Is the h-Index Enough? A Comprehensive Bibliometric Analysis of 871 Academic Plastic Surgeons and Their Departments/Divisions.

BACKGROUND: In plastic surgery academia, research output is heavily used as a metric of accreditation, from assessing residency applicants to evaluating faculty for promotion. The h index, defined as an author's h papers with at least h citations, is commonly used as a measure of academic success. However, the index itself disfavors junior researchers, favors publication quantity, and discounts highly cited works. Given the importance of bibliometrics within plastic surgery, there is a paramount need to adopt additional metrics to measure research productivity. The authors sought to validate the use of time-independent bibliometrics to complement the h index in measuring citation impact. METHODS: The genders and academic titles of plastic surgeons affiliated with US plastic surgery programs were recorded. Author publications were retrieved from Scopus. Bibliometrics software was used to calculate the following metrics per surgeon: h index, e index, and g index. Time-adjusted versions of these indices were used to correct for the number of years since first publication. Medians and interquartile ranges (IQRs) are reported. Departmental ranks were determined using the cumulative sum of time-corrected indices and compared with Doximity departmental research rankings. P < 0.05 was deemed significant. RESULTS: Indices were calculated for 871 academic plastic surgeons in 85 departments/divisions. Men had statistically greater h index (median, 13.0 [IQR, 7.0-21.0] vs 6.0 [IQR, 3.0-13]; P < 0.001), e index (18.3 [IQR, 10.0-28.7] vs 11.1 [IQR, 5.5-18.4]; P < 0.001), and g index (23.0 [IQR, 11.0-39.0] vs 11.0 [IQR, 5.0-22.0]; P < 0.001) than women. Professors had the highest median time-uncorrected indices. After adjusting for the number of years since an author's first publication, there were no significant differences in m quotient (men: 0.66 [IQR, 0.40-0.98] vs women: 0.57 [IQR, 0.33-0.90]; P = 0.05) and ec index (men: 0.93 [IQR, 0.62-1.3] vs women: 0.87 [IQR, 0.50-1.3]; P = 0.08) between genders. Departmental chairs had significantly higher indices than other faculty after correcting for time. The calculated program rankings were low to moderately correlated with that of Doximity (correlation coefficient τ = 0.49 [95% confidence interval, 0.37-0.59; P < 0.001]). CONCLUSIONS: Men and women have statistically similar citation patterns after correcting for the time. Citation differences between academic levels are less pronounced when controlling for time, suggesting comparable research quality between academic roles.

Examining Racial and Gender Diversity in the Plastic Surgery Pipeline: Where is the Leak?

Background: There is limited information about minority representation throughout the plastic and reconstructive surgery (PRS) pipeline. The aim of this study was to examine trends in representation among minorities at different stages of the PRS training pathway, starting with potential candidates in high school through practicing physicians. Methods: The PRS pipeline was defined as high school; college; medical school applicants, matriculants, and graduates; PRS residency applicants, matriculants, and active residents; and PRS practicing physicians. Racial data for each stage were obtained from the US Census and Association of American Medical Colleges. The proportion of races at each stage were divided by their US population counterpart proportions to produce representation quotients (RQs). Medians and interquartile ranges (IQRs) are reported. Mann-Whitney U tests compared RQ values within identities between successive stages. Results: Black students had high representation in high school (RQ = 1.26 [IQR: 1.21-1.29]) but had significant, stepwise decreases in representation in subsequent stages. A similar trend was observed for Hispanic individuals, who had their highest representation in high school (1.43 [1.37-1.50]), followed by significant decreases in RQ at nearly every subsequent stage up to and including practicing physicians (0.30 [0.28-0.31). Asian individuals were overrepresented at every stage (high school RQ: 1.01 [1.00-1.03]; practicing physician RQ: 2.30 [2.27-2.32]). White individuals were underrepresented before residency but had an RQ that approximated 1 in subsequent stages. Conclusions: Racial minorities experienced decreases in representation at each successive stage in the PRS pipeline following high school. Ongoing diversity efforts should focus on premedical recruitment and professional support for minority students.

Longitudinal impact of a residency-based postplacental levonorgestrel intrauterine device insertion program: Expulsion rates in years 1, 2, and 3.

