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ABSTRACTBackground The scholarship of teaching and learning (SoTL) is a field of academic research that focuses on improving learning through reflective and informed teaching. Currently, most SoTL-related work is faculty-driven; however, student involvement in SoTL has been shown to benefit both learners and educators. Our study aims to develop a framework for increasing medical students’ interest, confidence, and engagement in SoTL.Methods A student-led SoTL interest group was developed and a year-round program of SoTL was designed and delivered by student leaders of the group under the guidance of a faculty advisor. Individual post-session surveys were administered to evaluate participants’ perceptions of each session. Pre- and post-program surveys were administered to evaluate the program impact.Results The year-round SoTL program consistently attracted the participation of medical students and faculty. Survey responses indicated strong medical student interest in the program and positive impact of the program. Increased interest and confidence in medical education research were reported by the student participants. The program design provided opportunities for student participants to network and receive ongoing feedback about medical education research they were interested or involved in.Conclusion Our study provides insights for developing a framework that other institutions can reference and build upon to educate and engage students in SoTL.

Rationale: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes COVID-19 pneumonia. We hypothesize that SARS-CoV-2 causes alveolar injury and hypoxemia by damaging mitochondria in airway epithelial cells (AEC) and pulmonary artery smooth muscle cells (PASMC), triggering apoptosis and bioenergetic impairment, and impairing hypoxic pulmonary vasoconstriction (HPV), respectively. Objectives: We examined the effects of: A) human betacoronaviruses, SARS-CoV-2 and HCoV-OC43, and individual SARS-CoV-2 proteins on apoptosis, mitochondrial fission, and bioenergetics in AEC; and B) SARS-CoV-2 proteins and mouse hepatitis virus (MHV-1) infection on HPV. Methods: We used transcriptomic data to identify temporal changes in mitochondrial-relevant gene ontology (GO) pathways post-SARS-CoV-2 infection. We also transduced AECs with SARS-CoV-2 proteins (M, Nsp7 or Nsp9) and determined effects on mitochondrial permeability transition pore (mPTP) activity, relative membrane potential, apoptosis, mitochondrial fission, and oxygen consumption rates (OCR). In human PASMC, we assessed the effects of SARS-CoV-2 proteins on hypoxic increases in cytosolic calcium, an HPV proxy. In MHV-1 pneumonia, we assessed HPV via cardiac catheterization and apoptosis using the TUNEL assay. Results: SARS-CoV-2 regulated mitochondrial apoptosis, mitochondrial membrane permeabilization and electron transport chain (ETC) GO pathways within 2 hours of infection. SARS-CoV-2 downregulated ETC Complex I and ATP synthase genes, and upregulated apoptosis-inducing genes. SARS-CoV-2 and HCoV-OC43 upregulated and activated dynamin-related protein 1 (Drp1) and increased mitochondrial fission. SARS-CoV-2 and transduced SARS-CoV-2 proteins increased apoptosis inducing factor (AIF) expression and activated caspase 7, resulting in apoptosis. Coronaviruses also reduced OCR, decreased ETC Complex I activity and lowered ATP levels in AEC. M protein transduction also increased mPTP opening. In human PASMC, M and Nsp9 proteins inhibited HPV. In MHV-1 pneumonia, infected AEC displayed apoptosis and HPV was suppressed. BAY K8644, a calcium channel agonist, increased HPV and improved SpO2. Conclusions: Coronaviruses, including SARS-CoV-2, cause AEC apoptosis, mitochondrial fission, and bioenergetic impairment. SARS-CoV-2 also suppresses HPV by targeting mitochondria. This mitochondriopathy is replicated by transduction with SARS-CoV-2 proteins, indicating a mechanistic role for viral-host mitochondrial protein interactions. Mitochondriopathy is a conserved feature of coronaviral pneumonia that may exacerbate hypoxemia and constitutes a therapeutic target.

Patients with COVID-19 present with a wide variety of clinical manifestations. Thromboembolic events constitute a significant cause of morbidity and mortality in patients infected with SARS-CoV-2. Severe COVID-19 has been associated with hyperinflammation and pre-existing cardiovascular disease. Platelets are important mediators and sensors of inflammation and are directly affected by cardiovascular stressors. In this report, we found that platelets from severely ill, hospitalized COVID-19 patients exhibited higher basal levels of activation measured by P-selectin surface expression and had poor functional reserve upon in vitro stimulation. To investigate this question in more detail, we developed an assay to assess the capacity of plasma from COVID-19 patients to activate platelets from healthy donors. Platelet activation was a common feature of plasma from COVID-19 patients and correlated with key measures of clinical outcome including kidney and liver injury, and APACHEIII scores. Further, we identified ferritin as a pivotal clinical marker associated with platelet hyperactivation. The COVID-19 plasma-mediated effect on control platelets was highest for patients that subsequently developed inpatient thrombotic events. Proteomic analysis of plasma from COVID-19 patients identified key mediators of inflammation and cardiovascular disease that positively correlated with in vitro platelet activation. Mechanistically, blocking the signaling of the FcγRIIa-Syk and C5a-C5aR pathways on platelets, using antibody-mediated neutralization, IgG depletion or the Syk inhibitor fostamatinib, reversed this hyperactivity driven by COVID-19 plasma and prevented platelet aggregation in endothelial microfluidic chamber conditions. These data identified these potentially actionable pathways as central for platelet activation and/or vascular complications and clinical outcomes in COVID-19 patients. In conclusion, we reveal a key role of platelet-mediated immunothrombosis in COVID-19 and identify distinct, clinically relevant, targetable signaling pathways that mediate this effect.

