Gynecomastia Surgery Patient Education: An Information Quality Assessment of YouTube Videos.

BACKGROUND: YouTube is a platform for many topics, including plastic surgery. Previous studies have shown poor educational value in YouTube videos of plastic surgery procedures. The purpose of this study was to evaluate the quality and accuracy of YouTube videos concerning gynecomastia surgery (GS). METHODS: The phrases "gynecomastia surgery" (GS) and "man boobs surgery" (MB) were queried on YouTube. The first 50 videos for each search term were examined. The videos were rated using our novel Gynecomastia Surgery Specific Score to measure gynecomastia-specific information, the Patient Education Materials Assessment Tool (PEMAT) to measure understandability and actionability, and the Global Quality Scale to measure general quality. RESULTS: The most common upload source was a board-certified plastic surgeon (35%), and content category was surgery techniques and consultations (51%). Average scores for the Global Quality Scale (x̄ = 2.25), Gynecomastia Surgery Specific Score (x̄ = 3.50), and PEMAT Actionability (x̄ = 44.8%) were low, whereas PEMAT Understandability (x̄ = 77.4%) was moderate to high. There was no difference in all scoring modalities between the GS and MB groups. Internationally uploaded MB videos tended to originate from Asian countries, whereas GS videos tended to originate from non-US Western countries. Patient uploaders had higher PEMAT Actionability scores than plastic surgeon uploaders. CONCLUSIONS: The quality and amount of gynecomastia-specific information in GS videos on YouTube are low and contain few practical, take-home points for patients. However, understandability is adequate. Plastic surgeons and professional societies should strive to create high-quality medical media on platforms such as YouTube.

The story of the development of generic lenalidomide: How one company thwarted the Hatch-Waxman Act to generate billions of dollars in revenue.

Lenalidomide (Revlimid®) was originally approved by the Food and Drug Administration (FDA) in 2005, however, a generic version was not available until 2022. In that time, the price of lenalidomide has increased more than 20 times, and in 2021 alone, it accounted for >$5.8 billion dollars in Medicare Part D spending. This was a direct consequence of legal tactics employed by the manufacturer to thwart development of generic formulations of lenalidomide. In this report, we review the clinical development of lenalidomide, provide background on generic drug manufacturing in the United States (US), describe the steps that the manufacturer took to prevent entry of generic lenalidomide into the US market, and advocate for legislative reform of the FDA approval process and patent law protections in the US.

Low rates of primary medication nonadherence in patients prescribed oral oncology agents across health system specialty pharmacies.

BACKGROUND: New oral oncology medications bring novel challenges when patients are initiating treatment. Rates of primary medication nonadherence (PMN), the rate at which a medication is prescribed but not obtained, of up to 30% have been reported for oral oncology medications. More research is needed to identify causes and develop strategies for health system specialty pharmacies (HSSPs) to improve cancer treatment initiation rates. OBJECTIVE: To evaluate the rate and reasons for PMN to specialty oral oncology medications in an HSSP setting. METHODS: We performed a multisite retrospective cohort study across 7 HSSP sites. Patients were included if they had an orally self-administered oncology medication referral generated by the health system of the affiliated specialty pharmacy between May 1, 2020, and July 31, 2020. Data collected at each site using pharmacy software and the electronic health record were deidentified and aggregated for analysis. After identifying unfilled referrals within a 60-day fill window, a retrospective chart review was performed to identify final referral outcomes and reasons for unfilled referrals. Referral outcomes were categorized as unknown fill outcomes (because of being referred to another fulfillment method or if received for benefits investigation only), filled by the HSSP, or not filled. The primary outcome was PMN for each PMN-eligible referral and secondary outcomes included reason for PMN and time to fill. The final PMN rate was calculated by dividing the number of unfilled referrals by total referrals with a known fill outcome. RESULTS: Of 3,891 referrals, 947 were PMN eligible, representing patients with a median age of 65 years (interquartile range = 55-73), near equal distribution between male and female (53% vs 47%), and most commonly with Medicare pharmacy coverage (48%). The most referred medication was capecitabine (14%), and the most common diagnosis was prostate cancer (14%). Among PMN-eligible referrals, 346 (37%) had an unknown fill outcome. Of the 601 referrals with known fill outcome, 69 referrals were true instances of PMN, yielding the final PMN rate of 11%. Most referrals were filled by the HSSP (56%). Patient decision was the most common reason for not filling (25%; 17/69 PMN cases). The median time to fill after initial referral was 5 days (interquartile range = 2-10). CONCLUSIONS: HSSPs have a high percentage of patient initiation of new oral oncology medication treatments in a timely manner. More research is needed to understand patient reasons for deciding not to start therapy and to improve patient-centered cancer treatment planning decisions. DISCLOSURES: Dr Crumb was a planning committee member with Horizon CME for the Nashville APPOS 2022 Conference. Dr Patel received funding and support for attending meetings and/or travel from the University of Illinois Chicago College of Pharmacy.

