LETTERS AND INVITED COMMENTARY Inpatient Management of Pyoderma Gangrenosum Treatments, Outcomes, and Clinical Implications
and adverse effects of systemic immunosuppressants. It would have been better if the authors have mentioned the percentages of surgical approaches among PG subtypes, ulceration sizes, and localizations and associated comorbidities. Despite advances in medical therapy, the prognosis of PG remains unpredictable and, if untreated, almost always fatal. We thought that the clinical photographs of the patient who had shown complete healing with medical and surgical treatment, at the time of diagnosis and after the treatment, would be helpful. We would like to thank the authors for their contributions to our therapeutic perspectives of stable ulcerations of PG.
To the Editor: e have read the article by Cabalag et al1 with interest. The authors have retrospectively analyzed 29 patients who received a diagnosis of and were treated for pyoderma gangrenosum (PG). They have proposed an algorithm. Pyoderma gangrenosum is a rare skin disorder that may arise spontaneously or following cutaneous injury. We agree that surgery should be considered in conjunction with both hyperbaric oxygen and immunosuppressive therapy to reduce disease-related morbidity in classic ulcerative PG. Despite the fact that medical therapies are the cornerstone of therapy, corticosteroids and cytotoxic therapies may lead to serious adverse effects. On the basis of demographical data, mean age of cases, most of whom had systemic comorbidities, was 71 years.1 Pyoderma gangrenosum was reported to be encountered most often in the third to sixth decade; therefore, in our opinion, the complications secondary to medical treatments were seen in higher proportion (65.7%) in the authors’ series. The authors have mentioned the limited role of surgical interventions because of potential triggering or worsening PG due to pathergy. Postsurgical PG was first described by Ouazzani et al.2 Notably, it was a rare but serious complication.3 This was due to diagnostic challenge that surgical intervention was performed routinely before suspicion of the disease and resulted with the sequelae of multiple surgical interventions. As medical therapy failed to induce complete healing, surgical therapy might have been occasionally performed.4 However; there were reports indicating failure of graft or flap after surgical intervention.5 Risk factors included a history of PG, hematologic disorders, inflammatory bowel disease, rheumatoid arthritis, and a first-degree relative with PG. For the patients with these risks who were undergoing surgery, full consideration needed to be given to the use of perioperative immunosuppressive therapy.4 Thus, in our opinion, the authors should have mentioned the term postsurgical PG in this comprehensive article and have advised to keep surgical intervention at a minimum in patients with these risk factors. More and long-term research should be done to investigate the impact of surgical procedures to reduce disease-related comorbidity
feel that an important concept in student education has been made by an article recently published in this journal.1 While the path to becoming a US physician might differ from that in Europe, and specifically the United Kingdom, I agree with the authors’ premise that exposure to plastic surgery among medical students is limited, and I am not surprised by their findings. Clearly, early exposure improves student’s decision making, reduces incorrect
Conflicts of interest and sources of funding: none declared. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7603–0364 DOI: 10.1097/SAP.0000000000000737
Conflicts of interest and sources of funding: none declared. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7603–0364 DOI: 10.1097/SAP.0000000000000736
W
364
www.annalsplasticsurgery.com
Pinar Incel Uysal, MD Ferda Artuz, MD Department of Dermatology Ankara Numune Training and Research Hospital Ankara, Turkey [email protected]
REFERENCES 1. Cabalag MS, Wasiak J, Lim SW, et al. Inpatient management of pyoderma gangrenosum: treatments, outcomes, and clinical implications. Ann Plast Surg. 2015;74:354–360. 2. Ouazzani A, Berthe JV, de Fontaine S. Post-surgical pyoderma gangrenosum: a clinical entity. Acta Chir Belg. 2007;107:424–428. 3. Ahronowitz I, Harp J, Shinkai K. Etiology and management of pyoderma gangrenosum: a comprehensive review. Am J Clin Dermatol. 2012;13:191–211. 4. Zuo KJ, Fung E, Tredget EE, et al. A systematic review of post-surgical pyoderma gangrenosum: identification of risk factors and proposed management strategy. J Plast Reconstr Aesthet Surg. 2015;68:295–303. 5. Bennett ML, Jackson JM, Jorizzo JL, et al. Pyoderma gangrenosum. A comparison of typical and atypical forms with an emphasis on time to remission. Case review of 86 patients from 2 institutions. Medicine (Baltimore). 2000;79:37–46.
