Perioperative Use of Antiestrogen Therapies in Breast Reconstruction: A Systematic Review and Treatment Recommendations.

BACKGROUND: Patients with hormone receptor-positive breast tumors receive hormonal therapy with either selective estrogen receptor modulators (SERMs) (eg, tamoxifen) or aromatase inhibitors (AIs) (eg, anastrozole) for 5 to 10 years. Patients are using these therapies frequently during breast reconstruction. Literature investigating the effects of hormonal modulators on breast reconstruction outcomes demonstrates conflicting results. We sought to perform a systematic evaluation to assess the effects of hormonal therapy on breast reconstruction outcomes and to guide perioperative management of antiestrogen therapies. METHODS: A MEDLINE, PubMed, and EBSCO Host search of articles regarding the effects of SERMs and AIs on breast reconstruction was performed. Outcomes evaluated included wound complications, total or partial flap loss, and thromboembolic events. Included studies were assigned Methodological Index for Nonrandomized Studies quality scores. RESULTS: A total of 2581 flaps were analyzed for complete loss: patients taking SERMs at the time of reconstruction had higher rates of flap loss compared with patients not taking hormone modulators (P < 0.001). Flap loss was not affected by concurrent AI use (P = 0.11). Both SERMs and AIs had an increased risk of donor site complications (P = 0.0021 and P < 0.0001, respectively). Neither hormone modulator had an effect on flap wound complications or venous thromboembolic event rates. CONCLUSIONS: Evidence indicates patients using SERMs at the time of operation are at an increased risk of flap loss and those taking either SERMs or AIs have higher rates of donor site complications. These findings support holding these medications for 1 to 2 half lives (tamoxifen, 14-28 days; AIs, 2-4 days) preoperatively.

Pediatric pyoderma gangrenosum: is it just big wounds on little adults?

BACKGROUND: Pyoderma gangrenosum (PG) is an uncommon, ulcerative, cutaneous condition, often caused by surgical trauma that can masquerade as a pyogenic disease process requiring debridement and antibiotics. Treatment is, however, medical, with delay leading to significant morbidity. In addition, medical workup for coincident disorders has been suggested. The purpose of this study was to test the hypothesis that pediatric PG has differing disease associations and therefore requires a differing medical workup. METHODS: The National Inpatient Sample and the Kids' Inpatient Database were used to identify all hospitalized patients with PG. PG patients were identified using International Classification of Diseases-9 code and divided into adults and children. For each age group, the PG patients were compared with non-PG patients. The Breslow-Day test was used to determine the relationship between PG and associated diagnoses. RESULTS: There were 204 of 7,384,591 children and 10,154 of 89,674,318 adults with PG. Both adult and pediatric PG patients were more likely to be female and have arteritis, arthropathy, and colitis. The PG children had a significantly greater odds ratio for having arteritis, arthropathy, and colitis but not malignancy when compared to adults. CONCLUSIONS: This is the largest study of PG in adult and child populations. It validates the associations known regarding adult PG while demonstrating that pediatric PG is much more highly associated with gastroenterologic, rheumatologic, and vascular issues and less likely to be coincident with malignancy. These differences demonstrate a need to approach the disease differently in the pediatric population, with regard to associated diagnosis.

C-spine injury and mandibular fractures: lifesaver broken in two spots.

BACKGROUND: Trauma is a leading cause of injury and mortality and may involve mandibular fractures and cervical spine injuries. Manipulation of the spine during trauma protocols and operative treatment has the potential to cause serious spinal cord injuries. The purpose of this study was to identify risk factors associated with cervical spine injury (CSI) in patients with mandibular fractures. METHODS: The National Trauma Databank (2007-2010) was used to identify patients with mandibular fractures. RESULTS: A total of 59,028 patients were identified and separated into adult and pediatric cohorts. There were 50,711 adults (86%) and 8317 children (14%). There were statistically significant lower rates of associated CSI in pediatric patients than adults (3.5% versus 7.3%, P < 0.01). Predictors of associated CSI in mandible fractures for both adults and children were older age, lower Glasgow Coma Scale, thoracic injuries, firearm or motor vehicle accident mechanisms, and symphyseal fractures. In the pediatric cohort, body, ramus, and subcondylar fractures were significantly associated with CSI. In adults, female gender, and upper extremity, abdominopelvic, and head injuries were also significantly associated with CSI. CONCLUSIONS: Multiple mandibular fractures were inversely correlated with CSI. One possibility is that energy dissipation in the mandible with multiple fractures is protective of the C-spine leading to fewer fractures. Children and adults had different associations in the pattern of mandible fractures concomitant with CSI. This has implications in management, imaging, and workup of trauma patients.

