Making a Statement: Positions of Professional Medical Organizations Towards Gender-Affirming Care.

OBJECTIVE: Despite politically charged media coverage and legislation surrounding gender affirming care (GAC), many organizations have released position statements to provide scientifically backed clinical practice standards, combat misinformation, and inform medicolegal policies. The purpose of this study is to objectively assess the availability and the content of the official position statements of relevant medical professional organizations regarding GAC. SUMMARY BACKGROUND DATA: A list of U.S. medical professional organizations with likely involvement in GAC based on medical or surgical specialties was compiled. METHODS: For included organizations, we evaluated the availability, content, and publication year of positions on GAC through October 2023. When available, formal positions were categorized as supportive or unsupportive. RESULTS: A total of 314 professional medical organizations were screened for our study based on specialty, relevance to GAC, and issuance of patient guidelines or position statements. Inclusion criteria were met by 55 organizations. Most organizations (35, 63.6%) had formal position statements on GAC. Support for GAC was described in 97.1% (n=34). Further, 94.2% (n=33) of available statements explicitly addressed GAC in individuals less than 18 years old and were largely supportive (96.9%, n=32). CONCLUSIONS: This cross-sectional analysis demonstrates that a majority of multidisciplinary professional medical organizations with relevance to GAC have issued formal position statements on the topic. Available positions were overwhelmingly supportive of individualized access to gender-affirming therapies in adult and adolescent populations. However, silence from some organizations continues to represent a modifiable disparity in the provision of GAC.

Conscientious Objection to Gender-Affirming Surgery: A Cross-Sectional Analysis of Plastic Surgery and Urology Residency Programs.

OBJECTIVE: Medical conscientious objection is a federally protected right of physicians to refuse participation in medically indicated services or research activities that are incompatible with their ethical, moral, or religious beliefs. Individual provider objections to gender-affirming surgery have been documented, however the prevalence of such objections is unknown. Our study aimed to characterize physician objections to gender-affirming surgery in plastic surgery and urology residencies and to assess related institutional policies. DESIGN, SETTING, PARTICIPANTS: A cross-sectional electronic survey was administered to program leadership of 239 accredited US plastic surgery and urology residencies from February to October 2023. Trainee exposure to gender-affirming surgery, programmatic experience with objections, and presence and content of institutional objection policies were collected. Bivariate analyses were performed to determine associations with objectors. RESULTS: One-hundred and twenty-four plastic surgery (n = 59) and urology (n = 65) residencies completed the survey, representing a 52% response rate. Most programs included didactic training (n = 107, 86%) and direct clinical exposure (n = 98, 79%) to gender-affirming surgery. Few (n = 24, 19%) endorsed existent objection policies. Sixteen programs (13%) experienced objections to gender-affirming surgery by trainees (n = 15), faculty (n = 6), and staff (n = 1). Neither geographic region, exposure to gender-affirming surgery, nor presence of objection policies significantly contributed to programmatic objections. Programs with formal objection policies reported increased confidence in addressing future objection events (p = 0.017). CONCLUSIONS: Objection to gender-affirming surgery is a rare, but plausible occurrence amongst plastic surgery and urology trainees. Residency programs should consider anticipatory policies to protect patients and, when feasible, provide reasonable accommodations for objecting trainees.

Osteoplastic Thumb Reconstruction in the Immediate Setting: A Case Series.

Background: Traumatic thumb amputation can have devastating effects on residual hand function. When replantation is not possible, thumb reconstruction is often performed in a delayed manner and may require multiple stages. Furthermore, reconstruction techniques often require microsurgical skills and equipment, which are not readily available at all institutions. This case series illustrates our technique for immediate osteoplastic thumb reconstruction following traumatic amputation. Methods: This is a case series involving all patients who sustained unreplantable thumb amputations and underwent immediate osteoplastic thumb reconstruction with bone autograft and pedicled groin flap by the senior author from September 2016 through August 2018. Results: Five patients underwent immediate osteoplastic thumb reconstruction during the study period. Total operative time for the initial osteoplastic reconstruction averaged 158 minutes (range 96-290 minutes). In addition to flap division surgery, patients underwent an average of 1.2 revision procedures (range 0-2), primarily for debulking and hardware removal. Patients achieved an average gain in length of 3.3 cm compared with the maximum anticipated length with revision amputation at the time of injury, and had stable clinical outcomes for a minimum of 12 months. Conclusions: Osteoplastic thumb reconstruction is a useful technique for thumb reconstruction for select patients following traumatic thumb amputation. Advantages of this approach include shorter overall operative times and hospital length of stay, minimal donor site morbidity, and a straightforward, reproducible technique.

Mechanisms of Action of Instillation and Dwell Negative Pressure Wound Therapy with Case Reports of Clinical Applications.

Negative pressure wound therapy (NPWT) has revolutionized the care of complex wounds since 1997. The addition of instillation (NPWTi-d) adds several potential benefits and challenges to clinicians dealing with complex wounds in a hospital setting. We surveyed the literature regarding the mechanism of action of these devices and reviewed our clinical experience to date. Potential mechanisms of action include the removal of microorganisms from the wound surface, dilution of cytotoxic molecules, upregulation of angiogenesis pathways, and maintenance of a moist wound environment. As we have extended our use of these devices to more complex wounds, we have taken advantage of and observed potential mechanisms of action, including facilitated removal of microorganisms, dilution of inflammatory and cytotoxic macromolecules, additional wound hydration, and enhanced angiogenesis through an intermittent application of NPWT. We have also observed complications, including bleeding, loss of a seal along the wound, and pain. NPWTi-d provides additional options for clinicians caring for complex wounds with favorable responses in wounds with significant contamination and those with poor inherent vascularity. Further studies to clarify the mechanisms of action, better define the wound types that would benefit, and techniques to manage complications using this device should further advance this field.