OBJECTIVE: To evaluate expulsion rates in the first 3 years of an academic postplacental levonorgestrel intrauterine device (LNG-IUD) insertion program. STUDY DESIGN: Retrospective case series, January 2016 to December 2018. We measured LNG-IUD expulsion rates by 12 weeks postpartum. RESULTS: Of 235 LNG-IUD insertions, in years 1, 2, and 3, expulsion rates were 11/39 (28%), 9/94 (10%), and 15/102 (15%) (p = 0.03). After vaginal delivery, manual insertion was associated with a higher expulsion rate than ring-forceps (10/28 [36%] vs 17/105 [16%], p = 0.04). CONCLUSIONS: LNG-IUD expulsion rates decreased after program year 1, suggesting program maturity may be associated with a lower expulsion risk.

The Impact of Venous Reconstruction on Finger Replantation Success Rates Based on Level of Injury.

PURPOSE: The requirement for anatomic venous reconstruction in digit replantation is an ongoing area of research. In this study, we evaluated our institutional experience to study whether replantation success is affected by the presence or absence of vein repair, stratified by the level of injury. METHODS: A retrospective review was performed at an urban, level-1 trauma center of all single-digit replantations performed in adults from 2012 to 2021. Patient demographics, injury mechanism, level of injury, whether a vein was repaired, and replant survival were recorded. RESULTS: Sixty-seven single replanted digits were included. Patients were, on average, 38 years old, and 94% were men. The most common mechanism of injury was a sharp laceration (81%). The overall survival rates for all replantations were 68.7% (46/67) and 60% (12/20) for distal finger replantation. Patients with digital replantations at Tamai zone III or more proximal exhibited a 1.8 times increase in survival rates when one vein was repaired versus zero veins (84.4% vs 46.7%). Patients with digital replantations at Tamai zones I and II exhibited similar survival rates. CONCLUSIONS: Replantations at or proximal to the middle phalanx should be repaired with at least one artery and vein to maximize the chance for success. However, for distal finger replantations, artery-only replantation is a viable option when vein anastomosis is not achievable. TYPO OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

CD30 Lateral Flow and Enzyme-Linked Immunosorbent Assays for Detection of BIA-ALCL: A Pilot Study.

INTRODUCTION: Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) commonly presents as a peri-implant effusion (seroma). CD30 (TNFRSF8) is a consistent marker of tumor cells but also can be expressed by activated lymphocytes in benign seromas. Diagnosis of BIA-ALCL currently includes cytology and detection of CD30 by immunohistochemistry or flow cytometry, but these studies require specialized equipment and pathologists' interpretation. We hypothesized that a CD30 lateral flow assay (LFA) could provide a less costly rapid test for soluble CD30 that eventually could be used by non-specialized personnel for point-of-care diagnosis of BIA-ALCL. METHODS: We performed LFA for CD30 and enzyme-linked immunosorbent assay (ELISA) for 15 patients with pathologically confirmed BIA-ALCL and 10 patients with benign seromas. To determine the dynamic range of CD30 detection by LFA, we added recombinant CD30 protein to universal buffer at seven different concentrations ranging from 125 pg/mL to 10,000 pg/mL. We then performed LFA for CD30 on cryopreserved seromas of 10 patients with pathologically confirmed BIA-ALCL and 10 patients with benign seromas. RESULTS: Recombinant CD30 protein added to universal buffer produced a distinct test line at concentrations higher than 1000 pg/mL and faint test lines at 250-500 pg/mL. LFA produced a positive test line for all BIA-ALCL seromas undiluted and for 8 of 10 malignant seromas at 1:10 dilution, whereas 3 of 10 benign seromas were positive undiluted but all were negative at 1:10 dilution. Undiluted CD30 LFA had a sensitivity of 100.00%, specificity of 70.00%, positive predictive value of 76.92%, and negative predictive value of 100.00% for BIA-ALCL. When specimens were diluted 1:10, sensitivity was reduced to 80.00% but specificity and positive predictive values increased to 100.00%, while negative predictive value was reduced to 88.33%. When measured by ELISA, CD30 was below 1200 pg/mL in each of six benign seromas, whereas seven BIA-ALCL seromas contained CD30 levels > 2300 pg/mL, in all but one case calculated from dilutions of 1:10 or 1:50. CONCLUSIONS: BIA-ALCL seromas can be distinguished from benign seromas by CD30 ELISA and LFA, but LFA requires less time (<20 min) and can be performed without special equipment by non-specialized personnel, suggesting future point-of-care testing for BIA-ALCL may be feasible.

