Are We Teaching Evidence-Based and Inclusive Practices in Gender-Affirming Care? Perspectives From Plastic Surgery In-Service Examinations

Background Resident physicians take annual in-service examinations (ISEs) as part of continuing medical education, which set educational priorities, allow for formative feedback, and guide preparation for final board examinations. Gender-affirming care is provided in many specialties but has been an underrepresented area in medical education. Plastic surgeons provide a large portion of gender-affirming surgical care. Educational gaps in standardized ISEs may contribute to ongoing health care disparities for transgender and gender diverse people. Objective To evaluate the quality of content pertaining to gender-affirming surgery (GAS) on plastic surgery ISEs. Methods Plastic surgery ISEs from years 2012 to 2020 were accessed online through the American Council of Academic Plastic Surgeons website in June 2022. All 5 gender diverse authors analyzed examinations for the presence of GAS questions; identified questions were analyzed for quantity, organization based on content category, affirming language, and accuracy against current guidelines. Results Of 1959 ISE questions available for review, 11 GAS questions were identified for a total frequency of 0.56%. Most GAS questions (6 of 11, 55%) were miscategorized. Inappropriate language, including misgendering of patients, occurred in 7 of 11 (64%) questions. No questions discussed GAS beyond chest or genital surgery, or common variations of these procedures. Transgender identities were represented as only binary, with no mention of nonbinary or gender-fluid individuals. Conclusions Our study illustrates that there are significant gaps in educational content pertaining to gender-affirming care on plastic surgery ISEs.

Incorporating hearing screening to an otolaryngology surgical mission in the rural Dominican Republic

INTRODUCTION

Hearing loss disproportionately affects low- and middle-income countries. Children with undiagnosed hearing loss may have difficulty with learning, language development, and behavior. The aim of this study was to understand the extent of hearing loss and common otologic disorders among school-age children in the rural western region of the Dominican Republic and to chronical the early stages of a limited-resource, locally-sustained hearing screening program in tandem with a bi-annual surgical mission.

METHODS

Hearing screenings were performed for 528 school-age children (1056 ears, age 5-17 years old) over 5 days in a village hospital in Peralta, DR. Testing initially included otoscopy and screening audiometry. Children who referred or could not be conditioned underwent distortion product otoacoustic emissions (OAEs), and tympanometry. Children who referred following both screening audiometry and OAEs were considered to have hearing loss. Those with normal tympanograms were considered potential hearing aid candidates.

RESULTS

Abnormal ear examination/otoscopic results were present in 43 children (8.1%) and included: microtia/atresia, impacted cerumen, ear canal foreign body, serous otitis media, otitis externa, and tympanosclerosis. 55 of 528 school-age children referred following screening audiometry and 7 were unable to condition. Of these 62 children, 56 tolerated OAEs and 20 referred following OAEs (3.8%). Fourteen children had type B or C tympanogram and 6 school-age children who were determined to have chronic otitis media with effusion (COME) underwent myringotomy and pressure equalization tube placement. Ten of 528 children (1.9%) had normal tympanometry and otoscopy, and referred following screening audiometry and OAEs suggesting the patients may be potential hearing aid candidates.

CONCLUSIONS

The prevalence of hearing loss in this cohort of children in the rural, western Dominican Republic was high at roughly 4% with roughly 2% of children being potential hearing aid candidates. Nearly 10% of children screened had an abnormal otologic examination; sometimes easily remedied by otolaryngologic intervention. With the support of local leadership, it is feasible to incorporate hearing services into otolaryngology outreach and build locally sustainable programs.

Laryngeal Chondrosarcoma Characteristics and Survival Analysis in the National Cancer Database

OBJECTIVE

To highlight various patient, tumor, diagnostic, and treatment characteristics of laryngeal chondrosarcoma (LC) as well as elucidate factors that may independently affect overall survival (OS) for LCs.

STUDY DESIGN

Retrospective cohort study.

SETTING

National Cancer Database (NCDB).

METHODS

All LC cases from 2004 to 2016 were extracted from the NCDB. Several demographic, diagnostic, and treatment variables were compared between LC subgroups using χ² and analysis of variance tests. Univariate and multivariate survival analyses were performed for LCs using univariate Kaplan-Meier analysis and Cox proportional hazards regression models.

RESULTS

There were 348 LCs included in the main cohort. LCs were predominantly non-Hispanic white males with similar rates of private and government insurance (49.4% vs 45.4%). Most LCs (81.6%) underwent primary surgery, particularly partial and total laryngectomy. The 1-, 5-, and 10-year survivals for LC were 95.7%, 88.2%, and 66.3%, respectively. On multivariate analysis, lack of insurance (P = .019; hazard ratio [HR], 8.21; 95% CI, 1.40-48.03), high grade (P = .001; HR, 13.51; 95% CI, 3.08-59.26), and myxoid/dedifferentiated histological subtypes (P = .0111; HR, 10.74; 95% CI, 1.71-67.33) correlated with worse OS. No difference in OS was found between partial and total laryngectomy.

CONCLUSION

This is the first multivariate survival analysis and largest single cohort study of LCs in the literature. Overall, LCs enjoy an excellent prognosis, with insurance status, grade, and histology as the main predictors of survival.

Rural-Urban Disparities in Otolaryngology: The State of Illinois

OBJECTIVES/HYPOTHESIS

To highlight rural-urban disparities in otolaryngology, and to quantify the disparities in access to otolaryngology specialist care across Illinois. Several studies across disciplines have shown increased prevalence and severity of disease in rural communities, relative to their urban counterparts. There is very little published quantifying a disparity in rural access to otolaryngologists.