Large-scale global reforestation goals have been proposed to help mitigate climate change and provide other ecosystem services. To explore reforestation potential in the United States, we used GIS analyses, surveys of nursery managers and foresters, and literature synthesis to assess the opportunities and challenges associated with meeting proposed reforestation goals. We considered a scenario where 26 million hectares (64 million acres) of natural and agricultural lands are reforested by 2040 with 30 billion trees at an estimated cost of $33 ($24–$53) billion USD. Cost per hectare will vary by region, site conditions, and other factors. This scenario would require increasing the number of tree seedlings produced each year by 1.7 billion, a 2.3-fold increase over current nursery production levels. Additional investment (not included in the reforestation cost estimate) will be needed to expand capacity for seed collection, seedling production, workforce development, and improvements in pre- and post-planting practices. Achieving this scenario will require public support for investing in these activities and incentives for landowners.

Spinal cord injury (SCI) often leads to impaired motor and sensory functions, partially because the injury-induced neuronal loss cannot be easily replenished through endogenous mechanisms. In vivo neuronal reprogramming has emerged as a novel technology to regenerate neurons from endogenous glial cells by forced expression of neurogenic transcription factors. We have previously demonstrated successful astrocyte-to-neuron conversion in mouse brains with injury or Alzheimer's disease by overexpressing a single neural transcription factor NeuroD1. Here we demonstrate regeneration of spinal cord neurons from reactive astrocytes after SCI through AAV NeuroD1-based gene therapy. We find that NeuroD1 converts reactive astrocytes into neurons in the dorsal horn of stab-injured spinal cord with high efficiency (~95%). Interestingly, NeuroD1-converted neurons in the dorsal horn mostly acquire glutamatergic neuronal subtype, expressing spinal cord-specific markers such as Tlx3 but not brain-specific markers such as Tbr1, suggesting that the astrocytic lineage and local microenvironment affect the cell fate after conversion. Electrophysiological recordings show that the NeuroD1-converted neurons can functionally mature and integrate into local spinal cord circuitry by displaying repetitive action potentials and spontaneous synaptic responses. We further show that NeuroD1-mediated neuronal conversion can occur in the contusive SCI model with a long delay after injury, allowing future studies to further evaluate this in vivo reprogramming technology for functional recovery after SCI. In conclusion, this study may suggest a paradigm shift from classical axonal regeneration to neuronal regeneration for spinal cord repair, using in vivo astrocyte-to-neuron conversion technology to regenerate functional new neurons in the gray matter.

While memory effects emerge from systems of wildly varying lengthscales and timescales, the reduction of a complex system with many interacting elements into one simple enough to be understood without also losing the complex behavior continues to be a challenge. Here, we investigate how bistable cylindrical origamis provide such a reduction via tunably interactive memory behaviors. We base our investigation on folded sheets of Kresling patterns that function as two-state memory units. By linking several units, each with a selected activation energy, we construct a one-dimensional material that exhibits return-point memory. After a comprehensive experimental analysis of the relation between the geometry of the pattern and the mechanical response for a single bit, we study the memory of a bellows composed of four bits arranged in series. Since these bits are decoupled, the system reduces to the Preisach model, and we can drive the bellows to any of its 16 allowable states by following a prescribed sequence of compression and extension. We show how to reasonably discriminate between states by measuring the system's total height and stiffness near equilibrium. Furthermore, we establish the existence of geometrically disallowed defective stable configurations that expand the configuration space to 64 states with a more complex transition pattern. Using empirical considerations of the mechanics, we analyze the hierarchical structure of the corresponding diagram, which includes Garden of Eden states and subgraphs. We highlight two irreversible transformations, namely shifting and erasure of defects, leading to memory behaviors reminiscent of those observed with more complex glassy systems.

The fields of meteorology, surface- and groundwater hydrology, and forestry are often decoupled despite the fact that they occur simultaneously at the intersection of living systems and the physical environment. In this work, we describe a system that allows concurrent measurement of canopy throughfall, transpiration, air temperature, pressure, and humidity at multiple heights, in addition to soil moisture and several surface water parameters. LEAF is designed to be generalizable to many other hydrology and meteorology applications, and is modular such that it is easily adaptable for use with additional, diverse environmental monitoring sensors. This low-cost, light-weight, solar-powered system is capable of simultaneous streaming telemetry as well as local data logging via SD card. Keywords: Precipitation, Transpiration, Throughfall, Micrometeorology, Microclimate, Surface hydrology, IoT, Sensing systems, Sensors, Sap flux, Rain gauge, Arboreal system, Microcontroller, Particle electron

MicroRNAs (miRNAs) are small non-protein coding RNAs and post-transcriptionally regulate cellular gene expression. In animal development, miRNAs play essential roles such as stem cell maintenance, organogenesis, and apoptosis. Using gain-of-function (GOF) screening with 160 miRNA lines in Drosophila melanogaster, we identified a set of miRNAs which regulates body fat contents and named them microCATs (microRNAs Controlling Adipose Tissue). Further examination of egg-to-adult developmental kinetics of selected miRNA lines showed a negative correlation between fat content and developmental time. Comparison of microCATs with loss-of-function miRNA screening data uncovered miR-969 as an essential regulator of adiposity. Subsequently, we demonstrated adipose tissue-specific knock-down of gustatory receptor 47b (Gr47b), a miR-969 target, greatly reduced the amount of body fat, recapitulating the miR-969 GOF phenotype.

