Water-in-oil emulsion incomplete Freund’s adjuvant (IFA) has been used as an adjuvant in preventive and therapeutic vaccines since its development. New generation, highly purified modulations of the adjuvant, Montanide incomplete seppic adjuvant (ISA)-51 and Montanide ISA-720, were developed to reduce toxicity. Montanide adjuvants are generally considered to be safe, with adverse events largely consisting of antigen and adjuvant dose-dependent injection site reactions (ISRs). Peptide vaccines in Montanide ISA-51 or ISA-720 are capable of inducing both high antibody titers and durable effector T cell responses. However, an efficient T cell response depends on the affinity of the peptide to the presenting major histocompatibility complex class I molecule, CD4+ T cell help and/or the level of co-stimulation. In fact, in the therapeutic cancer vaccine setting, presence of a CD4+ T cell epitope seems crucial to elicit a robust and durable systemic T cell response. Additional inclusion of a Toll-like receptor ligand can further increase the magnitude and durability of the response. Use of extended peptides that need a processing step only accomplished effectively by dendritic cells (DCs) can help to avoid antigen presentation by nucleated cells other than DC. Based on recent clinical trial results, therapeutic peptide-based cancer vaccines using emulsions in adjuvant Montanide ISA-51 can elicit robust antitumor immune responses, provided that sufficient tumor-specific CD4+ T cell help is given in addition to CD8+ T cell epitopes. Co-treatment with PD-1 T cell checkpoint inhibitor, chemotherapy or other immunomodulatory drugs may address local and systemic immunosuppressive mechanisms, and further enhance efficacy of therapeutic cancer peptide vaccines in IFA and its modern variants. Blinded randomized placebo-controlled trials are critical to definitively prove clinical efficacy. Mineral oil-based adjuvants for preventive vaccines, to tackle spread and severity of infectious disease, induce immune responses, but require more studies to reduce toxicity.

Background: Review platforms such as Yelp are increasingly used by patients establishing care and may contain substantial information regarding patient preferences and potential biases. The authors’ aims were to (1) analyze patient satisfaction through identifying factors associated with positive and negative patient reviews for plastic surgery providers across the United States, and (2) investigate the association between overall rating and different physician and practice factors based on gender and race. Methods: Reviews of plastic surgery provider practices from cities across seven different regions within the United States were obtained from Yelp. Quantitative and qualitative analyses were performed. Chi-square tests were used to determine whether race or sex was associated with overall rating (of five stars) and qualitative themes. Results: A total of 5210 reviews met inclusion criteria; 80.3% received a five-star rating and 13.5% received a one-star rating. Positive Yelp reviews and higher ratings were associated with positive comments regarding surgical and injectable outcomes, physical examination, communication, competency/knowledge base, temperament, scheduling, and staff interactions. When the following factors were mentioned negatively, the practice was more likely to receive a lower rating: temperament, communication, cost consciousness, surgical and injectable outcomes, physical examination, billing/insurance, scheduling, interactions with staff, and wait times. No association was identified in terms of overall physician rating based on sex or race; however, there were differences noted in distribution of positive and negative themes. Conclusions: Patient reviews on Yelp indicate that several physician and practice factors influence patient satisfaction. The themes reported in this study may be used by plastic surgery providers to identify areas for practice improvement to enhance the overall patient experience.