STUDY DESIGN

Population study.

METHODS

Counties in Illinois were classified based on urbanization level on a scale from I (most urban) to VI (least urban) using the 2013 National Center for Health Statistics (NCHS) Urban-Rural Classification scheme. The six urbanization levels include four metropolitan (I-IV) and two nonmetropolitan levels (V and VI). The name and practice location of all registered otolaryngologists in Illinois were collected using the American Academy of Otolaryngology website (ENTnet.org). Population data were recorded from the most recent US Census (2010).

RESULTS

Two hundred seventy-eight academy-registered otolaryngologists were identified in Illinois. One hundred fifty-one of these providers were located in a single county categorized as a level I by the NCHS scheme. There are over 18,000 square miles and 600,000 persons living in NCHS level VI counties in Illinois with zero registered otolaryngologists. Overall, metropolitan counties (I-IV) averaged 1.32 otolaryngologists per 100,000 population, whereas nonmetropolitan counties (V and VI) averaged 0.46 otolaryngologists per 100,000 (P < .01).

CONCLUSIONS

There is a paucity of academy-certified otolaryngologists with primary practice locations in rural counties of Illinois. There is a significant rural population and massive land area with limited spatial access to otolaryngologic specialist care.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:E70-E75, 2021.

Cyclodextrin enhances spermicidal effects of magainin-2-amide

Magainins are antimicrobial peptides with known spermicidal activity. Their activity is inhibited by cholesterol present in eukaryotic cell membranes. Pretreatment of spermatozoa with methyl-beta-cyclodextrin, which extracts cholesterol from cell membranes and induces capacitation, sensitizes them to magainin-2-amide as shown by a decrease in human sperm motility determined by computer-assisted sperm analysis and a concomitant decrease in sperm viability, as measured by MitoTracker(R) Red CMXRos labeling. Magainin-2-amide affects mainly the fast progressive spermatozoa inducing them directly into an immotile state, without an increase in motile non-progressive and slow progressive spermatozoa. We conclude that methyl-beta-cyclodextrin highly potentiates the deleterious effect of magainin-2-amide on human spermatozoa. Most probably, this effect can be explained by cholesterol extraction from sperm cell membranes.

Proteasomes in human spermatozoa

In the present study we describe the localization of proteasomes in human spermatozoa by means of immunolabelling with different monoclonal and polyclonal antibodies detected by confocal microscopy. Western blotting confirmed the specificity of the antibodies and has shown that proteasomes are present in spermatozoa and in seminal fluid. In spermatozoa proteasomes are concentrated in the neck region where the centrioles are located. Some labelling was also detected at the periphery of the head, but no proteasomal antigens were detected in either the nucleus or associated with the flagellum. Proteasome inhibitors did not affect the motility of the spermatozoa, acrosome reaction nor zona binding. It is hypothesized that paternal proteasomes enter the oocyte during fertilization in tight association with the centrioles and may serve a special function during further development which can be associated with the function of a hypothetical proteolysis centre.

Synergistic antitumor effects of a selective proteasome inhibitor and TNF in mice

The ubiquitin-proteasome pathway is becoming an attractive target in cancer therapy. The inhibitors of proteasomes have recently been shown to induce apoptosis of tumor cells in vitro and to exert significant antitumor effects in murine tumor models in vivo. Proteasome inhibitors, also prevent NF-kappa B activation. Since this transcription factor is responsible for counteracting apoptosis induced by numerous agents, and proteasome inhibitors have already proved efficacious in increasing the proapoptotic activity of TNF in vitro, we decided to evaluate the antitumor effects of the combined PSI and TNF treatment against a murine C-26 carcinoma. Both agents separately exerted moderate antitumor efficacy. However, their combination proved to exert dramatic antitumor activity with retardation of tumor growth and prolongation of mice survival time. Moreover, 50% of the mice were completely cured by this drug combination. Unexpectedly, there was no potentiation of the cytostatic/cytotoxic effects of these drugs in in vitro assays which argues against the direct influence on C-26 cells. Similarly, the influence of these drugs on tumor induced angiogenesis does not seem to explain the observed antitumor effects. Further studies are necessary to explain the striking antitumor effects of the PSI and TNF combination.

Lactacystin, a specific inhibitor of the proteasome, inhibits human platelet lysosomal cathepsin A-like enzyme

Lactacystin, the most specific inhibitor of the proteasome, strongly inhibited at pH 5.5 the activity of human platelet lysosomal cathepsin A-like enzyme. At a concentration as low as 1-5 microM it almost completely decreased the hydrolysis rate of cathepsin A specific substrates: Cbz-Phe-Ala and FA-Phe-Phe. This inhibition was probably due to the lactacystin intermediate beta-lactone formed during 10 min hydrolysis at pH 8.0 since nonhydrolyzed inhibitor did not affect cathepsin A activity. Basing on similarities in the inhibitor sensitivity, pH optimum, and substrate preferences it is suggested that the cathepsin A-like activity may be involved in chymotrypsin-like activity of the proteasome.

Coding, documentation and dollars

Physicians would like to get reimbursed for the services they perform. Unfortunately, many of them are not very good at documenting what they do. The result is that physicians are being reimbursed far less than what they should be or are being asked to refund reimbursement for services they cannot substantiate. The financial impact to the physician's practice can be enormous. For many years, physicians have viewed HIM professionals as adversaries. There now exists the opportunity for HIM professionals to become allies with physicians by helping them obtain and maintain the reimbursement they are entitled to. Physicians have the need, and HIM professionals have the knowledge and skill. It is up to our profession to show them what we can do.