Blood Pressure Challenge Reduces Hematomas in Gender-Affirming Mastectomy: A Retrospective Chart Review of 92 Consecutive Patients.

BACKGROUND: Gender-affirming mastectomy is a common surgery for the treatment of gender incongruence and gender dysphoria and improves quality of life. Hematoma rates for gender-affirming double incision mastectomies are between 2.8% and 8.1%. This study aims to investigate the utility of a blood pressure challenge, whereby the patient's blood pressure is medically increased intraoperatively to reveal bleeding vessels that can be addressed with additional hemostasis before skin closure, to reduce postoperative hematoma. METHODS: A retrospective chart review of patients who underwent gender-affirming double incision mastectomies over a 6-year period by a single surgeon was conducted. Surgeries were separated into a blood pressure challenge experimental group and a non-blood pressure challenge control group. Demographics, surgical characteristics, and postoperative complications were compared between the 2 cohorts using Pearson χ2, Fisher exact, t tests, univariate logistic regression, and multivariable logistical regression. Significance was established at P < 0.05. RESULTS: A total of 92 patients (184 breasts) were included with 32 patients (64 breasts) in the control group and 60 (120 breasts) in the blood pressure challenge group. In the control group, there were 5 hematomas (7.81%) compared with 1 (0.83%) in the blood pressure challenge group (P = 0.02). On univariate logistical regression analysis, blood pressure challenge was the only variable significantly associated with hematoma (odds ratio, 0.1; 95% confidence interval, 0.01-0.63; P = 0.04). On multivariable logistical regression, after controlling for age, body mass index, smoking status, and mass of excised breast tissue, patients who underwent blood pressure challenge demonstrated lower hematoma rates (odds ratio, 0.08; 95% CI, 0.004-0.59; P = 0.04). CONCLUSIONS: Using an intraoperative blood pressure challenge was associated with reduced hematoma rates. Guidelines for blood pressure challenge goals should be established to standardize care and reduce complications in gender-affirming mastectomies.

Applying Representation Quotient Methodology to Racial, Ethnic, and Gender Trends of Applicants and Matriculants to Urology Residency Programs From 2010-2018.

OBJECTIVE: To accurately examine the trends in the racial and gender composition of medical students applying and matriculating to urology residency programs. METHODS: Reports on race/ethnicity and gender for medical school graduates, and urology residency applicants and matriculants were obtained for years 2010-2018. The proportions of individuals representing different racial and gender identities among urology applicants and matriculants were divided by a denominator of their proportion in medical school graduating classes to produce representation quotients (RQapp and RQmat, respectively). Linear regression models were performed on yearly RQs to estimate the RQ changes over time. Nonparametric testing was used to evaluate for differences in applicant to matriculant representation within each identity. ANOVA was performed separately on RQapp and RQmat values to assess differences in representation between identities in the applicant and matriculant populations. RESULTS: Asian men experienced increases in representation among urology applicants (RQapp: slope 2.04 × 10-2; P = .03) and matriculants (RQmat slope: 7.46 × 10-2; P = .0076) during the study period. Black men trended towards under-representation among applicants (RQapp slope -1.51 × 10-1; P = .03) and matriculants (RQmat slope: -1.71 × 10-1; P = .02). When examining genders, both men (RQapp=1.43 vs RQmat=1.44; P = .80) and women (RQapp=0.52 vs RQmat = 0.51; P = .67) had unchanged representation in the applicant and matriculant cohorts, but women severely underrepresented on average. CONCLUSIONS: Women and Black men are underrepresented in the urology workforce. These concerning findings demonstrate the dire need for initiatives regarding recruitment into urology to support and to ensure successful entry into the field for minority groups.

Pediatric Orthognathic Surgery: A NSQIP-P Comparison of Peri-Operative Factors and Outcome Differences Between Cleft and Noncleft Patients.

