Return of the Flap; The Empire State Mandate: A Multi-decade Multi-institutional Analysis of the 2010 New York State Legislature's Impact on Postmastectomy Immediate Flap-Based Reconstruction.

PURPOSE: Immediate postmastectomy breast reconstruction plays an integral role in patient care because of its psychosocial benefits. New York State (NYS) passed the 2010 Breast Cancer Provider Discussion Law with the aim of increasing patient awareness of reconstructive options through mandating plastic surgery referral at the time of cancer diagnosis. Short-term analysis of the years surrounding implementation suggests the law increased access to reconstruction, especially for certain minority groups. However, given the continued presence of disparities in access to autologous reconstruction, we aimed to investigate the longitudinal effects of the bill on access to autologous reconstruction along various sociodemographic cohorts. METHODS: Retrospective review identified demographic, socioeconomic, and clinical data for patients undergoing mastectomy with immediate reconstruction at Weill Cornell Medicine and Columbia University Irving Medical Center from 2002 to 2019. Primary outcome was receiving implant or autologous-based reconstruction. Subgroup analysis was based on sociodemographic factors. Multivariate logistic regression identified predictors of autologous reconstruction. Interrupted time series modeling analyzed differences in reconstructive trends for subgroups before and after the 2011 implementation of the NYS law. RESULTS: We included 3178 patients; 2418 (76.1%) and 760 (23.9%) patients underwent implant and autologous-based reconstruction, respectively. Multivariate analysis indicated that race, Hispanic status, and income were not predictors of autologous reconstruction. Interrupted time series showed that with each year leading up to 2011 implementation, patients were 19% less likely to receive autologous-based reconstruction. Following implementation, there was a 34% increase in the odds of receiving autologous-based reconstruction with each passing year. Following implementation, Asian American and Pacific Islander patients experienced a 55% greater increase in the rate of flap reconstruction than White patients. Following implementation, the highest-income quartile experienced a 26% greater increase in the rate of autologous-based reconstruction compared with the lowest-income quartile. After implementation, Hispanic patients experienced a 30% greater decrease in the rate of autologous-based reconstruction compared with non-Hispanic patients. CONCLUSIONS: Our data indicate the long-term efficacy of the NYS Breast Cancer Provider Discussion Law in increasing access to autologous-based reconstruction, especially for certain minority groups. These findings underscore the importance of this bill and encourage its adoption into other states.

A Comparative Analysis of Sensory Return in Delayed-Immediate Versus Immediate Neurotized Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

BACKGROUND: Breast reconstruction patients who anticipate adjuvant radiation are not suitable candidates for immediate deep inferior epigastric perforator (DIEP) flap reconstruction due to the risk of flap fibrosis, shrinkage, and fat necrosis. Rather, many of these patients undergo delayed-immediate, or "babysitter," reconstruction, where a tissue expander is placed first as a temporizing measure during adjuvant therapy before definitive flap reconstruction. In this study, we aim to compare sensory changes in delayed-immediate to immediate DIEP flap patients. METHODS: Ninety-one patients, including 26 patients (46 breasts) with "babysitter" procedures and 65 patients (120 breasts) with immediate DIEP flaps, were prospectively identified at their preoperative visit. For both cohorts, baseline level (t = 0) is defined as before mastectomy. RESULTS: "Babysitter" patients underwent final-stage neurotized flap reconstruction on average at 12 months after initial tissue expander placement (range, 3-18 months). At 18 month after mastectomy (6 months after DIEP), delayed-immediate patients had comparable sensitivity measurements as immediate DIEP flap patients in all regions of the breast (P > 0.05). For delayed immediate patients, at 18 months postoperatively, sensitivity measurements were comparable with baseline levels only in the outer superior, outer medial, and outer lateral regions of the breast (P > 0.05). At 24 months postoperatively, cutaneous thresholds were comparable with baseline in all regions of the breast except the inner inferior region (P > 0.05), following a similar sensory recovery trajectory as immediate DIEP flap patients. CONCLUSIONS: In patients who undergo "babysitter" procedures, the combination of sensory return from the native mastectomy skin flap along with the neurotized DIEP flap yields sensory recovery comparable with immediate DIEP flap patients after definitive flap reconstruction. When final-stage flap reconstruction occurs by 12 months after mastectomy, sensation can return beginning 24 months postoperatively, or even sooner in some regions of the breast.

Association between thiamine deficiency and hyperlactatemia among critically ill patients with diabetes infected by SARS-CoV-2.