Assessment of the role of the Edinburgh dysphagia score in referral triage in a national service evaluation of the urgent suspected upper gastrointestinal cancer pathway.

BACKGROUND: The British Society of Gastroenterology has recommended the Edinburgh Dysphagia Score (EDS) to risk-stratify dysphagia referrals during the endoscopy COVID recovery phase. AIMS: External validation of the diagnostic accuracy of EDS and exploration of potential changes to improve its diagnostic performance. METHODS: A prospective multicentre study of consecutive patients referred with dysphagia on an urgent suspected upper gastrointestinal (UGI) cancer pathway between May 2020 and February 2021. The sensitivity and negative predictive value (NPV) of EDS were calculated. Variables associated with UGI cancer were identified by forward stepwise logistic regression and a modified Cancer Dysphagia Score (CDS) developed. RESULTS: 1301 patients were included from 19 endoscopy providers; 43% male; median age 62 (IQR 51-73) years. 91 (7%) UGI cancers were diagnosed, including 80 oesophageal, 10 gastric and one duodenal cancer. An EDS ≥3.5 had a sensitivity of 96.7 (95% CI 90.7-99.3)% and an NPV of 99.3 (97.8-99.8)%. Age, male sex, progressive dysphagia and unintentional weight loss >3 kg were positively associated and acid reflux and localisation to the neck were negatively associated with UGI cancer. Dysphagia duration <6 months utilised in EDS was replaced with progressive dysphagia in CDS. CDS ≥5.5 had a sensitivity of 97.8 (92.3-99.7)% and NPV of 99.5 (98.1-99.9)%. Area under receiver operating curve was 0.83 for CDS, compared to 0.81 for EDS. CONCLUSIONS: In a national cohort, the EDS has high sensitivity and NPV as a triage tool for UGI cancer. The CDS offers even higher diagnostic accuracy. The EDS or CDS should be incorporated into the urgent suspected UGI cancer pathway.

Addressing Surgical Care Disparities: Residents' Involvement in Global Mission Trips.

ABSTRACT: Humanitarian mission trips have been organized by several residency programs and organizations to cater to surgical care in underdeveloped countries. While there is cross-talk on the existence of such opportunities, there is a paucity of guidance to residents on participation in such trips, their benefits, and the myriad of intangibles to consider while planning to pursue such opportunities. Through this article, the authors highlight the background and utility of humanitarian surgical missions and summarize the clinical and surgical experiences that these trips offer for residents choosing to embark on these altruistic journeys.

Gender Disparity in Abstract Presentation at Plastic Surgery Meetings.

