Comparing Gender Congruency in Nonsurgical versus Postsurgical Top Surgery Patients: A Prospective Survey Study.

Background: Gender dysphoria can result in reduced quality of life. Treatments include hormone replacement therapy (HRT) and gender-affirming surgery. Our study compared congruency, satisfaction, and discrimination in patients who underwent top surgery and HRT versus HRT alone. We hypothesized improved outcomes in top surgery patients but that lack of access is a common barrier. Methods: Transgender and nonbinary subjects who underwent at least 6 months of HRT were recruited and answered questions on gender congruency, discrimination, and barriers to care. Surgical patients were asked about postoperative satisfaction using the BREAST-Q. A Mann-Whitney test compared survey responses between study arms. Results: One hundred twelve eligible subjects completed the survey. Surgical subjects answered significantly more positively (P < 0.001) on all questions regarding gender congruency. The greatest difference was observed in how subjects' physical bodies represented their gender identity, where the surgery group rated higher on the five-point Likert scale by 2.0 points (P < 0.001). Surgical patients also reported less violence, verbal abuse, and discrimination (P < 0.003). Within the hormone arm, 87.1% stated desire for surgery and 62.5% declared barriers to surgery, with cost and insurance coverage representing the most common barriers. Finally, surgical subjects reported high satisfaction on the BREAST-Q, scoring more than 3.0 in all categories of breast augmentation and more than 2.6 for breast reduction on a four-point Likert scale. Conclusions: Top surgery, in addition to HRT, significantly improves gender congruency and decreases discrimination and abuse, compared with HRT alone. Unfortunately, barriers including cost and lack of insurance continue to be obstacles for care.

Defining Key Features in Patient Perspectives of Hand Aesthetics.

BACKGROUND: The hand is highly visible and contributes to an individual's aesthetic image and perceived age. Current perspectives on hand aesthetics are primarily based on expert opinion rather than on lay population perspectives, which are less understood. Our study explores general population perceptions on the features that contribute most to an attractive hand. METHODS: Participants rated the attractiveness of 20 standardized hands as well as the appearance based on each characteristic: freckles, hair presence, skin tone, wrinkles, vein appearance, and soft tissue volume. The relative importance of each feature was assessed by comparison with overall attractiveness scores through multivariate analysis of variance. RESULTS: A total of 223 participants completed the survey. Soft tissue volume ( r = 0.73) was most strongly correlated with overall attractiveness, followed by wrinkles ( r = 0.71), skin tone consistency ( r = 0.69), veins ( r = 0.65), freckles ( r = 0.61), and hair ( r = 0.47). Female hands were perceived as more attractive, with a mean rating of 4.7 of 10, compared with 4.4 in males ( P < 0.001). Participants correctly identified the gender of 90.4% of male hands and 65.0% of female hands. Age was strongly inversely correlated with attractiveness ( r = -0.80). CONCLUSIONS: Soft tissue volume is the most important factor in lay perception of hand aesthetics. Female and younger hands were perceived as more attractive. Hand rejuvenation may be optimized by prioritizing soft tissue volume with filler or fat grafting, with secondary priority on resurfacing to address skin tone and wrinkling. An understanding of the factors most important to patients in aesthetic appearance is critical to achieving a pleasing result.

Impending Backlog of Cleft Palate Patients Due to COVID-19.

Coronavirus disease 2019 (COVID-19) has placed an unprecedented strain on healthcare systems worldwide, but while high-income countries (HICs) have been able to adapt, low- and middle-income countries (LMICs) have been much slower to do so due to a lack of funding, skilled healthcare providers, equipment, and facilities. The redistribution of resources to combat the pandemic in LMICs has resulted in decreased surgical volumes at local surgical centers as well as a dramatic reduction in the number of humanitarian aid missions. Despite recent global investment in improving the surgical capacities of LMICs, even in the pre-COVID-19 era there was a vast unmet surgical need. This deficit in surgical capacity has grown during the pandemic and it will be a significant struggle to overcome the resulting backlog of patients. A topic of particular concern to the authors is the effect that the pandemic will have on the delivery of time-sensitive surgical care to patients with cleft palate deformities as delay in providing care can have enormous physical and psychosocial consequences. This paper draws increased attention to the lasting impact that the COVID-19 pandemic may have on cleft palate patients in LMICs. SSRN Pre-print server link: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3898055.

Rethinking Farkas: Updating Cephalic Index Norms in a Large, Diverse Population.

