the gastrointestinal tract.

Epidemiological data reveals the gastrointestinal (GI) tract as one of the main sites for low-LET radiation-induced cancers. Importantly, the use of particle therapy is increasing, but cancer risk by high-LET particles is still poorly understood. This gap in our knowledge also remains a major limiting factor in planning long-term space missions. Therefore, assessing risks and identifying predisposing factors for carcinogenesis induced by particle radiation is crucial for both astronauts and cancer survivors. We have previously shown that exposure to relatively high doses of high-energy (56)Fe ions induced higher intestinal tumor frequency and grade in the small intestine of Apc(Min/+) mice than γ rays. However, due to the high number of spontaneous lesions (∼30) that develop in Apc(Min/+) animals, this Apc mutant model is not suitable to investigate effects of cumulative doses <1 Gy, which are relevant for risk assessment in astronauts and particle radiotherapy patients. However, Apc(1638N/+) mice develop a relatively small number of spontaneous lesions (∼3 per animal) in both small intestine and colon, and thus we propose a better model for studies on radiation-induced carcinogenesis. Here, we investigated model particle radiation increases tumor frequency and grade in the entire gastrointestinal tract (stomach and more distal intestine) after high- and low-radiation doses whether in the Apc(1638N/+). We have previously reported that an increase in small intestinal tumor multiplicity after exposure to γ rays was dependent on gender in Apc(1638N/+) mice, and here we investigated responses to particle radiation in the same model. Phenotypical and histopathological observations were accompanied by late changes in number and position of mitotic cells in intestinal crypts from animals exposed to different radiation types.

Routes to S-nitroso-hemoglobin formation with heme redox and preferential reactivity in the beta subunits.

Previous studies of the interactions of NO with human hemoglobin have implied the predominance of reaction channels that alternatively eliminate NO by converting it to nitrate, or tightly complex it on the alpha subunit ferrous hemes. Both channels could effectively quench NO bioactivity. More recent work has raised the idea that NO groups can efficiently transfer from the hemes to cysteine thiols within the beta subunit (cysbeta-93) to form bioactive nitrosothiols. The regulation of NO function, through its chemical position in the hemoglobin, is supported by response to oxygen and to redox agents that modulate the molecular and electronic structure of the protein. In this article, we focus on reactions in which Fe(III) hemes could provide the oxidative requirements of this NO-group transfer chemistry. We report a detailed investigation of the reductive nitrosylation of human met-Hb, in which we demonstrate the production of S-nitroso (SNO)-Hb through a heme-Fe(III)NO intermediate. The production of SNO-Hb is strongly favored (over nitrite) when NO is gradually introduced in limited total quantities; in this situation, moreover, heme nitrosylation occurs primarily within the beta subunits of the hemoglobin tetramer. SNO-Hb can similarly be produced when Fe(II)NO hemes are subjected to mild oxidation. The reaction of deoxygenated hemoglobin with limited quantities of nitrite leads to the production of beta subunit Fe(II)NO hemes, with SNO-Hb produced on subsequent oxygenation. The common theme of these reactions is the effective coupling of heme-iron and NO redox chemistries. Collectively, they establish a connectivity between hemes and thiols in Hb, through which NO is readily dislodged from storage on the heme to form bioactive SNO-Hb.