BACKGROUND: Medical and surgical fields continue to be marred by gender disparities. The "leaky pipeline" effect, representing a gradual decline in female representation along the academic ladder, has been well documented in plastic surgery. However, gender differences in abstract presentation at national plastic surgery meetings and subsequent publications remains elusive. METHODS: We reviewed abstracts presented at the 2014 and 2015 annual meetings of the American Association of Plastic Surgeons (AAPS); American Society of Plastic Surgeons (ASPS), and the Plastic Surgery Research Council (PSRC). Several abstract characteristics including the names of the first and last authors were extracted. Genderize.io and Google search were used to identify the authors' gender. RESULTS: We identified 1174 abstracts presented at the three identified meetings. Females comprised 29% of the presenters and 16% of abstract senior authors (ASAs). No gender differences were identified between the meetings, type of presentation (oral versus poster), and year of presentation. The only difference was in the subspecialty of the abstracts. Successful conversion to full-text articles was similar for male and female presenters (68% versus 62%, P = 0.065) but higher for male ASAs (68% versus 59%, P = 0.01). When an author change occurred, female presenters and ASAs were more likely to be replaced by males (P < 0.001). CONCLUSION: Gender differences continue to be evident in academic plastic surgery with women constituting a minority of both presenters and senior authors on abstracts presented at national plastic surgery meetings. Future work should assess whether flexible and supportive work policies can foster greater female representation in academic plastic surgery.

Biochar increases soil organic carbon, avocado yields and economic return over 4 years of cultivation.

The use of biochar in avocado orchard soils has not yet been investigated in rigorous scientific experiments. We determine the effect of wood biochar on avocado growth, fruit production and economic benefit. Biochar was applied at 0%, 5%, 10% and 20% volume by volume basis. Biochar significantly improved the growth of avocado seedlings and increased fruit yield in the first three years after planting. There was an overall increase in soil carbon, fruit yield, tree diameter and height in all biochar treatments relative to the control over the seasons. Trees planted with biochar had 18-26% greater growth rates (in terms of height and stem diameter) than the control. Tree diameter was significantly greater with biochar (145.4 ± 3.3 mm) relative to the control treatment (125.0 ± 2.7 mm). Tree height was also significantly greater with biochar (3.7 ± 0.1 m) relative to the control treatment (3.4 ± 0.1 m). The fruit count from the biochar row was significantly greater (97%) in 2018. Heavy bearing trees typically have a lower yield in the subsequent year but despite this, the 2019 fruit counts were higher in aggregate for the biochar amended trees (20%) relative to the control. A cost-benefit analysis indicated that if yield surplus of fruit trees continued for three years, and assuming avocado prices remain at similar levels, then the discounted net benefit over a hectare would amount to US$8581, or US$105 per metric tonne of biochar applied.

Wheat straw vinegar: A more cost-effective solution than chemical fungicides for sustainable wheat plant protection.

Fusarium head blight (FHB), caused by the fungal pathogen Fusarium graminearum, is a destructive and widespread wheat disease. Chemical fungicides are becoming less effective at reducing the disease severity of FHB, and there is a need to find a more effective, low-cost natural product. A by-product of the pyrolysis of wheat straw is a condensate known as wheat straw vinegar, which was hypothesized to be an effective F. graminearum inhibitor in wheat. The organic and mineral compositions of wheat straw vinegar were analyzed. The results of GC-MS indicated that the major organic compounds in wheat straw vinegar are phenolics and acetic acid. The main inorganic elements in the liquid were K, Ca, S and Mg. A bio-test of wheat straw vinegar showed strong antifungal activity on F. graminearum growth and production of deoxynivalenol (DON) with an EC50 (concentration for 50% of maximal effect) value of 3.1 µl ml-1. Field tests showed that the application of wheat straw vinegar diluted 200-fold significantly decreased the wheat FHB infection rate and DON content by 66% and 69%, respectively. The control efficacy of wheat straw vinegar at a dilution of 200-fold was similar to that of typical chemical fungicide applications. The use of wheat straw vinegar may increase farmers' income by reducing the net fungicide costs. Therefore, wheat straw vinegar has high potential as a natural fungicide for the control of FHB and can reduce the dependence on synthetic fungicides.

Rapid recovery following hip and knee arthroplasty using local infiltration analgesia: length of stay, rehabilitation protocol and cost savings.