OBJECTIVE: The present study aimed to investigate the risk factors, complication profiles, and clinical outcomes of cleft and noncleft patients undergoing single jaw (mandibular or LeFort 1) and bimaxillary (BSSO + LeFort 1). DESIGN: Retrospective Cross-sectional Study Setting: National Surgical Quality Improvement Program database 2018-2019. PATIENTS: Pediatric patients. INTERVENTIONS: Outcomes for mandibular, LeFort 1, and bimaxillary osteotomy were retrospectively evaluated for cleft and noncleft patients. MAIN OUTCOME MEASURES: Multivariate logistic regression was used to determine the odds of complications and length of stay for cleft and noncleft patients undergoing single jaw and double jaw surgery. RESULTS: 669 pediatric patient underwent orthognathic surgery in the study period; the majority received LF1 only (n = 385; 58.3%), followed by mandible only (n = 179; 27.1%), and bimaxillary (n = 105; 15.9%%). Cleft differences were present in 56% of LFI patients, 32% of mandibular patients, and 22% of bimaxillary patients. After multivariate adjustment, ASA class III was associated with nearly 400% increased odds of any complication including readmission and reoperation (OR = 5.99; CI [[1.54-23.32]], p < 0.01, and 65% increased LOS (ß-coefficient = 1.65, CI [1.37-1.99], p < 0.01). Presence of cleft was not significantly associated with odds of any complication (p = 0.69) nor increased LOS (p = 0.46) in this population. CONCLUSION: Complications remained low between surgery types among cleft and noncleft patients. The most significant risk factor in pediatric orthognathic surgery was not the presence of cleft but rather increased ASA class. Though common in patients seeking orthognathic surgery, cleft differences did not cause additional risk after adjustment for other variables.

Continued underrepresentation of historically excluded groups in the neurosurgery pipeline: an analysis of racial and ethnic trends across stages of medical training from 2012 to 2020.

OBJECTIVE: US allopathic medical schools have experienced improvements in racial and ethnic diversity among matriculants in the past decade. It is not clear, however, whether better representation of historically excluded racial and ethnic groups at medical school entry impacts subsequent stages of the medical training pipeline leading into a specific field. The aim of this study was to examine these trends as they relate to the neurosurgical medical education pipeline and consider the drivers that sustain barriers for underrepresented groups. METHODS: Race and ethnicity reports from the American Association of Medical Colleges were obtained on allopathic medical school applicants, acceptees, and graduates and applicants to US neurosurgical residency programs from 2012 to 2020. The representation of groups categorized by self-reported race and ethnicity was compared with their US population counterparts to determine the representation quotient (RQ) for each group. Annual racial composition differences and changes in representation over time at each stage of medical training were evaluated by estimating incidence rate ratios (IRRs) and 95% confidence intervals (CIs) using non-Hispanic Whites as the reference group. RESULTS: On average, Asian and White individuals most frequently applied and were accepted to medical school, had the highest graduation rates, and applied to neurosurgery residency programs more often than other racial groups. The medical school application and acceptance rates for Black individuals increased from 2012 to 2020 relative to Whites by 30% (95% CI 1.23-1.36) and 42% (95% CI 1.31-1.53), respectively. During this same period, however, inequities in neurosurgical residency applications grew across all non-Asian racialized groups relative to Whites. While the incidence of active Black neurosurgery residents increased from 2012 to 2020 (0.6 to 0.7/100,000 Black US inhabitants), the prevalence of White neurosurgery residents grew in the active neurosurgery resident population by 16% more. CONCLUSIONS: The increased racial diversity of medical school students in recent years is not yet reflected in racial representation among neurosurgery applicants. Disproportionately fewer Black relative to White US medical students apply to neurosurgery residency, which contributes to declining racial representation among all active neurosurgery resident physicians. Hispanic individuals are becoming increasingly represented in neurosurgery residency but continue to remain underrepresented relative to the US population. Ongoing efforts to recruit medical students into neurosurgery who more accurately reflect the diversity of the general US population are necessary to ensure equitable patient care.

Characterizing the Impact of Socioeconomic Status on Orbital Floor Reconstruction: A National Inpatient Sample (NIS) Analysis.

ABSTRACT: Orbital floor fractures result in posterior globe displacement known as enophthalmos, and diplopia due to extraorbital soft tissue impingement. Surgical repair may involve the use of autolo-gous or synthetic materials. Previous studies have demonstrated a higher prevalence of orbital floor fractures among lower socioeconomic status (SES) populations. The authors aimed to characterize the impact of socioeconomic status on surgical management, outcomes, and use of synthetic orbital implant. The authors conducted a cross-sectional study of adult orbital floor fracture patients from 2002 to 2017 using the National Inpatient Sample. Among patients who underwent surgical treatment, our study found decreased synthetic orbital implant use among uninsured and Black patients and decreased home discharge among Medicare patients. There were no differences in orbital reconstruction. Further research is needed to elucidate possible mechanisms driving these findings.

