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BACKGROUND: Following the integration of the electronic health record (EHR) into the healthcare system, concern has grown regarding EHR use on physician well-being. For surgical residents, time spent on the EHR increases the burden of a demanding, hourly restricted schedule and detracts from time spent honing surgical skills. To better characterize these burdens, we sought to describe EHR utilization patterns for plastic surgery residents. METHODS: Integrated plastic surgery resident EHR utilization from March 2019 to March 2020 was extracted via Cerner Analytics at a tertiary academic medical center. Time spent in the EHR on-duty (0600-1759) and off-duty (1800-0559) in the form of chart review, orders, documentation, and patient discovery was analyzed. Statistical analysis was performed in the form of independent t tests and Analysis of Variance (ANOVA). RESULTS: Twelve plastic surgery residents spent a daily average of 94 ± 84 minutes on the EHR, one-third of which was spent off-duty. Juniors (postgraduate years 1-3) spent 123 ± 99 minutes versus seniors (postgraduate years 4-6) who spent 61 ± 49 minutes (P < 0.01). Seniors spent 19% of time on the EHR off-duty, compared with 37% for juniors (P < 0.01). Chart review comprised the majority (42%) of EHR usage, followed by patient discovery (22%), orders (14%), documentation (12%), other (6%), and messaging (1%). Seniors spent more time on patient discovery (25% vs 21%, P < 0.001), while juniors spent more time performing chart review (48% vs 36%, P = 0.19). CONCLUSION: Integrated plastic surgery residents average 1.5 hours on the EHR daily. Junior residents spend 1 hour more per day on the EHR, including more time off-duty and more time performing chart review. These added hours may play a role in duty hour violations and detract from obtaining operative skill sets.

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The Argentine Black and White Tegu (Salvator merianae, formerly Tupinambis merianae) is a large lizard from South America. Now established and invasive in southern Florida, and it poses threats to populations of many native species. Models suggest much of the southern United States may contain suitable temperature regimes for this species, yet there is considerable uncertainty regarding either the potential for range expansion northward out of tropical and subtropical zones or the potential for the species establishing elsewhere following additional independent introductions. We evaluated survival, body temperature, duration and timing of winter dormancy, and health of wild-caught tegus from southern Florida held in semi-natural enclosures for over a year in Auburn, Alabama (> 900 km northwest of capture location). Nine of twelve lizards emerged from winter dormancy and seven survived the greater-than-one-year duration of the study. Average length of dormancy (176 d) was greater than that reported in the native range or for invasive populations in southern Florida and females remained dormant longer than males. Tegus grew rapidly throughout the study and the presence of sperm in the testes of males and previtellogenic or early vitellogenic follicles in female ovaries at the end of our study suggest the animals would have been capable of reproduction the following spring. The survival and overall health of the majority of adult tegus in our study suggests weather and climate patterns are unlikely to prevent survival following introduction in many areas of the United States far from their current invasive range.

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BACKGROUND: The care of unilateral cleft lip (UCL) patients is extremely variable. Historical benchmarks for perioperative and intraoperative choices by cleft surgeons were produced by Sitzman et al (Plast Reconstr Surg. 2008;121:261e-270e) in 2005. However, emerging data and cleft lip repair methods around this period were not captured by this study. The aim of this study was to update the current practice patterns of cleft lip surgeons. METHODS: An electronic survey was distributed to surgeons in the American Cleft Palate Association. Demographic data about the surgeon were collected as well as their choices regarding perioperative and intraoperative cleft lip care. RESULTS: Eighty-six surgeons responded to the survey. Nearly 40% of surgeons have changed their technique for UCL repair with Fisher anatomical subunit repair gaining significant popularity. Nasoalveolar molding is also being used more frequently (41% vs 22%). At the time of the cleft lip repair, closure of the nasal floor is occurring in 83.1% of patients and primary cleft rhinoplasty is being performed routinely 57% of the time. CONCLUSIONS: Over the last 10 years, there has been an increase in the use of modified rotation advancement repairs and Fisher anatomic subunit approximation technique for treatment of UCL. There continues to be a lack of evidence regarding superiority of specific repair techniques or the benefits of adjunct procedures, which results in varying practice patterns. Educating all cleft surgeons on practices that are well supported is important to improve care to cleft patients.