Long-Term Pulmonary Sequelae After Inhalation Injury: A Retrospective Case-Control Study.

Inhalation injury (INHI) has strong associations with increased rates of in-patient mortality and pneumonia. This study's aim is to review long-term pulmonary outcomes in INHI patients. We present a retrospective cohort of burn patients admitted to an ABA-certified burn unit. Burn patients with or without medically confirmed INHI who were admitted were studied. The control groups were ventilated patients (V) and nonventilated patients (NV). Primary study outcomes were rates of postdischarge pulmonary sequelae, including ineffective airway clearance, infections, shortness of breath, and malignancy. Secondary outcomes included rates of postdischarge surgeries and readmission, postdischarge nonpulmonary sequelae, and postdischarge days to pulmonary/nonpulmonary sequelae. The study population included 33 INHI, 45 V, and 50 NV patients. There were no significant differences in age (P = .98), sex (P = .68), % TBSA (P = .18), pulmonary comorbidity (P = .5), or smoking status (P = .92). Outpatient pulmonary sequelae were significantly higher for both INHI and V groups as compared to NV (21% and 17% vs 4%, P = .023, .043). The number of days from discharge to pulmonary sequelae was significantly shorter in the INHI group vs the V group (162 ± 139 vs 513 ± 314 days, P = .024). All other measures were not significant when comparing INHI to V or NV (P > .05). Both INHI and V groups resulted in higher rates of outpatient pulmonary sequelae independent of inpatient course as compared to NV. While outpatient pulmonary sequelae were not significantly different between INHI and V, the INHI patients presented with complaints earlier.

Burn Patient Insurance Status Influences Hospital Discharge Disposition and Utilization of Postdischarge Outpatient Care.

Postdischarge services, such as outpatient wound care, may affect long-term health outcomes and postrecovery quality-of-life. Access to these services may vary according to insurance status and ability to cover out-of-pocket expenses. Our objective was to compare discharge location between burn patients who were uninsured, publicly insured, and privately insured at the time of their burn unit admissions. A retrospective review from July 1, 2015 to November 1, 2019 was performed at an American Burn Association-verified burn center. All admitted burn patients 18 years and older were identified and categorized according to insurance payer type. The primary outcome was discharge location, and secondary outcomes included readmission and outpatient burn care attendance. In total, 284 uninsured, 565 publicly insured, and 293 privately insured patients were identified. There were no significant differences in TBSA (P = .3), inhalation injury (P = .3), intensive care unit days (P = .09), or need for skin grafting (P = .1) between the three groups. For primary outcome, uninsured patients were more likely to be discharged without ancillary services (P < .0001) compared to both publicly and privately insured. Publicly insured patients were more likely to receive skilled nursing care (P = .0007). Privately insured patients were more likely to receive homecare (P = .0005) or transfer for ongoing inpatient care (P < .0001). There was no difference in burn unit readmission rates (P = .5). The uninsured were more likely to follow up with outpatient burn clinic after discharge (P = .004). Uninsured patients were less likely to receive postdischarge resources. Uninsured patients received fewer postdischarge wound care resources which could result in suboptimal long-term results, and diminished return to preinjury functional status. Given the impact of insurance status on discharge location and resources, efforts to increase access for uninsured patients to postdischarge resources will ensure greater healthcare equity and improve quality of comprehensive care regardless of insurance status.

Evaluation of the Role of a Clinical Pharmacist on Medication Management in an Adult Burn Clinic via a Collaborative Drug Therapy Management Protocol.

Historically, pharmacists have not been formally involved in managing burn clinic patients. Collaborative Drug Therapy Management (CDTM) protocols allow pharmacists working within a defined context to independently assume responsibility for direct patient care activities. The objective of this study was to evaluate the number and type of medication-related interventions made by a clinical pharmacist, in an adult burn clinic, via a CDTM protocol. The protocol allows pharmacists to independently manage the following disease states: pain, agitation, delirium, insomnia, venous thromboembolism, skin/soft tissue infections, and hypermetabolic complications. All pharmacist visits between 1/1/22 and 9/22/22 were included. A total of 16 patients were seen at 28 visits with a clinical pharmacist for a total of 148 interventions. Patients were mostly males (81%) with a mean ± SD age of 41 ± 15 years. The majority of patients were in-state (94%), with 9 (56%) being from an outlying county. Patients were seen for a median (IQR) of 2 (1,2) visits. Interventions were made at all visits (100%) with a median of 5 (4,6) per visit. Interventions (per visit) included medication reconciliation [28 (100%)], a median of 1 (0,2) medication ordered or adjusted, labs ordered at 7 (25%) visits, with adherence and patient education both reviewed at over 90% of visits. To the best of our knowledge, ours is the first burn center to implement a Clinical Pharmacist CDTM Protocol, with a pharmacist directly impacting transitions of care. This may serve as a framework for other sites. Future directions include continuing to track data for medication adherence and access, billing/reimbursement, and clinical outcomes.

