Reduced Access to Acute Hand Care and Potential Role of Telemedicine in Tennessee During the COVID Pandemic.

INTRODUCTION: Previous studies have identified that there is limited, although expanding, access to acute hand care in Tennessee. Because of the rapid changes that occurred in health delivery and access during the coronavirus disease pandemic, we reassessed access to acute hand care, with particular interest in the utilization of telemedicine to assess if this increased access. METHOD: We surveyed Tennessee hospitals listed by the Tennessee Hospital Association on their management of hand trauma and availability of telemedicine programs. Census data including population demographics such as race, age, income, and county size were merged with the survey data. Descriptive analysis was performed comparing the 2021 cohort with the historic 2018 cohort and between counties that had hand care versus counties that had no hand care. RESULT: Survey response rate was 71.4% (n = 80 of 112). Telemedicine was used in 80% of the hospitals for other specialties but was not used for hand care. Overall, counties that offered hand trauma care reduced from 60% to 26% from 2018 to 2021 ( P < 0.001). This change was associated with a significant reduction of acute hand care among counties that were classified micropolitan (from 56.3% to 6.7%, P < 0.01). Percentage of hand specialists on staff and 24/7 specialists availability remained low and were similar to the availability in 2018. CONCLUSIONS: There was a decrease of acute hand care access in Tennessee during the coronavirus disease pandemic despite widespread utilization of telemedicine for other specialty consults. Expansion of telemedicine in acute hand care, targeted to micropolitan areas, may help to reduce variability in access to care.

The Plastic Surgery Common Application: Improving Efficiency and Reducing Inequity in the Application Process.

The residency application process is expensive, costing an average of $2149 in application fees per applicant during the 2020-2021 cycle. Additionally, the number of applications per applicant continues to rise annually across all specialties. This considerable cost creates a financial barrier for students, particularly those from first-generation and underrepresented backgrounds. Moreover, the Electronic Residency Application Service (ERAS) application generates a lengthy, diluted output that hinders a holistic review. We developed the Plastic Surgery Common Application (PSCA), a focused, specialty-specific application external to ERAS with the goal of lessening the financial barrier for students and improving reviewer satisfaction. The PSCA was revised over a 5-month period after prepiloting with stakeholders. All integrated plastic surgery programs were invited to participate. Of the 86 plastic surgery programs, 20 agreed to participate in the pilot, accepting both ERAS and PSCA for direct comparison. A total of 181 completed applications were received through the PSCA. In a postparticipation survey, most applicants and reviewers felt that the PSCA offered a reasonable alternative to ERAS, despite minor technical difficulties. The PSCA pilot demonstrates that there is a reasonable alternative to applying to residency through ERAS and offers a template for developing a system that is not cost-prohibitive to applicants. The PSCA also demonstrates the benefit of a specialty-specific, customizable application for reviewer efficiency and satisfaction.

Evaluation of Racial Microaggressions Experienced During Medical School Training and the Effect on Medical Student Education and Burnout: A Validation Study.

INTRODUCTION: Microaggressions in the learning environment have been documented at various levels of medical training. However, there is lack of data detailing the prevalence and effects of racial microaggressions in medical school. This limits interventions that might improve the learning environment for underrepresented minority medical students (URMMS). This study describes the creation and validation of a survey instrument characterizing the experience of microaggressions in medical school and their impact on medical student education and burnout. METHODS: An anonymous survey instrument was adapted for medical students from the validated Racial and Ethnic Microaggressions Scale (REMS) and distributed to the national listservs of the Student National Medical Association (SNMA), Latino Medical Student Association (LMSA), and the Asian Pacific American Medical Student Association. Responses were categorized into two cohorts: under-represented minority (URM) and non-URM based on self-reported race or ethnicity. RESULTS: A total of 217 responses were collected from medical students across the United States, with 148 (68.2%) students identifying as URM. URM respondents were significantly (p < 0.05) more likely to report experiencing race-related microaggressions during medical school (55% vs 31%), and to report that these microaggressions contributed to feelings of burnout (62% vs 29%) and compromised learning (64% vs 49%). URM students were significantly less likely to feel that adequate resources were available to address microaggressions (26% vs 39%, p < 0.05). CONCLUSIONS: Our results suggest that microaggressions experienced by URMMS can be evaluated using an adapted REMS. Additionally, the experience of microaggressions negatively impact the learning environment, and students feel the availability of sufficient resources to address microaggressions and their effects are lacking. Further research is needed to evaluate microaggressions and their impact on a larger scale. This should be followed by interventions to minimize the frequency and impact of these microaggressions.