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INTRODUCTION: Breast implant selection is multifactorial and must assess risk profiles of the implants. Textured implants are available in an anatomically shaped form and are thought to have lower rates of capsular contracture. However, evidence is mounting that they carry a significantly higher risk of breast implant associated anaplastic large cell lymphoma. Given this relationship, we aimed to assess breast implant preferences and device selection for members of the American Society of Plastic Surgeons (ASPS). METHODS: An online survey of all active members of ASPS was performed. Questions analyzed the surgeons' demographic data as well as implant and tissue expander choices for patients receiving either breast augmentation or reconstruction. Logistic regression models of summarized data were used to assess surgeons' implant choices. RESULTS: The survey was sent to 5000 members and was completed by 824 for a response rate of 16.5%. Demographic data indicate a homogenous sampling of ASPS members from all geographical areas. A majority of surgeons reported that they perform 21-50 implant cases in the last year (n = 219, 28.5%), followed closely by surgeons performing greater than 100 cases (n = 194, 25.3%) and those placing between 51 and 100 (n = 189, 24.6%). Almost one-half of respondents (n = 361, 46.9%) stated that the majority (>50%) of the implants they placed were for cosmetic purposes. Conversely, 306 (37.9%) respondents stated that the majority of implants they placed were for reconstructive purposes and 102 (13.3%) respondents indicated equal placement of cosmetic and reconstructive implants. There were 40.9% (n = 318) surgeons who continue to use textured implants, whereas 59.1% (n = 460) report using only smooth implants. This data includes 47.7% (n = 363) of respondents who report switching to only smooth implants due to awareness of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). CONCLUSIONS: The incidence of BIA-ALCL continues to rise. All known cases have some link to textured implants. With equally efficacious alternatives available with smooth implants, surgeons and patients are altering their implant choices.

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Background The Zika virus has become an international health issue and poses a systematic risk for a growing number of travelers. Qatar is no exception to this status, where its Hamad International Airport (HIA) has become an important hub for many travelers to and from affected countries. Thus, it is a national necessity to determine the knowledge, attitude, and practice of travelers' regarding this emerging disease in the State of Qatar. Methods This was a cross-sectional study that employed a self-administered questionnaire (n=100) and was conducted at Hamad International Airport. Descriptive and inferential statistical tests were applied to analyze the data using the Statistical Package for the Social Sciences (SPSS) (IBM SPSS Statistics 21, IBM Corporation, Armonk, NY, USA, 2014). Results The majority of travelers (75%) reported hearing about the Zika disease prior to their current flight, mainly from the media (73%) and the internet (46%). The majority of participants (69%) knew about the vector-borne transmission and symptomatology of a Zika infection while more than half (54%) correctly identified effective methods to prevent infection. Regarding their attitude, less than two-thirds (58%) of the participants agreed that pregnant women must postpone their travel to any Zika-affected area. Regarding their practice, only a quarter of the sampled travelers (24%) sought pre-travel medical advice before going to Brazil. Comparing the knowledge score among different education levels, we found that high-school students scored significantly better than those with diplomas and bachelors, p=0.042 and p=0.012, respectively. Conclusion The survey findings revealed that the knowledge of Zika infection is low among travelers to Brazil. Thus, stronger efforts to educate travelers about Zika are recommended. It is also vital that travelers be encouraged to seek proper medical advice prior to travel.

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UNLABELLED:  Introduction. Men have higher risk for hepatocellular carcinoma (HCC) than women. Pre liver transplant (LT) alpha fetoprotein (AFP) levels strongly predict post LT HCC recurrence. Though women with HCC have higher AFP, the contribution of AFP level by gender to post LT HCC recurrence is unknown. MATERIAL AND METHODS: In this UNOSbased, retrospective cohort study we investigate sex differences in HCC recurrence among LT recipients with MELD exception between 2006-2010. Covariates include race, disease etiology, co-morbidities, AFP at listing and LT, tumor burden, loco-regional therapy, and donor risk index. HCC recurrence was assessed by competing risks regression. RESULTS: Of the eligible cohort (n = 5,002) included 3,872 men and 1,130 women. HCC recurred in 258 men (7%) and 66 women (6%). Median listing AFP was higher in women than men (14 vs. 11 ng/dL, p < 0.001). While no sex difference in overall HCC recurrence was detected (HR 0.9, 95% CI 0.7-1.2, p = 0.38), there was a strong interaction between gender and AFP on recurrence risk (p = 0.02). HCC recurrence was nearly three times higher in women (HR 4.2, 95% CI 2.2-8.2, p < 0.001) than men (HR 1.5, 95% CI 1.1-2.1, p = 0.02) with AFP at LT between 101-500 ng/dL. CONCLUSION: This study reveals novel sex differences in post LT HCC recurrence, which was nearly three times higher in women than men with high AFP at LT. Pre-LT AFP levels appear to carry a different prognosis in women than men, and a subset of female LT recipients may benefit from more intensive HCC surveillance after LT.

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