Characterizing the Association of Race and Insurance Status with Resource Utilization in Brachial Plexopathy Surgery.

BACKGROUND: Understanding the link between socioeconomic status and immediate postoperative brachial plexus injury (BPI) management outcomes is critical to mitigating disparities and optimizing postoperative recovery plans. The present study aimed to elucidate the association between socioeconomic status and resource utilization following surgery for BPI. METHODS: We conducted a cross-sectional study of adult patients (18 years) with a BPI diagnosis from the 2002-2017 National Inpatient Sample. Primary outcomes included home discharge rates, length of stay (LOS), and cost. We used multivariable regressions to analyze outcome measures. RESULTS: A total of 23,755 BPI admissions were identified, 14.67% of whom received surgical intervention. Patients receiving Medicare had lower odds of home discharge compared with privately insured patients (adjusted odds ratio 0.65, 95% confidence interval 0.58-0.74; P < 0.001). Medicaid, Medicare, and uninsured patients had 6%-32% longer LOS than privately insured patients (P < 0.001, P = 0.004, and P = 0.006, respectively). Patients in the top income quartile had a 12% increase in costs compared with those in the bottom quartile (P < 0.001). Latinx and Other race groups had 11%-14% increased costs compared with White patients (Latinx P < 0.001, Other P = 0.003). CONCLUSIONS: Differences in BPI resource utilization and allocation exist, from increased LOS among non-privately insured and non-White patients to increased BPI treatment costs among patients in higher-income quartiles. Further research is necessary to elucidate how these disparities exist and impact functional outcomes.

Predicting the Impact of Race and Socioeconomic Status on Cranioplasty Materials and Outcomes.

BACKGROUND: Cranioplasty can be performed with either autologous or synthetic materials. No clear consensus has been reached regarding which material is superior and which social factors might influence the choice of treatment modality and the outcomes. We investigated the effects of race and socioeconomic status on the implant choice and outcomes. METHODS: We conducted a cross-sectional study of adult cranioplasty patients from 2002 to 2017 using the National Inpatient Sample. Autologous implant use, admission costs, length of stay (LOS), and home discharge were analyzed by race, income quartile, and insurance type using multivariable regression models. RESULTS: A total of 105,714 admissions met the inclusion criteria. Most of the patients were women (50.3%) and White (73.7%). Black, other race, and Medicaid patients had greater odds of autologous graft usage, and patients in the 76th-100th income quartile had lower usage. Higher income patients (51th-75th and 76th-100th) had had significantly higher hospitalization costs, amounting to a $1547.2 increase, compared with the bottom quartile. The Medicaid patients had a longer LOS (odds ratio, 1.06; P = 0.008) and decreased rates of home discharge (odds ratio, 0.41; P < 0.001). CONCLUSIONS: We found increased autologous cranioplasty usage for non-White and Medicaid patients and increased use of higher cost synthetic implants for high-income patients. Non-White patients and those from higher income quartiles incurred higher admission costs. Medicaid patients had a longer LOS and decreased rates of home discharge.

Sinestre, deviance, or biology? An investigation of hand dominance in relation to tendon absence.

The present study aimed to examine the relationship between hand dominance and the presence or absence of the flexor digitorum superficialis (FDS) in the fifth digit to add to the current body of knowledge. We hypothesized that the absence of the FDS in the right small finger is more prevalent in left-handed individuals. This was a prospective study conducted from January 2020 to April 2021 and performed at the plastic surgery department of a university hospital. The sample consisted of volunteers with no history of upper limb trauma, surgery, or any other condition. The study included male and female individuals over 18 years old at a local Rhode Island university campus. The FDS tendons of the bilateral fifth fingers were evaluated through clinical testing by an independent examiner. A total of 236 hands from 118 volunteers were analyzed. Left-hand dominant participants composed of 5% of the population. For these participants, the prevalence of absence of the fifth finger FDS tendon in the right hand was significantly higher than that of right-hand dominant participants (71.4% vs. 28.8%). No significant difference between sex assigned at birth (male vs. female) was noted and the absence of the FDS in either hand, regardless of hand dominance. The results from the current study demonstrate that anatomy may contribute to one's preference for left-handedness. For children who have difficulty using their right hand, perhaps, an assessment of their FDS status may result in earlier acceptance of using their left hand.

Comparing perceptions of long-acting reversible contraception among women during periods of incarceration and women attending a local clinic: An exploratory study.