Plastic Surgery Undergraduate Training How a Single Local Event Can Inspire and Educate Medical Students
I
perceptions, and benefits plastic surgery as a whole. Early exposure to plastic surgery had a big impact on my preparation to become a plastic surgeon. As such, it allowed me to research the demands of the field and the competitiveness of the specialty, which helped me focus on academics, STEP scores, and what plastic surgery programs are looking for in a candidate. Those who get their exposure later in medical school have less time to do these things. I believe a similar national program to educate premedical and medical students about plastic surgery would have a positive impact. The authors report on the role of a national UK event, educating students about the practice of plastic surgery. In the United States, misconceptions about the practice of plastic surgery are rampant. Students wanting to pursue a career in medicine enter a university for approximately 4 years after high school and obtain an education, which does not necessarily have a focus on medicine. Although prerequisite classes for entry into medical school exist, the overall education at a university is broad. After entry into medical school, students spend the first 2 years learning the basic sciences, having little clinical exposure. By the time they reach the clinical clerkships of the third year, many do not know what encompasses each specialty, let alone what specialty they will choose. They have spent the last 6 years in basic sciences. During the last 2 years of medical school, students are given times for electives, to explore different specialties. However, this happens late in medical school, and experiences vary depending on attending physicians, residents, and the time of the year. As the number of integrated plastic surgery residency programs increases, medical students have the opportunity to match directly into a plastic surgery residency, which reduces the time for decision making. The integrated plastic surgery residency is one of the most competitive residency programs currently in the United States, making it even more important for medical students to know early on if this specialty is the right fit, so that more effort can be put into preparing for the residency match process. Unfortunately, practical surgical skills are sometimes not taught until one’s surgical rotation in the junior year of medical school, the timing of which depends on the schedule of the medical student. This means that surgical skills, for some, are not learned until the end of the junior year, with exposure to plastic surgery in particular being limited. If not assigned to a plastic surgery service, and if a medical student does not want to take it as an elective rotation, some medical students can graduate and become physicians without ever having experienced what plastic surgery encompasses. Having an event where medical students are exposed to more information about the specialty and have hands-on exposure to certain skills required for it is a much-needed change
Annals of Plastic Surgery • Volume 76, Number 3, March 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 76, Number 3, March 2016
in our curriculum. Even if the students do not end up pursuing plastic surgery as a career, they, at the very least, will know what plastic surgeons do and be better able to refer patients in need of plastic surgery. The variety of plastic surgery subspecialties, such as craniofacial, hand, and flap reconstruction, is also important for students to know about. Having a time for students to listen to all of this explained, as well as other helpful information about the path to a plastic surgery residency, will be an enormous benefit. As shown in a study by Greene and May,2 medical schools that provided greater exposure to plastic surgery and schools with plastic surgery training had a higher percentage of
graduates applying to plastic surgery residency. The authors recognized exposure to plastic surgery as the most influential factor in the student’s decision-making process for careers in the field. Most of the students surveyed decided on plastic survey as their career choice during their third year of medical school. In summary, having a favorable exposure to a particular specialty has been shown to impact medical student career choice. An event for students to spread awareness of what the field of plastic surgery does is beneficial, as shown in the study. To engage medical students, educate them about how to pursue this as a career, and teach them surgical skills not otherwise taught in medical school are
© 2016 Wolters Kluwer Health, Inc. All rights reserved.