The transition from β-cell compensation to β-cell failure is not well understood. Previous works by our group and others have demonstrated a role for Prostaglandin EP3 receptor (EP3), encoded by the Ptger3 gene, in the loss of functional β-cell mass in Type 2 diabetes (T2D). The primary endogenous EP3 ligand is the arachidonic acid metabolite prostaglandin E2 (PGE2). Expression of the pancreatic islet EP3 and PGE2 synthetic enzymes and/or PGE2 excretion itself have all been shown to be upregulated in primary mouse and human islets isolated from animals or human organ donors with established T2D compared to nondiabetic controls. In this study, we took advantage of a rare and fleeting phenotype in which a subset of Black and Tan BRachyury (BTBR) mice homozygous for the Leptinob/ob mutation—a strong genetic model of T2D—were entirely protected from fasting hyperglycemia even with equal obesity and insulin resistance as their hyperglycemic littermates. Utilizing this model, we found numerous alterations in full-body metabolic parameters in T2D-protected mice (e.g., gut microbiome composition, circulating pancreatic and incretin hormones, and markers of systemic inflammation) that correlate with improvements in EP3-mediated β-cell dysfunction.

Breast augmentation is the most commonly performed aesthetic surgery procedure in women worldwide. The use of the subfascial plane has been suggested to decrease the incidence of capsular contracture compared with the subglandular plane, while simultaneously avoiding the complication of animation deformity in the subpectoral plane. The aim of this systematic review and meta-analysis was to compare the adverse outcomes of subfascial vs subglandular planes in breast augmentation. This review was registered a priori on OSF (https://osf.io/pm92e/). A search from inception to June 2023 was performed on MEDLINE, Embase, and CENTRAL. A hand search was also performed. All randomized and comparative cohort studies that assessed the use of the subfascial plane for breast augmentation were included. Outcomes evaluated included the incidences of seroma, hematoma, infection, rippling, capsular contracture, and revision surgery. Ten studies were included in this systematic review. Three randomized controlled trials and 7 comparative cohort studies were used for quantitative synthesis. There was a significant difference favoring subfascial compared with subglandular planes in the incidence of hematoma, rippling, and capsular contracture. All included studies had a high risk of bias. The current evidence suggests that the subfascial plane for breast augmentation decreases the risk of capsular contracture, hematoma, and rippling compared with the subglandular plane. Further randomized evidence with high methodological rigor is still required to validate these findings., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Innovation in healthcare has led to the development of numerous implantable medical devices (IMDs). However, advances in our knowledge of breast implant-associated malignancies have raised questions about the prevalence, etiology and management of malignancies associated with non-breast IMDs. The objective of this study was to examine the prevalence and characteristics of malignancies associated with non-breast IMDs. An expert medical librarian developed the search strategy for this review. Databases included MEDLINE (National Library of Medicine, Bethesda, MD; date range of search: 1946 to June 21, 2023), EMBASE (Elsevier, Amsterdam, the Netherlands; date range of search: 1946 to June 21, 2023), and Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Library, Wiley, Hoboken, NJ; date range of search: 1946 to June 21, 2023). In addition, grey literature sources were searched and relevant references from systematic reviews and meta-analyses were included. The PRISMA guideline was used to guide the review. Risk of bias was evaluated using the JBI Critical Appraisal tools. A total of 12,230 articles were reviewed with a total of 77 meeting inclusion criteria. Risk of bias was highest with case reports (moderate, average of 65.1% with range of 37.5 to 100%) and low for the remaining study types. In total, 616 cases of IMD-associated malignancies were identified. Malignancies associated with IMDs were reported in the head/neck (543, 88.1%), lower extremity (57, 9.6%), thorax (9, 1.4%), abdomen (3, 0.5%), and genitourinary system (2, 0.3%). The most common malignancy type in the lower extremity was sarcoma, in the head and neck was squamous cell carcinoma, and in the thorax was lymphoma. This study is the first comprehensive systematic review of its kind. Overall, the oncologic risk of IMDs is low. The discussion of malignancy is an important part to the overall consent process and malignancy should be considered with any new signs or symptoms in the anatomic area of an implant. More data is needed to better understand how primary malignancies occur around IMDs and how to reduce this risk., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

How individual animals respond to climate change is key to whether populations will persist or go extinct. Yet, few studies investigate how changes in individual behavior underpin these population-level phenomena. Shifts in the distributions of migratory animals can occur through adaptation in migratory behaviors, but there is little understanding of how selection and plasticity contribute to population range shift. Here, we use long-term geolocator tracking of Balearic shearwaters ( Puffinus mauretanicus ) to investigate how year-to-year changes in individual birds' migrations underpin a range shift in the post-breeding migration. We demonstrate a northward shift in the post-breeding range and show that this is brought about by individual plasticity in migratory destination, with individuals migrating further north in response to changes in sea-surface temperature. Furthermore, we find that when individuals migrate further, they return faster, perhaps minimizing delays in return to the breeding area. Birds apparently judge the increased distance that they will need to migrate via memory of the migration route, suggesting that spatial cognitive mechanisms may contribute to this plasticity and the resulting range shift. Our study exemplifies the role that individual behavior plays in populations' responses to environmental change and highlights some of the behavioral mechanisms that might be key to understanding and predicting species persistence in response to climate change., Competing Interests: Competing interests statement:The authors declare no competing interest.