OBJECTIVES: The objective of this study was to understand perceptions of long-acting reversible contraception (LARC) among incarcerated women. We compared survey responses specific to IUDs and implants between a convenience sample of incarcerated women to a sample of women attending a local ob/gyn clinic. STUDY DESIGN: We conducted a cross-sectional survey among two groups: (1) incarcerated women receiving medical care at the state correctional facility, and (2) women receiving care at an ob/gyn clinic in the same community. The anonymous survey included questions about demographic variables, current and past contraceptive use, and perception of IUDs and implants. RESULTS: Almost half of the total sample stated that they might consider an IUD or implant for contraception. Incarcerated women tended to be less likely to give an affirmative answer to current or future use of an IUD or implant (29% vs 39%, p = 0.19). Concerns about pain and side effects were similar between the groups, but more incarcerated women cited concerns about device removal (72% vs 57%, p = 0.02) and the level of training of the provider inserting the device (68% vs 53%, p = 0.02). Incarcerated women interested in using the IUD or implant were more comfortable with device placement in the community than in the correctional setting (42% to 30%, p < 0.001). CONCLUSIONS: Incarcerated women have concerns about LARC that may be specific to their experience of incarceration. Providers working with incarcerated women should consider these when counseling patients on contraceptive choices. Options for post-release follow-up care and device removal should be included in this discussion. IMPLICATIONS: Incarcerated women should receive comprehensive reproductive health care, including contraceptive services if desired. However, incarceration itself may introduce fundamental concerns regarding contraception and these concerns need to be better understood to balance the provision of services with the potential for reproductive coercion.

An analysis of publication trajectory in plastic surgery across the decades.

The classic canonical publication trajectory for academicians has been well-described by a rapid increase followed by a slower decrease in productivity, leading to a plateau. This trajectory has not been investigated in plastic surgery. In this communication, we aimed to: (1) visualize the publication trajectory per decade for plastic surgeons certified from 1980 to 2010, and (2) characterize and quantify the changes in publishing trends across decades. A list of plastic and reconstructive surgeons board certified between 1980 and 2010 was obtained. Number of publications per year was recorded for each plastic surgeon. The median cumulative publication trajectory was graphed for each decade. Kruskal-Wallis analysis was performed to determine whether there were differences in number of publications across generations. The trajectory for a surgeon from the 1980s follows the established canonical trajectory. Surgeons from the 1990s and 2000s had significantly more publications by board certification than those from the 1980s (7 and 8 vs. 5, respectively, p < 0.01). Surgeons from the 2010s on average achieved 8 publications by board certification. It is clear that the publication arc for plastic surgeons from successive generations has greatly changed. Over the last 40 years, there has been a trend for increasing productivity and involvement in research at a much earlier stage in career, potentially due to increasing demands for matching into residency programs.

What Do You Know About Maryjane? A Systematic Review of the Current Data on the THC:CBD Ratio.

Background: Ratios of delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) impact metabolism and therapeutic effects of cannabis. Currently, no states with legalized medical or recreational cannabis consider ratios THC:CBD in regulations. Objective: Determine what THC:CBD ratios are selected for use in clinical cannabis trials and what is the rationale. Methods: This is a systematic literature review of Central, CINAHL, Embase, PsycInfo, and PubMed of the last 10 years of English language medical cannabis publications highlighting THC:CBD ratios. Included were clinical studies of products containing and listing both THC and CBD ratios, percentages, or weighted amounts. Case reports and series, abstracts, reviews, and meta-analysis were excluded. Non-human, non-therapeutic, or studies examining approved cannabis pharmaceuticals were excluded. Results: Four hundred and seventy-nine (479) unique references were found, of which 11 met inclusion criteria. THC:CBD ratios listed and/or calculated: 1:0, 22:1, 2:1, 1:1, 1:2, 1:6, 1:9, 1:20, 1:33, 1:50, and 0:1. Rationale for ratios selected was often not listed, or simply trivialized as the ratios available to patients in the area, or ratios that were pharmaceutically available throughout the study country. One study compared ratios of high and low THC:CBD, but did not specify the ratios. Conclusion: The medical and scientific communities have not drawn substantive conclusions nor thoroughly explored THC:CBD ratios for "best practice" treatment of different disease processes and their sequelae. While there is evidence that cannabis provides medical benefits, research is lacking on standardization of medical cannabis use in modern medical practices.