BACKGROUND: The present study aims to verify the association between diabetes and thiamine deficiency in critically ill patients infected by severe acute respiratory syndrome coronavirus 2. METHODS: This is a descriptive cross-sectional study, whose demographic, anthropometric, and laboratory data (arterial lactate, bicarbonate, and plasma thiamine) were obtained in the first hours of admission to the intensive care unit. Patients with diabetes were compared with individuals without diabetes, and the correlation was performed between thiamine and lactate levels. Thiamine levels <28 µg/L were considered as thiamine deficiency. RESULTS: Overall, 270 patients met the inclusion criteria; 51.1% were men, and the median age was 74 years (66.8-81). The median value of thiamine was 54.0 µg/L (38-72.3), and 15.6% had thiamine deficiency. Among patients with diabetes, 26.3% had thiamine deficiency, and 69.3% had hyperlactatemia. There was an association between thiamine deficiency and diabetes (odds ratio 4.28; 95% CI, 2.08-8.81; P < .001). There was a strong negative correlation between thiamine and arterial lactate in patients with diabetes (r = -0.711, P < .001) and a moderate negative correlation in critically ill patients without diabetes (r = -0.489, P < .001). CONCLUSIONS: The prevalence of thiamine deficiency in critically ill patients due to coronavirus disease 2019 is higher in patients with diabetes. There is a negative correlation between thiamine and arterial lactate levels, which is higher in people with diabetes.

Association Between Low Zinc Levels and Severity of Acute Respiratory Distress Syndrome by New Coronavirus SARS-CoV-2.

BACKGROUND: We verify the prevalence of low zinc levels among critically ill patients infected by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in the intensive care unit (ICU) who required invasive mechanical ventilation, as well as its association with severity of acute respiratory distress syndrome (ARDS). METHODS: This is an observational study composed of patients admitted to the ICU. Demographics, anthropometric data for calculating body mass index (BMI), and laboratory data were obtained at admission: blood count, ferritin, arterial blood gas, serum zinc levels, and C-reactive protein. Also, arterial oxygen tension (PaO2 ) divided by fractional inspired oxygen (FiO2 ) was calculated by the first arterial blood gas after intubation. A diagnosis of severe ARDS was determined if the PaO2 /FiO2 ratio was ≤100 mm Hg. Low zinc levels were established if zinc levels were <70 µg/dL. RESULTS: A total of 269 patients met inclusion criteria; 51.3% were men; median age was 74 (66-81) years; 91.1% (245 of 269) were elderly. The median BMI was 30.1 (24.7-32.1) kg/m2 , with 59.9% (161 of 269) of patients having overweight and obesity. The prevalence of low zinc levels was 79.6% (214 of 269) and severe ARDS was 56.5% (152 of 269). There was an association of low zinc levels and severe ARDS (odds ratio [OR], 14.4; 95% CI, 6.2-33.5; P < .001), even after adjusting for baseline variables (OR, 15.4; 95% CI, 6.5-36.3; P < .001). CONCLUSION: Critically ill patients infected by SARS-CoV-2 with severe ARDS have a high prevalence of low serum zinc levels.

Prevalence of obesity and hypovitaminosis D in elderly with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

BACKGROUND & AIM: Verify the prevalence of hypovitaminosis D and obesity in elderly patients infected by new coronavirus. The patients developed severe symptoms and were admitted in intensive care unit (ICU) to receive invasive ventilation due to diagnosis of acute respiratory distress syndrome (ARDS). METHODS: A cross-sectional descriptive study composed of elderly (age ≥ 60 years) admitted to the ICU. Were collected demographic (sex, age), anthropometric data, presence of comorbidities (hypertension, diabetes, heart disease, lung, neurological and oncological diseases), severity score in ICU (SAPS III), PaO2/FiO2 ratio, analysis of C-reactive protein (CRP) and serum dosage of 25-hydroxy vitamin D (25 OHD) in the first day of hospitalization to identify elderly with hypovitaminosis D (low values < 30 ng/mL). The diagnosis of obesity in elderly was determined by calculating the body mass index (BMI) ≥ 30 kg/m2. RESULTS: A total of 176 elderly met the inclusion criteria. 54% were elderly men and mean age of 72.9 ± 9.1 years. The median BMI was 30.5 (28.1-33) kg/m2 with 68.7% having a nutritional diagnosis of obesity and 15.3% had BMI ≥ 35 kg/m2. The most prevalent comorbidities were hypertension (72.2%) and diabetes (40.9%). Prevalence of hypovitaminosis D with values of 25 OHD <30 ng/mL, < 20 ng/mL and <10 ng/mL was 93.8%, 65.9% and 21% respectively. The prevalence of hypovitaminosis D (<30 ng/mL) in obese elderly was 94.2%. There was a negative and significant bivariate correlation between BMI and levels of 25 OHD (r = - 0.15; p = 0.04). CONCLUSION: Hypovitaminosis D and obesity in elderly have a high prevalence in critically ill patients in ICU infected by the new coronavirus. Laboratory investigation of vitamin D becomes important, especially in obese elderly patients.