Summary: Today’s model of healthcare has persistent challenges with cultural competency, and racial, gender, and ethnic disparities. Health is determined by many factors outside the traditional healthcare setting. These social determinants of health (SDH) include, but are not limited to, education, housing quality, and access to healthy foods. It has been proposed that racial and ethnic minorities have unfavorable SDH that contributes to their lack of access to healthcare. Additionally, African American, Hispanic, and Asian women have been shown to be less likely to proceed with breast reconstructive surgery post-mastectomy compared to Caucasian women. At the healthcare level, there is underrepresentation of cultural, gender, and ethnic diversity during training and in leadership. To serve the needs of a diverse population, it is imperative that the healthcare system take measures to improve cultural competence, as well as racial and ethnic diversity. Cultural competence is the ability to collaborate effectively with individuals from different cultures; and such competence improves health care experiences and outcomes. Measures to improve cultural competence and ethnic diversity will help alleviate healthcare disparities and improve health care outcomes in these patient populations. Efforts must begin early in the pipeline to attract qualified minorities and women to the field. The authors are not advocating for diversity for its own sake at the cost of merit or qualification, but rather, these efforts must evolve not only to attract, but also to retain and promote highly motivated and skilled women and minorities. At the trainee level, measures to educate residents and students through national conferences and their own institutions will help promote culturally appropriate health education to improve cultural competency. Various opportunities exist to improve cultural competency and healthcare diversity at the medical student, resident, attending, management, and leadership levels. In this article, the authors explore and discuss various measures to improve cultural competency as well as ethnic, racial, and gender diversity in healthcare.

Frostbite is a cold injury that results in soft tissue loss and can lead to amputation. Vascular thrombosis following injury causes ischemic tissue damage. Despite understanding the pathology, its treatment has remained largely unchanged for over 30 years. Threatened extremities may be salvaged with thrombolytics to restore perfusion. The authors performed a systematic review to determine whether thrombolytic therapy is effective and to identify patients who may benefit from this treatment. The Pubmed, EBSCO, and Google Scholar databases were queried using the key words “thrombolytics,” “frostbite,” “fibrinolytics,” and “tPA.” Studies written after 1990 in English met inclusion criteria. Exclusion criteria were failure to delineate anatomic parts injured, failure to report number of limbs salvaged, animal studies, and non-English language publications. Thrombolytic therapy was defined as administration of tPA, alteplase, urokinase, or streptokinase. Forty-two studies were identified and 17 included. Included were 1 randomized trial, 10 retrospective studies, 2 case series, and 4 case reports. One thousand eight hundred and forty-four limbs and digits in 325 patients were studied and 216 patients treated with thrombolytics and 346 amputations performed. The most common means of thrombolysis was intra-arterial tPA. The most common duration of therapy was 48 hours. Limb salvage rates ranged from 0% to 100% with a weighted average of 78.7%. Thrombolytics are a safe and effective treatment of severe frostbite. They represent the first significant advancement in frostbite treatment by preventing otherwise inevitable amputations warranting both greater utilization and further research to clarify the ideal thrombolytic protocol.

Background Reconstruction of head and neck defects resulting from resection of head and neck masses is performed by both plastic surgeons and otolaryngologists. The American College of Surgeons National Surgical Quality Improvement (NSQIP) database allows one to directly compare the outcomes for a given procedure based upon specialty. The purpose of this study is to compare outcomes and resource utilization of microvascular head and neck reconstruction between plastic surgery and otolaryngology. Methods Institutional review board approval was obtained and NSQIP was queried from 2005 to 2015 with inclusion of Current Procedural Terminology codes for free tissue transfer performed for head and neck reconstruction. Outcomes were compared between cases having otolaryngology and plastic surgery as performing the free flap reconstruction. Results During 2005 to 2015, a total of 2,322 flaps were performed, 893 by plastic surgery and 1,429 by otolaryngology. Average length of stay (LOS) was 13.7 and 11.4 days for plastic surgery and otolaryngology, respectively. It was found that plastic surgery performed more osteocutaneous flaps than otolaryngology. Higher rates of superficial surgical site infection, deep surgical site infections, wound dehiscence, myocardial infarction, bleeding complications, sepsis, unplanned return to the operating room, and unplanned readmission were observed for patients treated by otolaryngology (p < 0.05). Conclusion This study shows plastic surgery patients have superior outcomes with regards to free tissue transfers of the head and neck when compared with otolaryngology patients. Although plastic surgery patients experienced a longer LOS, the significantly lower complication rate supports an overall more optimal resource utilization. Future studies may elucidate potential cost savings in patients treated by plastic surgery.

Marjolin’s ulcer (MU) is a rare, aggressive entity with frequent delay in diagnosis for a variety of regions. Although well described and classically taught in medical school, aspects of its treatment remain ill-defined and controversial. A systematic review was performed according to PRISMA guidelines to identify studies discussing patients who underwent surgical treatment of Marjolin’s Ulcer. A total of 31 papers, reporting on 1,016 patients, were included. Burns were the most common etiology of malignant degeneration (68%), followed by trauma. The lower extremity was most affected (51%) and Squamous Cell Carcinoma (SCC) was found in 94% of cases, with the majority being well differentiated. Basal cell Carcinoma and Melenoma composed a minority of cases. Melanoma occurred more frequently in previously skin grafted wounds and had a higher rate of metastases than SCC. Most patients did not have associated regional or distant metastases present at diagnosis. Wide local excision (71%) was performed in most cases, unless amputation was indicated for severe disease or bone involvement. Lymphadenectomy and sentinel lymph node biopsy (SLNB) were variably reported, with conflicting evidence on the efficacy. Lymphadenectomy was most commonly indicated for known lymph node involvement. In cases of metastatic disease chemotherapy and radiation were used in conjunction with surgical treatment. Despite numerous articles on this topic, controversy remains in the management of MU. Early diagnosis of suspicious chronic wounds and prompt surgical intervention remain imperative to its treatment.

Background: Medical professionals often incur a significant financial burden in pursuit of a medical education. Despite rigorous medical education, financial education appears to be lacking during training. This study intended to explore the financial preparedness and education of 2 cohorts of medical professionals—alumni graduates of a single institution and current plastic surgery residency trainees. Methods: An electronic survey of the residency alumni at a single institution across all specialties over a 50-year period was conducted. This was conducted concurrent with a survey to current plastic surgery residency trainees across the country. The survey explored several core financially relevant areas, including financial education at various levels of training, fiscal goals, debt profile, spending and saving habits, investment management, financial and family obligations, estate planning, and retirement preparedness. Results: A total of 521 alumni and 84 residents completed the survey from the residency alumni cohort and plastic surgery training programs cohort, respectively. Results from both groups demonstrated that although the large majority considered financial education a priority, this was not prioritized in medical or residency training. Most were introduced to financial education either by a family member or by self-directed learning. Data on investments, savings, finances, and retirement planning are also presented. Conclusions: As a very literate group, there is an unacceptably high level of “illiteracy” concerning financial education at an early stage. Practicing physicians and current trainees believe that a more directed approach to financial education should be adopted, rather than the current laissez-faire climate during medical education and residency training.