The authors describe aesthetic refinements to the approach for male chest lifting in male patients with grade 3 gynecomastia and/or significant chest skin excess. An inferior pedicle is used to transpose the nipple-areolar complex allowing preservation of pigment and sensation, liposuction and direct excision are used to reduce volume and excess skin, and the resulting curvilinear scar along the inferior and lateral border of the chest provide a more masculine appearance. Early experience with this technique has shown it to be safe and effective. Perioperative management and the detailed steps of the procedure are outlined., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Aesthetic Society.)

The authors describe their technique for vertical scar mastopexy with a centrally based auto-augmentation flap. Since 2011, the authors have performed this procedure in 212 patients and found that this operative technique has allowed us to achieve reproducible aesthetic outcomes while minimizing complications. Vertical scar mastopexy with a centrally based auto-augmentation flap is an excellent procedure for patients with breast ptosis who desire improved breast shape and superior pole fullness without the use of a breast implant. The perioperative management and detailed steps of the procedure are outlined., (© 2022 The Aesthetic Society.)

Background: Breast reconstruction is an important aspect in breast cancer treatment., Methods: A comprehensive search of MEDLINE, Embase, and the Cochrane Library of Systematic Reviews was performed. Systematic reviews and meta-analyses that focused on breast reconstruction and were published between 2000 and 2020 were included. Quality assessment was performed using A Measurement Tool to Assess Systematic Reviews (AMSTAR). Study characteristics were extracted, including journal and impact factor, year of publication, country affiliation, reporting adherence to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, number of citations, and number of studies included., Results: The average AMSTAR score was moderate (5.32). There was a significant increase in AMSTAR score ( P < 0.01) and number of studies ( P < 0.01) over time. There were no significant correlations between AMSTAR score and impact factor ( P = 0.038), and AMSTAR score and number of citations ( P = 0.52), but there was a significant association between AMSTAR score and number of studies ( P = 0.013). Studies that adhered to the PRISMA statement had a higher AMSTAR score on average ( P < 0.01)., Conclusions: Systematic reviews and meta-analyses about breast reconstruction had, on average, a moderate AMSTAR score. The number of studies and methodological quality have increased over time. Study characteristics including adherence to PRISMA guidelines are associated with improved methodological quality. Further improvements in specific AMSTAR domains would improve the overall methodological quality., Competing Interests: Disclosure: Dr. Ahmad is a consultant for Mentor Worldwide LLC and Allergan Inc. All the other authors have no financial interest to declare in relation to the content of this article., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Biogenic iron (Fe) (oxyhydr)oxides (BIOS) partially control the cycling of organic matter, nutrients, and pollutants in soils and water via sorption and redox reactions. Although recent studies have shown that the structure of BIOS resembles that of two-line ferrihydrite (2LFh), we lack detailed knowledge of the BIOS local coordination environment and structure required to understand the drivers of BIOS reactivity in redox active environments. Therefore, we used a combination of microscopy, scattering, and spectroscopic methods to elucidate the structure of BIOS sampled from a groundwater seep in North Carolina and compare them to 2LFh. We also simulated the effects of wet-dry cycles by varying sample preparation (e.g., freezing, flash freezing with freeze drying, freezing with freeze drying and oven drying). In general, the results show that both the long- and short-range ordering in BIOS are structurally distinct and notably more disordered than 2LFh. Our structure analysis, which utilized Fe K-edge X-ray absorption spectroscopy, Mössbauer spectroscopy, X-ray diffraction, and pair distribution function analyses, showed that the BIOS samples were more poorly ordered than 2LFh and intimately mixed with organic matter. Furthermore, pair distribution function analyses resulted in coherent scattering domains for the BIOS samples ranging from 12-18 Å, smaller than those of 2LFh (21-27 Å), consistent with reduced ordering. Additionally, Fe L-edge XAS indicated that the local coordination environment of 2LFh samples consisted of minor amounts of tetrahedral Fe(III), whereas BIOS were dominated by octahedral Fe(III), consistent with depletion of the sites due to small domain size and incorporation of impurities (e.g., organic C, Al, Si, P). Within sample sets, the frozen freeze dried and oven dried sample preparation increased the crystallinity of the 2LFh samples when compared to the frozen treatment, whereas the BIOS samples remained more poorly crystalline under all sample preparations. This research shows that BIOS formed in circumneutral pH waters are poorly ordered and more environmentally stable than 2LFh.