BACKGROUND: We implemented local infiltration analgesia (LIA) as a technique of providing post-operative pain management and early mobilization after arthroplasty surgery and have progressively found patients able to go home earlier. This study compares the national data on hip and knee arthroplasty provided by the Royal Australasian College of Surgeons and Medibank Private with our outcomes using LIA and rapid recovery. METHODS: Prospective study of one surgeon including 200 knees, and 165 hips in the two years till June 2016. Variables included in comparison to the two groups were: length of stay, percentage of patients transferred to rehabilitation or intensive care unit (ICU), readmitted within 30 days and average separation cost. RESULTS: Hip replacement median length of stay in our series was two nights versus five nights, inpatient rehabilitation 7% versus 36%, ICU admission zero versus 4%, and readmissions 3.9% versus 6.0%, the average hospital separation cost in our series was $17 813 versus $26 734. Knee replacement median length of stay in our study was one night versus five nights, ICU 0.5% versus 3%, rehabilitation 4.5% versus 43%, and readmission 6% versus 7%, the average hospital separation cost in our group was $16 437 versus $27 505. CONCLUSION: The comprehensive approach of LIA and rapid recovery enables patients to have shorter hospitalization, lower rehabilitation incidence and a resultant reduction in health expenditure.

Kilogram-scale prexasertib monolactate monohydrate synthesis under continuous-flow CGMP conditions.

Advances in drug potency and tailored therapeutics are promoting pharmaceutical manufacturing to transition from a traditional batch paradigm to more flexible continuous processing. Here we report the development of a multistep continuous-flow CGMP (current good manufacturing practices) process that produced 24 kilograms of prexasertib monolactate monohydrate suitable for use in human clinical trials. Eight continuous unit operations were conducted to produce the target at roughly 3 kilograms per day using small continuous reactors, extractors, evaporators, crystallizers, and filters in laboratory fume hoods. Success was enabled by advances in chemistry, engineering, analytical science, process modeling, and equipment design. Substantial technical and business drivers were identified, which merited the continuous process. The continuous process afforded improved performance and safety relative to batch processes and also improved containment of a highly potent compound.

Race-specific molecular alterations correlate with differential outcomes for black and white endometrioid endometrial cancer patients.

BACKGROUND: The objective of this study was to identify molecular alterations associated with disease outcomes for white and black patients with endometrioid endometrial cancer (EEC). METHODS: EEC samples from black (n = 17) and white patients (n = 13) were analyzed by proteomics (liquid chromatography-tandem mass spectrometry) and transcriptomics (RNA-seq). Coordinate alterations were validated with RNA-seq data from black (n = 49) and white patients (n = 216). Concordantly altered candidates were further tested for associations with race-specific progression-free survival (PFS) in black (n = 64) or white patients (n = 267) via univariate and multivariate Cox regression modeling and log-rank testing. RESULTS: Discovery analyses revealed significantly altered candidate proteins and transcripts between black and white patients, suggesting modulation of tumor cell viability in black patients and cell death signaling in black and white patients. Eighty-nine candidates were validated as altered between these patient cohorts, and a subset significantly correlated with differential PFS. White-specific PFS candidates included serpin family A member 4 (SERPINA4; hazard ratio [HR], 0.89; Wald P value = .02), integrin subunit α3 (ITGA3; HR, 0.76; P = .03), and Bet1 Golgi vesicular membrane trafficking protein like (BET1L; HR, 0.48; P = .04). Black-specific PFS candidates included family with sequence similarity 228 member B (FAM228B; HR, 0.13; P = .001) and HEAT repeat containing 6 (HEATR6; HR, 4.94; P = .047). Several candidates were also associated with overall survival (SERPINA4 and ITGA3) as well as PFS independent of disease stage, grade and myometrial invasion (SERPINA4, BET1L and FAM228B). CONCLUSIONS: This study has identified and validated molecular alterations in tumors from black and white EEC patients, including candidates significantly associated with altered disease outcomes within these patient cohorts. Cancer 2017;123:4004-12. © 2017 American Cancer Society.