BACKGROUND: Cephalic index, the ratio of head width to length, is one normative indicator used by insurers to derive criteria for plagiocephaly helmet authorization. Current norms were established by a small sample of white children in the 1987 Farkas and Munro data set. This study establishes updated cephalic index values for infants and children in a large, diverse patient population. METHODS: Children aged 0 to 3 months, 3 to 6 months, 9 to 12 months, 2 to 3 years, and 12 to 14 years were recruited at their well-child appointment. Cephalic index was calculated for each age group and compared to previously established norms. RESULTS: Eight hundred seventy patients met inclusion criteria. The means for boys and girls between 0 and 6 months were 83.5 (n = 155, SD 6.01) and 83.5 (n = 191, SD 5.80), respectively. Established means for boys and girls between 0 and 6 months were 74.4 (n = 38, SD 5.2) and 74.3 (n = 49, SD 6.1), respectively. The difference between norms is highly statistically significant (p < 0.0001). For this age range, insurance criteria for a helmet is >83.7 for boys and >82.7 for girls. Using previous norms, 74 boys (44.6 percent) and 104 girls (54.5 percent) would meet criteria for a helmet under current guidelines. CONCLUSIONS: The mean cephalic index of children has changed. The reasons could include diversifying populations in the United States and the introduction of the Back to Sleep campaign. Over 50 percent of children may inappropriately meet criteria for a helmet based on prior norms. Updating norms could change the definition of plagiocephaly for a helmet orthosis.

The Use of Visible-Light Hyperspectral Imaging in Evaluating Burn Wounds: A Case Report.

Burn depth is a critical factor in determining the healing potential of a burn as the extent of injury ultimately guides overall treatment. Visible-Light Hyperspectral Imaging is an FDA-approved, noninvasive, and noncontrast imaging technology that uses light waves within the visible spectrum to evaluate skin and superficial soft tissue perfusion. In this case report, visible-light hyperspectral imaging was used to evaluate a 37-year-old male who presented to the Emergency Department with a thermal burn of the trunk, back, and right upper extremity. Images were taken at initial evaluation, 6 hours postinjury, and again during daily dressing changes until hospital day 5 when the patient underwent surgical debridement. In this patient, operative treatment was postponed until 89.7 hours postinjury, at which point the clinical examination showed clear visual demarcation in regions of irreversible damage. Comparatively, visible-light hyperspectral imaging analysis of the permanently injured tissue demonstrated acute but varying changes in both oxygenated hemoglobin and deoxygenated hemoglobin at the time of initial evaluation. The most dramatic change in tissue oxygenation occurred between 6.5 and 39.3 hours, demonstrating visible-light hyperspectral imaging's ability to detect significant differences in oxygenation values between areas of second-degree superficial burns and areas of second-degree deep and third-degree burns in the acute period. The data suggest that the utilization of visible-light hyperspectral imaging in this 6.5- to 39.3-hour window may help predict final burn depth before clinical assessment, potentially allowing for surgical intervention within the first 48 hours following injury.

Hedgehog Pathway Activation Requires Coreceptor-Catalyzed, Lipid-Dependent Relay of the Sonic Hedgehog Ligand.

Hedgehog signaling governs critical processes in embryogenesis, adult stem cell maintenance, and tumorigenesis. The activating ligand, Sonic hedgehog (SHH), is highly hydrophobic because of dual palmitate and cholesterol modification, and thus, its release from cells requires the secreted SCUBE proteins. We demonstrate that the soluble SCUBE-SHH complex, although highly potent in cellular assays, cannot directly signal through the SHH receptor, Patched1 (PTCH1). Rather, signaling by SCUBE-SHH requires a molecular relay mediated by the coreceptors CDON/BOC and GAS1, which relieves SHH inhibition by SCUBE. CDON/BOC bind both SCUBE and SHH, recruiting the complex to the cell surface. SHH is then handed off, in a dual lipid-dependent manner, to GAS1, and from GAS1 to PTCH1, initiating signaling. These results define an essential step in Hedgehog signaling, whereby coreceptors activate SHH by chaperoning it from a latent extracellular complex to its cell-surface receptor, and point to a broader paradigm of coreceptor function.

Repurposing Hsp90 inhibitors as antibiotics targeting histidine kinases.

To address the growing need for new antimicrobial agents, we explored whether inhibition of bacterial signaling machinery could inhibit bacterial growth. Because bacteria rely on two-component signaling systems to respond to environmental changes, and because these systems are both highly conserved and mediated by histidine kinases, inhibiting histidine kinases may provide broad spectrum antimicrobial activity. The histidine kinase ATP binding domain is conserved with the ATPase domain of eukaryotic Hsp90 molecular chaperones. To find a chemical scaffold for compounds that target histidine kinases, we leveraged this conservation. We screened ATP competitive Hsp90 inhibitors against CckA, an essential histidine kinase in Caulobacter crescentus that controls cell growth, and showed that the diaryl pyrazole is a promising scaffold for histidine kinase inhibition. We synthesized a panel of derivatives and found that they inhibit the histidine kinases C. crescentus CckA and Salmonella PhoQ but not C. crescentus DivJ; and they inhibit bacterial growth in both Gram-negative and Gram-positive bacterial strains.