The Impact of Race/Ethnicity on the Outcomes of Burn Patients: A Systematic Review of the Literature.

Racial and ethnic disparities are endemic to the United States and are only beginning to attract the attention of researchers. With an increasingly diverse population, focused and tailored medicine to provide more equitable care is needed. For surgical trauma populations, this topic is a small but expanding field and still rarely mentioned in burn medicine. Disparities in prevention, treatment, and recovery outcomes between different racial and ethnic minorities who are burned are rarely discussed. The purpose of this study is to determine the current status of identified disparities of care in the burn population literature and areas of future research. A systematic review was conducted of literature utilizing PubMed for articles published between 2000 and 2020. Searches were used to identify articles that crossed the burn term (burn patient OR burn recovery OR burn survivor OR burn care) and a race/ethnicity and insurance status-related term (race/ethnicity OR African-American OR Black OR Asian OR Hispanic OR Latino OR Native American OR Indigenous OR Mixed race OR 2 or more races OR socioeconomic status OR insurance status). Inclusion criteria were English studies in the United States that discussed disparities in burn injury outcomes or risk factors associated with race/ethnicity. One thousand one hundred and sixty-nine papers were populated, 55 were reviewed, and 36 articles met inclusion criteria. Most studies showed minorities had poorer inpatient and outpatient outcomes. While this is a concerning trend, there is a paucity of literature in this field and more research is needed to create culturally tailored medical care and address the needs of disadvantaged burn survivors.

Incisions and reconstruction approaches for large sarcomas.

Large intraabdominal, retroperitoneal, and abdominal wall sarcomas provide unique challenges in treatment due to their variable histology, potential considerable size at the time of diagnosis, and the ability to invade into critical structures. Historically, some of these tumors were considered inoperable if surgical access was limited or the consequential defect was unable to be closed primarily as reconstructive options were limited. Over time, there has been a greater understanding of the abdominal wall anatomy and mechanics, which has resulted in the development of new techniques to allow for sound oncologic resections and viable, durable options for abdominal wall reconstruction. Currently, intra-operative positioning and employment of a variety of abdominal and posterior trunk incisions have made more intraabdominal and retroperitoneal tumors accessible. Primary involvement or direct invasion of tumor into the abdominal wall is no longer prohibitive as utilization of advanced hernia repair techniques along with the application of vascularized tissue transfer have been shown to have the ability to repair large area defects involving multiple quadrants of the abdominal wall. Both local and distant free tissue transfer may be incorporated, depending on the size and location of the area needing reconstruction and what residual structures are remaining surrounding the resection bed. There is an emphasis on selecting the techniques that will be associated with the least amount of morbidity yet will restore and provide the appropriate structure and function necessary for the trunk. This review article summarizes both initial surgical incisional planning for the oncologic resection and a variety of repair options for the abdominal wall spanning the reconstructive ladder.

Utility of Tongue Stitch and Nasal Trumpet in the Immediate Postoperative Outcome of Cleft Palatoplasty.

BACKGROUND: Postoperative airway obstruction is a feared complication following cleft palate repair. The aim of this study was to evaluate the effectiveness of tongue stitches and nasal trumpets that have been used in an attempt to prevent this complication. METHODS: An 8-year (2005 to 2013) retrospective review of palatoplasties performed at a tertiary care center was conducted. Patients were divided into three groups: those with no airway protective measure, those with a tongue stitch only, and a group with nasal trumpet and tongue stitch. Recorded variables included sex, age, Veau classification, and comorbidities. Primary outcomes measured were postoperative respiratory distress, readmission, and reoperation rates. RESULTS: Fifty-eight patients underwent palatoplasties with no airway protective measure, 252 patients had tongue stitch only, and 87 had tongue stitch and nasal trumpet. There were no significant differences between groups with respect to comorbidities except that cleft lip was more prevalent in the no-airway protection group than in the other two groups (p = 0.04). There was no significant difference in the incidence of reintubation, intensive care unit transfer, surgery-related readmissions, or reoperation. Respiratory complications were significantly increased in the nasal trumpet group even after adjusting for age and weight. Length of stay was also significantly (p < 0.01) shortened when comparing no airway protection to those who underwent both nasal trumpet and tongue suture placement. CONCLUSIONS: The use of a tongue stitch, with or without nasal trumpet, did not correlate with improved safety and outcomes. Patients without these airway protective measures had a shorter hospital stay. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.