Background: Social interactions, reproductive demands and intrinsic constraints all influence foraging decisions in animals. Understanding the relative importance of these factors in shaping the way that coexisting species within communities use and partition resources is central to knowledge of ecological and evolutionary processes. However, in marine environments, our understanding of the mechanisms that lead to and allow coexistence is limited, particularly in the tropics., Methods: Using simultaneous data from a suite of animal-borne data loggers (GPS, depth recorders, immersion and video), dietary samples and stable isotopes, we investigated interspecific and intraspecific differences in foraging of two closely-related seabird species (the red-footed booby and brown booby) from neighbouring colonies on the Cayman Islands in the Caribbean., Results: The two species employed notably different foraging strategies, with marked spatial segregation, but limited evidence of interspecific dietary partitioning. The larger-bodied brown booby foraged within neritic waters, with the smaller-bodied red-footed booby travelling further offshore. Almost no sex differences were detected in foraging behaviour of red-footed boobies, while male and female brown boobies differed in their habitat use, foraging characteristics and dietary contributions. We suggest that these behavioural differences may relate to size dimorphism and competition: In the small brown booby population (n < 200 individuals), larger females showed a higher propensity to remain in coastal waters where they experienced kleptoparasitic attacks from magnificent frigatebirds, while smaller males that were never kleptoparasitised travelled further offshore, presumably into habitats with lower kleptoparasitic pressure. In weakly dimorphic red-footed boobies, these differences are less pronounced. Instead, density-dependent pressures on their large population (n > 2000 individuals) and avoidance of kleptoparasitism may be more prevalent in driving movements for both sexes., Conclusions: Our results reveal how, in an environment where opportunities for prey diversification are limited, neighbouring seabird species segregate at-sea, while exhibiting differing degrees of sexual differentiation. While the mechanisms underlying observed patterns remain unclear, our data are consistent with the idea that multiple factors involving both conspecifics and heterospecifics, as well as reproductive pressures, may combine to influence foraging differences in these neighbouring tropical species.

Background: Breast augmentation is one of the most commonly performed cosmetic surgeries worldwide. Therefore, it is imperative to have evidence with high methodological quality to guide clinical decision making., Objectives: To evaluate the methodological quality of the systematic reviews (SRs) focused on breast augmentation., Methods: A comprehensive search of MEDLINE, Embase, and the Cochrane Library of Systematic Reviews was performed. SRs that have a particular focus on breast augmentation and were published in the top 15 plastic and reconstructive surgery journals were included. Quality assessment was performed using a measurement tool to assess systematic reviews (AMSTAR). Study characteristics were extracted including journal and impact factor, year of publication, country affiliation of the corresponding author, reporting adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, number of citations, and number of studies included., Results: Among the 22 studies included for analysis, the mean AMSTAR score was moderate (5.55), with no SR achieving good quality (AMSTAR score of ≥9). There were no significant associations between AMSTAR score and journal impact factor, number of citations, year of publication, or number of included studies. Studies that reported adherence to PRISMA guidelines on average scored higher on the AMSTAR tool ( P = 0.03)., Conclusions: The methodological quality of reviews about breast augmentation was found to be moderate, with no significant increase in studies or quality over time. Adherence to PRISMA guidelines and increased appraisal of SRs about breast augmentation using methodological assessment tools would further strengthen methodological quality and confidence in study findings., (© 2021 The Aesthetic Society.)

Since the first implant-based breast surgeries were performed nearly 70 years ago, breast augmentation it has changed drastically. As understanding of breast augmentation has advanced, so too have the technologies and techniques used to improve results and minimize the risk of complications in breast implant surgery. This article reviews some of the novel techniques and technologies used today in breast augmentation surgery. How these tools and techniques will withstand the test of time remains to be seen, but they no doubt will add to the fascinating and ever-evolving history of breast augmentation., Competing Interests: Disclosure Dr J. Ahmad is a consultant for Mentor Worldwide, LLC., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Business and practice management principles are critical components of healthcare provision. Business and practice management is currently undertaught in plastic surgery training programs. The objective was to assess the status of business and practice management teaching amongst plastic surgery programs in Canada. An online survey of all enrolled plastic surgery residents was conducted in 2019 to 2020. Participants were invited to rate their knowledge and confidence about core principles in business and practice management. Sixty-five out of 126 residents responded to this survey (response rate, 51.6%). Only 7.8% of participants had previous business and practice management training; 23.1% reported receiving training in business and practice management during their residency. Participants reported a low level of knowledge and confidence in business and practice management (average Likert score between 3 and 4). Participants reported a high desire for future training in business and practice management particularly in billing and coding (91.2%) and business operations (91.2%). Plastic surgery residents in Canada reported a low level of knowledge and confidence about business and practice management. They desire the inclusion of business and practice management training in future curriculum., (© 2020 The Aesthetic Society.)