Eliminating blurry bands in gels with a simple cost-effective repair to the gel cassette.

Gel electrophoresis and subsequent imaging using phosphorimagers is one of the most important and widely used techniques in RNA and DNA analysis. Radiolabeling nucleic acids with 32P and detecting bands using a phoshorimager are useful both in a qualitative sense for nucleic acid detection and in a quantitative sense for structural, kinetic, or binding-based assays. Because of this, good resolution of gel bands based on molecular weight and size of RNA or DNA is essential for analysis. The appearance of blurry gel bands of 32P-labeled RNA and DNA thus represents a serious problem in the laboratory. A quick search on the Internet uncovers numerous reports begrudging the appearance of blurry bands, as well as attempts to fix them without success. Indeed, our laboratories were beset by the intermittent problem of blurry gels for over one year before we found a solution. Herein we describe a simple and cost-effective solution to a problem that we show originates from the phosphorimager cassettes rather than the integrity of the gel itself. We hope that the information provided here will lead to immediate help for other laboratories experiencing similar issues with labeled nucleic acid gel-based assays. The improvement in the clarity of the gels is nothing short of astonishing in many instances and will lead to higher resolution images for analysis and publications.

Public health value of universal HPV vaccination.

BACKGROUND: The story of Human Papillomavirus vaccination demands reflection not only for its public health impact on the prophylactic management of HPV disease, but also for its relevant economic and social outcomes. Greater than ever data confirm the efficacy and support the urge for effective vaccination plans for both genders before sexual debut. METHODS: A review of previous experience in gender-restricted vaccination programs has demonstrated a lower effectiveness. Limiting vaccination to women might increase the psychological burden on women by confirming a perceived inequality between genders; and even if all women were immunized, the HPV chain of transmission would still be maintained through men. RESULTS: The cost-effectiveness of including boys into HPV vaccination programs should be re-assessed in view of the progressive drop of the economic burden of HPV-related diseases in men and women due to universal vaccination. The cost of the remarkable increase in anal and oropharyngeal HPV driven cancers in both sexes has been grossly underestimated or ignored. CONCLUSIONS: Steps must be taken by relevant bodies to achieve the target of universal vaccination. The analysis of HPV vaccination's clinical effectiveness vs. economic efficacy are supportive of the economic sustainability of vaccination programs both in women and men. In Europe, these achievements demand urgent attention to the social equity for both genders in healthcare. There is sufficient ethical, scientific, strategic and economic evidence to urge the European Community to develop and implement a coordinated and comprehensive strategy aimed at both genders and geographically balanced, to eradicate cervical cancer and other diseases caused by HPV in Europe. Policymakers must take into consideration effective vaccination programs in the prevention of cancers.

Special training in maxillofacial surgery for medical students--economic burden or investment in the future?

We measured the motivation and interest of medical students in oral and maxillofacial surgery at a German university. After a detailed cost-benefit analysis of a course that used an ex-vivo animal model and active participation in the operating theatre, we measured changes in the students' interest in taking up a surgical specialty in the future. We found that practical experience could lower the expenses of the course by almost 70%. Twenty per cent of students chose oral and maxillofacial surgery as an elective in their final year. These students could be residents one day.

Objective qualitative and quantitative assessment of blood flow with near-infrared angiography in microvascular anastomoses in the rat model.