Letters to the Editor
a worthy aim and something that should be offered. Amanda Daggett, BA School of Medicine University of Mississippi Jackson, MS [email protected]
REFERENCES 1. Khatib M, Soukup B, Boughton O, et al. Plastic surgery undergraduate training: how a single local event can inspire and educate medical students. Ann Plast Surg. 2015;75:208–212. 2. Greene AK, May JW Jr. Applying to plastic surgery residency: factors associated with medical student career choice. Plast Reconstr Surg. 2008;121:1049–1053; discussion 1054.
www.annalsplasticsurgery.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
365
and adverse effects of systemic immunosuppressants. It would have been better if the authors have mentioned the percentages of surgical approaches among PG subtypes, ulceration sizes, and localizations and associated comorbidities. Despite advances in medical therapy, the prognosis of PG remains unpredictable and, if untreated, almost always fatal. We thought that the clinical photographs of the patient who had shown complete healing with medical and surgical treatment, at the time of diagnosis and after the treatment, would be helpful. We would like to thank the authors for their contributions to our therapeutic perspectives of stable ulcerations of PG.
To the Editor: e have read the article by Cabalag et al1 with interest. The authors have retrospectively analyzed 29 patients who received a diagnosis of and were treated for pyoderma gangrenosum (PG). They have proposed an algorithm. Pyoderma gangrenosum is a rare skin disorder that may arise spontaneously or following cutaneous injury. We agree that surgery should be considered in conjunction with both hyperbaric oxygen and immunosuppressive therapy to reduce disease-related morbidity in classic ulcerative PG. Despite the fact that medical therapies are the cornerstone of therapy, corticosteroids and cytotoxic therapies may lead to serious adverse effects. On the basis of demographical data, mean age of cases, most of whom had systemic comorbidities, was 71 years.1 Pyoderma gangrenosum was reported to be encountered most often in the third to sixth decade; therefore, in our opinion, the complications secondary to medical treatments were seen in higher proportion (65.7%) in the authors’ series. The authors have mentioned the limited role of surgical interventions because of potential triggering or worsening PG due to pathergy. Postsurgical PG was first described by Ouazzani et al.2 Notably, it was a rare but serious complication.3 This was due to diagnostic challenge that surgical intervention was performed routinely before suspicion of the disease and resulted with the sequelae of multiple surgical interventions. As medical therapy failed to induce complete healing, surgical therapy might have been occasionally performed.4 However; there were reports indicating failure of graft or flap after surgical intervention.5 Risk factors included a history of PG, hematologic disorders, inflammatory bowel disease, rheumatoid arthritis, and a first-degree relative with PG. For the patients with these risks who were undergoing surgery, full consideration needed to be given to the use of perioperative immunosuppressive therapy.4 Thus, in our opinion, the authors should have mentioned the term postsurgical PG in this comprehensive article and have advised to keep surgical intervention at a minimum in patients with these risk factors. More and long-term research should be done to investigate the impact of surgical procedures to reduce disease-related comorbidity
feel that an important concept in student education has been made by an article recently published in this journal.1 While the path to becoming a US physician might differ from that in Europe, and specifically the United Kingdom, I agree with the authors’ premise that exposure to plastic surgery among medical students is limited, and I am not surprised by their findings. Clearly, early exposure improves student’s decision making, reduces incorrect
Conflicts of interest and sources of funding: none declared. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7603–0364 DOI: 10.1097/SAP.0000000000000737
Conflicts of interest and sources of funding: none declared. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7603–0364 DOI: 10.1097/SAP.0000000000000736
W
364
www.annalsplasticsurgery.com
Pinar Incel Uysal, MD Ferda Artuz, MD Department of Dermatology Ankara Numune Training and Research Hospital Ankara, Turkey [email protected]
REFERENCES 1. Cabalag MS, Wasiak J, Lim SW, et al. Inpatient management of pyoderma gangrenosum: treatments, outcomes, and clinical implications. Ann Plast Surg. 2015;74:354–360. 2. Ouazzani A, Berthe JV, de Fontaine S. Post-surgical pyoderma gangrenosum: a clinical entity. Acta Chir Belg. 2007;107:424–428. 3. Ahronowitz I, Harp J, Shinkai K. Etiology and management of pyoderma gangrenosum: a comprehensive review. Am J Clin Dermatol. 2012;13:191–211. 4. Zuo KJ, Fung E, Tredget EE, et al. A systematic review of post-surgical pyoderma gangrenosum: identification of risk factors and proposed management strategy. J Plast Reconstr Aesthet Surg. 2015;68:295–303. 5. Bennett ML, Jackson JM, Jorizzo JL, et al. Pyoderma gangrenosum. A comparison of typical and atypical forms with an emphasis on time to remission. Case review of 86 patients from 2 institutions. Medicine (Baltimore). 2000;79:37–46.