Background: Previous studies have reported decreased rates of capsular contracture associated with the use of textured surface breast implants placed in the subglandular plane during breast augmentation. However, since the publication of these studies, our understanding of the pathophysiology of capsular contracture, as well as the surgical techniques utilized to minimize bacterial contamination of the implant, have advanced considerably., Objectives: The purpose of this study was to re-evaluate the relation between implant surface texturization and capsular contracture rates for breast implants placed in the subglandular plane during primary breast augmentation., Methods: Retrospective chart review was performed of all primary subglandular breast augmentation procedures involving the use of either smooth or textured round silicone gel implants, with or without simultaneous mastopexy. The primary outcome measures included clinically significant capsular contracture (Baker grade III/IV) and revision surgery for capsular contracture., Results: Between 2010 and 2017, 526 patients underwent primary subglandular breast augmentation with either smooth (n = 212) or textured (n = 314) round silicone gel implants; 248 patients underwent breast augmentation, whereas 278 underwent breast augmentation-mastopexy. Average follow-up was 756 days in the textured group and 461 days in the smooth group. Five cases of capsular contracture were observed in the textured group, and 7 cases of capsular contracture were observed in the smooth group (P = 0.20)., Conclusions: Smooth surface implants placed in the subglandular plane were not at a significantly increased risk of capsular contracture compared with textured surface implants. We suggest that adherence to a surgical technique focused on minimizing bacterial contamination of the implant is of greater clinical significance than implant surface characteristics when discussing capsular contracture., (© 2019 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

Background: Despite significant growth of the global skin care market, many plastic surgeons do not offer skin care products through their aesthetic practice. However, skin care products represent a significant potential revenue stream for plastic surgeons, not only by generating revenue from product sales but by improving patient retention over time and, in turn, generating additional surgical and nonsurgical revenue., Objectives: The purpose of this study was to determine the financial implications that skin care sales can have for an aesthetic surgery practice. Our hypothesis was that patients making skin care purchases would generate higher non-skin care revenue than patients not purchasing skin care products., Methods: A retrospective chart review was performed of all purchases made within a single aesthetic surgery practice during a 6-year period (2012-2017). Pre-tax revenue ($CAD) from each category was recorded for any patient who made a purchase during the study period., Results: A total 3785 patients purchased skin care products, 5088 patients purchased nonsurgical treatments, and 3504 patients underwent surgery. Average patient spending was $720.73 (skin care), $1272.63 (nonsurgical), and $10,048.34 (surgery), respectively. Overall, patients who purchased skin care generated more revenue from the purchases of nonsurgical treatments and surgery than patients who did not purchase skin care products., Conclusions: Skin care sales not only generate revenue, but over time these patients spend more on nonsurgical and surgical treatments than patients who do not purchase skin care. Skin care is an important adjuvant to nonsurgical and surgical treatments that should be considered by all aesthetic surgeons., (© 2019 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

Patterns of behavioural variation and migratory connectivity are important characteristics of populations, particularly at the edges of species distributions, where processes involved in influencing evolutionary trajectories, such as divergence, mutual persistence, and natural hybridization, can occur. Here, we focused on two closely related seabird species that breed in the Mediterranean: Balearic shearwaters (Puffinus mauretanicus) and Yelkouan shearwaters (Puffinus yelkouan). Genetic and phenotypic evidence of hybridization between the two species on Menorca (the eastern and westernmost island in the breeding ranges of the two shearwaters, respectively) has provided important insights into relationships between these recently diverged species. Nevertheless, levels of behavioural and ecological differentiation amongst these populations remain largely unknown. Using geolocation and stable isotopes, we compared the at-sea movement behaviour of birds from the Menorcan 'hybrid' population with the nearest neighbouring populations of Balearic and Yelkouan shearwaters. The Menorcan population displayed a suite of behavioural features intermediate to those seen in the two species (including migration strategies, breeding season movements and limited data on phenology). Our findings provide new evidence to support suggestions that the Menorcan population is admixed, and indicate a role of non-breeding behaviours in the evolutionary trajectories of Puffinus shearwaters in the Mediterranean.

Background: Practice management is an overlooked and undertaught subject in medical education. Many physicians feel that their exposure to billing education during residency training was inadequate. The purpose of this study was to compare resident and staff physicians in terms of their billing knowledge and exposure to billing education during residency training., Methods: Senior residents and staff physicians completed a scenario-based clinical billing assessment. Posttest surveys were completed to determine exposure to practice management and billing education during training., Results: A total of 16 resident physicians and 17 staff physicians completed the billing assessment. Overall, the billing accuracy of respondents was poor. Staff physicians had a greater percentage of correct billing codes (55.3% v. 37.5%, p < 0.001) and underbilled codes (6.2% v. 3.4%, p = 0.009), with fewer missed billing codes (38.5% v. 59.1%, p < 0.001), compared with resident physicians. The percentage value of correct billings was significantly higher for staff physicians (71.5% v. 56.8%, p = 0.01). In the posttest survey, 100.0% of residents and 79.0% of staff physicians desired more billing education during training., Conclusion: In general, staff physicians billed more accurately than resident physicians, but even experienced staff physicians missed a substantial amount of potential revenue because of billing errors and omissions. The majority of the residents and staff physicians who participated in our study felt that current billing education is both insufficient and ineffective. Incorporating practice management and billing education into residency training is critical to ensure that the next generation of medical trainees possess the financial competence to required to manage a successful medical practice., Competing Interests: None declared., (© 2019 Joule Inc. or its licensors)

The authors describe their surgical technique for single-stage periareolar mastopexy with subglandular breast augmentation. They have performed this procedure in 85 patients since 2009 and found that this operative technique has allowed them to achieve reproducible outcomes in a single-stage procedure. Periareolar mastopexy with subglandular breast augmentation is an excellent procedure for patients who desire a larger breast size and who present with mild to moderate nipple ptosis with a paucity of excess skin in the lower pole of the breast. This article will review the perioperative management and detailed steps of the procedure and outline its indications for utilization and some of the common complications the authors have encountered., (© 2019 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