Eosinophilic recruitment in thermally injured older animals is associated with worse outcomes and higher conversion to full thickness burn.

BACKGROUND: Partial burn injury in older patients is associated with higher rates of morbidity, mortality, and conversion to full thickness burn (Finnerty et al., 2009; Pham et al., 2009). Both human and mouse models demonstrate an altered systemic immune response in older subjects, however less is known about the localized response (Jeschke et al., 2016; Farinas et al., 2018; Mohs et al., 2017). We hypothesized that a mouse model could demonstrate differences in the localized inflammatory response of the old. METHODS: Six old (66 weeks) and young (8 weeks) mice received partial thickness thermal burns. Localized and systemic expression of nine chemokines (TNFalpha, MCP-1, MIP-2, S100A9, EGF, IL-10, RANTES, G-CSF, and EOTAXIN) were evaluated at day 3 after burn using Luminex analysis. Vimentin immunostaining was used to evaluate injury depth. RESULTS: Vimentin staining demonstrated increased burn depth in old mice (449±38µm) as compared to young (166±18µm) (p<0.05). Both groups exhibited increased localized expression of EOTAXIN after burn (p<0.05), however expression in old mice (83.6±6.1pg/ml) was lower than that of young (126.8±18.7pg/ml) (p<0.05). Systemically, however, old mice had increased baseline EOTAXIN expression (1332.40±110.78pg/ml) compared to young (666.12±45.8pg/ml) (p<0.005). CONCLUSIONS: EOTAXIN is one of the primary chemoattractants for selective eosinophilic recruitment and activation. While eosinophils are important for wound healing, a hyperactive eosinophilic response can result in tissue damage. We hypothesize that the increased baseline serum EOTAXIN in the old may prime their hyperactive response, and may contribute to their worse clinical outcomes. Long-term eosinophil activation requires further study, however our findings indicate a role for EOTAXIN and eosinophils in burn response.

An Evaluation of Emergency Hand Coverage in Tennessee After Implementation of the Affordable Care Act.

Although the upper extremity is the most commonly injured part of the body, many studies have indicated that there is a lack of emergency hand coverage in the United States. In 2010, our laboratory evaluated on-call hand coverage in Tennessee (TN) and found that only 7% of hospitals had a hand surgeon on call for emergency cases at all times. In 2014, the Affordable Care Act (ACA) was implemented with the goal of increasing overall access to care and decreasing health care costs. Hand surgeons were surveyed on their attitudes toward the ACA, and the majority of surgeons surveyed disagreed or strongly disagree that the ACA would improve access to emergent hand surgery. This study aimed to determine if there has been an increase in emergency hand coverage in TN since the implementation of the ACA. A survey was administered to all hospitals in TN with both an emergency department and operating room to determine the percentage of TN hospitals offering elective hand surgery and on-call emergency hand coverage. With 94% of TN hospitals responding to the emergency department survey, we determined that there has been a 138% significant increase in the percentage of hospitals reporting 24/7 emergency hand coverage by a hand specialist since our last study in 2010. There has also been a significant increase in elective hand coverage in TN, although much smaller at 13% since 2010. This study suggests that there has been an overall increase in access to hand care in TN since the implementation of the ACA, most profoundly seen in the increase in hand specialists available for emergent cases.