Plastic Surgery Undergraduate Training How a Single Local Event Can Inspire and Educate Medical Students
I
perceptions, and benefits plastic surgery as a whole. Early exposure to plastic surgery had a big impact on my preparation to become a plastic surgeon. As such, it allowed me to research the demands of the field and the competitiveness of the specialty, which helped me focus on academics, STEP scores, and what plastic surgery programs are looking for in a candidate. Those who get their exposure later in medical school have less time to do these things. I believe a similar national program to educate premedical and medical students about plastic surgery would have a positive impact. The authors report on the role of a national UK event, educating students about the practice of plastic surgery. In the United States, misconceptions about the practice of plastic surgery are rampant. Students wanting to pursue a career in medicine enter a university for approximately 4 years after high school and obtain an education, which does not necessarily have a focus on medicine. Although prerequisite classes for entry into medical school exist, the overall education at a university is broad. After entry into medical school, students spend the first 2 years learning the basic sciences, having little clinical exposure. By the time they reach the clinical clerkships of the third year, many do not know what encompasses each specialty, let alone what specialty they will choose. They have spent the last 6 years in basic sciences. During the last 2 years of medical school, students are given times for electives, to explore different specialties. However, this happens late in medical school, and experiences vary depending on attending physicians, residents, and the time of the year. As the number of integrated plastic surgery residency programs increases, medical students have the opportunity to match directly into a plastic surgery residency, which reduces the time for decision making. The integrated plastic surgery residency is one of the most competitive residency programs currently in the United States, making it even more important for medical students to know early on if this specialty is the right fit, so that more effort can be put into preparing for the residency match process. Unfortunately, practical surgical skills are sometimes not taught until one’s surgical rotation in the junior year of medical school, the timing of which depends on the schedule of the medical student. This means that surgical skills, for some, are not learned until the end of the junior year, with exposure to plastic surgery in particular being limited. If not assigned to a plastic surgery service, and if a medical student does not want to take it as an elective rotation, some medical students can graduate and become physicians without ever having experienced what plastic surgery encompasses. Having an event where medical students are exposed to more information about the specialty and have hands-on exposure to certain skills required for it is a much-needed change
Annals of Plastic Surgery • Volume 76, Number 3, March 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 76, Number 3, March 2016
in our curriculum. Even if the students do not end up pursuing plastic surgery as a career, they, at the very least, will know what plastic surgeons do and be better able to refer patients in need of plastic surgery. The variety of plastic surgery subspecialties, such as craniofacial, hand, and flap reconstruction, is also important for students to know about. Having a time for students to listen to all of this explained, as well as other helpful information about the path to a plastic surgery residency, will be an enormous benefit. As shown in a study by Greene and May,2 medical schools that provided greater exposure to plastic surgery and schools with plastic surgery training had a higher percentage of
graduates applying to plastic surgery residency. The authors recognized exposure to plastic surgery as the most influential factor in the student’s decision-making process for careers in the field. Most of the students surveyed decided on plastic survey as their career choice during their third year of medical school. In summary, having a favorable exposure to a particular specialty has been shown to impact medical student career choice. An event for students to spread awareness of what the field of plastic surgery does is beneficial, as shown in the study. To engage medical students, educate them about how to pursue this as a career, and teach them surgical skills not otherwise taught in medical school are
© 2016 Wolters Kluwer Health, Inc. All rights reserved.
Letters to the Editor
a worthy aim and something that should be offered. Amanda Daggett, BA School of Medicine University of Mississippi Jackson, MS [email protected]
REFERENCES 1. Khatib M, Soukup B, Boughton O, et al. Plastic surgery undergraduate training: how a single local event can inspire and educate medical students. Ann Plast Surg. 2015;75:208–212. 2. Greene AK, May JW Jr. Applying to plastic surgery residency: factors associated with medical student career choice. Plast Reconstr Surg. 2008;121:1049–1053; discussion 1054.
www.annalsplasticsurgery.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
365