The transport of thermally injured patients can involve significant costs; however, not all thermally injured patients necessitate transfer to a burn center. The purpose of this study was to review transfers to an American Burn Association-verified regional burn center to determine whether the transfers were necessary and the cost associated with unnecessary transfers. A retrospective chart review identified 707 patients transferred to an American Burn Association-verified burn center with an acute burn injury during a 7-year period. For the purposes of this study, "unnecessary transfer" was defined as any patient admitted fewer than 7 days who did not undergo operative intervention. Transfer cost estimates were based on records from regional land paramedic and land and air medical transport services. In total, 27.3% of transfers were potentially "unnecessary transfers," with an associated cost of approximately $227,396.93 (18.9% of total transfer costs in study). Average unnecessary transfer cost varied by method of transport: land ambulance (n = 130) $285.72, helicopter (n = 27) $4,136.34, and airplane (n = 15) $4,908.67. The transfer of thermally injured patients is associated with significant cost. Unnecessary transfers represent an inefficient use of a limited resource in an already strained healthcare system. The findings of this study suggest that further initiatives should be explored to ensure the appropriate transfer of thermally injured patients.

Manganese (Mn) contamination of well water is recognized as an environmental health concern. In the southeastern Piedmont region of the United States, well water Mn concentrations can be >2 orders of magnitude above health limits, but the specific sources and causes of elevated Mn in groundwater are generally unknown. Here, using field, laboratory, spectroscopic, and geospatial analyses, we propose that natural pedogenetic and hydrogeochemical processes couple to export Mn from the near-surface to fractured-bedrock aquifers within the Piedmont. Dissolved Mn concentrations are greatest just below the water table and decrease with depth. Solid-phase concentration, chemical extraction, and X-ray absorption spectroscopy data show that secondary Mn oxides accumulate near the water table within the chemically weathering saprolite, whereas less-reactive, primary Mn-bearing minerals dominate Mn speciation within the physically weathered transition zone and bedrock. Mass-balance calculations indicate soil weathering has depleted over 40% of the original solid-phase Mn from the near-surface, and hydrologic gradients provide a driving force for downward delivery of Mn. Overall, we estimate that >1 million people in the southeastern Piedmont consume well water containing Mn at concentrations exceeding recommended standards, and collectively, these results suggest that integrated soil-bedrock-system analyses are needed to predict and manage Mn in drinking-water wells.

Catastrophic events require rapid, scientifically sound decision making to mitigate impacts on human welfare and the environment. The objective of this study was to analyze potential impacts of coal ash-derived trace elements on agriculture following a 35,000-tonne release of coal ash into the Dan River at the Duke Energy Steam Station in Eden, North Carolina. We performed scenario calculations to assess the potential for excessive trace element loading to soils via irrigation and flooding with Dan River water, uptake of trace elements by crops, and livestock consumption of trace elements via drinking water. Concentrations of 13 trace elements measured in Dan River water samples within 4 km of the release site declined sharply after the release and were equivalent within 5 d to measurements taken upriver. Mass-balance calculations based on estimates of soil trace-element concentrations and the nominal river water concentrations indicated that irrigation or flooding with 25 cm of Dan River water would increase soil concentrations of all trace elements by less than 0.5%. Calculations of potential increases of trace elements in corn grain and silage, fescue, and tobacco leaves suggested that As, Cr, Se, Sr, and V were elements of most concern. Concentrations of trace elements measured in river water following the ash release never exceeded adopted standards for livestock drinking water. Based on our analyses, we present guidelines for safe usage of Dan River water to diminish negative impacts of trace elements on soils and crop production. In general, the approach we describe here may serve as a basis for rapid assessment of environmental and agricultural risks associated with any similar types of releases that arise in the future., (© 2015 SETAC.)