Intraoperative near-infrared indocyanine-green (ICG) angiography enables the visualization of microvascular perfusion and may help in the early detection of complications. The purpose of the present study was to examine whether the effect of microvascular stenoses can be quantitatively assessed by analysis of ICG-angiography in a microvascular model. Graded stenoses and total vessel occlusion of the carotid, aorta, and femoral arteries were created in 25 Wistar rats. Stenoses were graded to reduce arterial flow by 25%, 50%, 75%, and 100% of baseline flow as measured by transit-time flowmeter analyzing the emission signal of the ICG detected and investigated by the mathematical software tool (FLOW 800). ICG angiography was performed to assess vessel perfusion and flow curves were analyzed and correlated with the stenosis rate. A total of 576 investigations were performed. The area under the curve (P < 0.001), first and second maximum (P < 0.001), and the maximum slope to the first maximum (P < 0.001) were found to be of high prognostic value in evaluating the different flow patterns. Differences were displayed in comparisons by the maximum intensity of the ICG-concentrations. The maximum slope to the second maximum was found to be predictive in selected vessel types, and specific changes of the flow curve were found to indicate compromised vascular flow. The FLOW 800 tool applied for ICG angiography has shown to be a quick and reliable method for assessing blood flow in vessels in this study. The dynamic assessment of the ICG signal allows reliable identification of microanastomotic complications with the described parameters.

The Erf4 subunit of the yeast Ras palmitoyl acyltransferase is required for stability of the Acyl-Erf2 intermediate and palmitoyl transfer to a Ras2 substrate.

Protein S-palmitoylation is a posttranslational modification in which a palmitoyl group is added to a protein via a thioester linkage on cysteine. Palmitoylation is a reversible modification involved in protein membrane targeting, receptor trafficking and signaling, vesicular biogenesis and trafficking, protein aggregation, and protein degradation. An example of the dynamic nature of this modification is the palmitoylation-depalmitoylation cycle that regulates the subcellular trafficking of Ras family GTPases. The Ras protein acyltransferase (PAT) consists of a complex of Erf2-Erf4 and DHHC9-GCP16 in yeast and mammalian cells, respectively. Both subunits are required for PAT activity, but the function of the Erf4 and Gcp16 subunits has not been established. This study elucidates the function of Erf4 and shows that one role of Erf4 is to regulate Erf2 stability through an ubiquitin-mediated pathway. In addition, Erf4 is required for the stable formation of the palmitoyl-Erf2 intermediate, the first step of palmitoyl transfer to protein substrates. In the absence of Erf4, the rate of hydrolysis of the active site palmitoyl thioester intermediate is increased, resulting in reduced palmitoyl transfer to a Ras2 substrate. This is the first demonstration of regulation of a DHHC PAT enzyme by an associated protein.

Assessment of the perfusion and morbidity of the buccal mucosal donor site for grafting of urethral strictures.

UNLABELLED: Buccal mucosal grafting has become the gold standard for reconstruction of urethral strictures. The aim of this study was to investigate donor site morbidity with a unique emphasis on objective measurements of perfusion and oxygenation. METHODS: In a prospective study 15 male patients with recurrent urethral strictures, underwent urethroplasty using an intraoral mucosal graft. Donor site was closed primarily (group 1) or left to granulation (group 2). Clinical examinations of recipient and donor sites, urograms and the modified SF-8™ health questionnaire were carried out 1, 3 and 24 weeks postoperatively. Oxygenation and perfusion parameters of the donor site were measured by the O2C (oxygen-to-see) monitoring device - a combined technique of laser Doppler flowmetry and tissue spectroscopy. RESULTS: No recurrence of strictures at recipient site or infections at either sites occurred. 24 weeks after operation, haemoglobin oxygenation (72.1±5.9%) and deep flow (177.2 Arbitrary Units (AU)) of the donor site were slightly, but not significantly, lower compared to the contralateral unoperated buccal mucosa (haemoglobin oxygenation: 75.4±5.2%, deep flow: 187.3 AU). Significant differences between the two groups of different wound healing could not be revealed. CONCLUSIONS: Using free mucosal grafts for urethroplasty is a simple and safe method in the interdisciplinary treatment of urethral strictures. Donor site morbidity within the first 3 weeks after operation is noticeable, but tolerable measured by a validated Quality of Life-tool. Six months after the operation, perfusion and oxygenation of the former graft harvest site are equal to the contralateral unoperated mucosa.