Recurrent or persistent macromastia can occur after breast reduction. This may be due to inadequate primary volume reduction, poor postoperative shape, and breast or nipple-areola complex asymmetry. Postpartum breast changes, weight change, and aging can also contribute to recurrent macromastia. The concern in these cases is the altered blood supply to the nipple-areola complex and the safety of nipple-areola complex transposition. Literature on the safety of repeated breast reduction is limited with conflicting approaches. This article discusses an approach to recurrent or persistent macromastia and outlines a modified breast reduction technique that is safe in cases of repeated breast reduction., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: As more patients undergo bariatric surgery to assist with weight loss, the demand for post-bariatric body contouring surgery, to address both functional and aesthetic concerns, is increasing. However, high wound healing complication rates remain a significant problem for these patients. One theory is that chronic malnourishment and hypoproteinemia may contribute significantly to these wound healing complications., Objective: The purpose of this study was to determine the effect of pretreatment protein nutritional supplementation on wound healing in post-bariatric surgery massive weight loss patients undergoing abdominoplasty. Our hypothesis was that protein supplementation would decrease wound healing complications., Methods: A retrospective review was performed of 23 post-bariatric surgery patients undergoing abdominoplasty who received pretreatment protein nutritional supplementation. This group was compared with a historical control group of 23 post-bariatric surgery patients who underwent abdominoplasty in the period immediately before the implementation of the protein supplementation protocol. Patient demographics and procedural characteristics were similar for the two groups., Results: Forty-six patients were identified who had undergone abdominoplasty, half of whom were prescribed the protein supplementation protocol. Overall wound healing complication rates were significantly lower in the protein-supplemented group (0.0% vs. 21.8%, p = 0.04). There was no significant difference between the protein supplementation and historical control groups in regards to total complication rate., Conclusions: Pretreatment protein supplementation is a simple intervention that can significantly decrease wound healing complications in post-bariatric surgery massive weight loss patients undergoing abdominoplasty. LEVEL OF EVIDENCE 4: Therapeutic., (© 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Tumors are typically sequenced to depths of 75-100× (exome) or 30-50× (whole genome). We demonstrate that current sequencing paradigms are inadequate for tumors that are impure, aneuploid or clonally heterogeneous. To reassess optimal sequencing strategies, we performed ultra-deep (up to ~312×) whole genome sequencing (WGS) and exome capture (up to ~433×) of a primary acute myeloid leukemia, its subsequent relapse, and a matched normal skin sample. We tested multiple alignment and variant calling algorithms and validated ~200,000 putative SNVs by sequencing them to depths of ~1,000×. Additional targeted sequencing provided over 10,000× coverage and ddPCR assays provided up to ~250,000× sampling of selected sites. We evaluated the effects of different library generation approaches, depth of sequencing, and analysis strategies on the ability to effectively characterize a complex tumor. This dataset, representing the most comprehensively sequenced tumor described to date, will serve as an invaluable community resource (dbGaP accession id phs000159).

Since 1989, the authors have performed vertical scar reduction mammaplasty on over 3000 patients. In 2006, the authors described their technique. Since then, the authors have made several modifications that they believe have improved both the reliability of the procedure and the outcomes that they are able to achieve. Key modifications are described in this article and the accompanying video.

Introduction: In many circumstances early burn excision and autografting is unsafe or even impossible. In these situations, skin substitute dressings can be utilized for temporary wound coverage. Two commonly used dressings for this purpose are cadaveric allograft and Biobrane™., Materials and Methods: Five year retrospective cohort study evaluating upper extremity burns treated with temporary wound coverage (Biobrane™ or allograft). The primary outcome was to determine the impact choice of wound coverage had on operative time and cost. The secondary outcome was the need for revision of upper extremity debridement prior to definitive autografting., Results: 45 patients were included in this study: 15 treated with cadaveric allograft and 30 treated with Biobrane™ skin substitute. Biobrane™ had a significantly lower procedure time (21.12 vs. 54.78 min per %TBSA excised, p=0.02) and cost (1.30 vs. 2.35 dollars per minute per %TBSA excised, p=0.002). Both techniques resulted in 2 revisions due to complications., Conclusion: Biobrane™ is superior to cadaveric allograft as a temporizing skin substitute in the acute burn wound, both in terms of procedure time and associated cost. We believe that this is largely due to the relative ease of application of Biobrane™. Furthermore, given its unique characteristics, Biobrane™ may serve as a triage and transport option for severe burns in the military and mass casualty settings., (Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.)

Despite increases in medical school enrolment, applications to surgical residency programs in Canada have been in decline over the past decade, with an increasing number of unmatched surgical residency positions. We examined the current status of surgical residency in Canada and analyzed application trends (2002–2013) for surgical training programs across Canada. Our findings suggest that most undergraduate medical schools across Canada are having difficulty fostering interest in surgical careers. We propose that a lack of adequate early exposure to the surgical specialties during undergraduate training is a critical factor. Moving forward, we must examine how the best-performing institutions and surgical programs have maintained interest in pursuing surgical careers and adapt our recruitment methods to both maintain and grow future interest. As Mary Engelbreit said, "If you don't like something, change it; if you can't change it, change the way you think about it."

Background: Applications to surgical residency programs have declined over the past decade. Even highly competitive programs, such as plastic surgery, have begun to witness these effects. Studies have shown that early surgical exposure has a positive influence on career selection., Objective: To review plastic surgery application trends across Canada, and to further investigate medical student exposure to plastic surgery., Methods: To examine plastic surgery application trends, national data from the Canadian Resident Matching Service database were analyzed, comparing 2002 to 2007 with 2008 to 2013. To evaluate plastic surgery exposure, a survey of all undergraduate medical students at the University of Toronto (Toronto, Ontario) during the 2012/2013 academic year was conducted., Results: Comparing 2002 to 2007 and 2008 to 2013, the average number of national plastic surgery training positions nearly doubled, while first-choice applicants decreased by 15.3%. The majority of Canadian academic institutions experienced a decrease in first-choice applicants; 84.7% of survey respondents indicated they had no exposure to plastic surgery during their medical education. Furthermore, 89.7% believed their education had not provided a basic understanding of issues commonly managed by plastic surgeons. The majority of students indicated they receive significantly less plastic surgery teaching than all other surgical subspecialties. More than 44% of students not considering plastic surgery as a career indicated they may be more likely to with increased exposure., Conclusion: If there is a desire to grow the specialty through future generations, recruiting tactics to foster greater interest in plastic surgery must be altered. The present study suggests increased and earlier exposure for medical students is a potential solution.