Predictors of Unplanned Reoperation after Gender-affirming Mastectomy: An Analysis of the NSQIP Database.

Background: Gender-affirming mastectomy (GAM) is a gender-affirmation surgery designed to remove or reduce breast tissue, with or without nipple reconstruction. GAM is the most commonly performed gender-affirmation surgery and risk factors associated with unplanned return to the operating room and reoperation continue to be investigated. This is the largest study of transgender and nonbinary patients undergoing GAM to determine predictors of unplanned reoperation. Methods: The National Surgical Quality Improvement Program database was queried for patients undergoing GAM from 2012 to 2020. The primary outcome was the incidence of unplanned reoperation within 30 days postoperatively. The secondary outcome was the indication for unplanned reoperation within this period. Descriptive statistics were calculated. Bivariate analysis and multivariate logistic regression were performed to determine significant predictors of reoperation after GAM. Results: A total of 2316 patients underwent GAM, of whom 2.2% (n = 51) underwent unplanned reoperation of the chest. The most common indication for unplanned reoperation was hematoma (n = 41, 71.9%) followed by abscess (n = 5, 8.8%). Significant predictors of reoperation were corticosteroid use [adjusted odds ratio (aOR) 95% confidence interval (CI) 5.07 (1.07-23.89)] and diabetes [aOR (CI) 10.98 (3.0-40.33)]. Hispanic/Latinx ethnicity [aOR (CI) 3.19 (1.22-8.33)] and corticosteroid use [aOR (CI) 6.81 (1.45-31.98)] were significant predictors of unplanned reoperation for hematoma evacuation after GAM. Conclusions: Diabetes mellitus and corticosteroid use were associated with unplanned reoperation after GAM. Ethnic correlations remain to be better elucidated as well as the effect of intersectionality. These findings can be used to guide patient selection and surgical decision-making.

Complications Following Tissue Expander-Based Reconstruction in Pediatric Burn Injuries: A Retrospective Analysis.

BACKGROUND: Tissue expansion has been widely used to reconstruct soft tissue defects following burn injuries in pediatric patients, allowing for satisfactory cosmetic and functional outcomes. Factors impacting the success of tissue expander (TE)-based reconstruction in these patients are poorly understood. Herein, we aim to determine the risk factors for postoperative complications following TE-based reconstruction in pediatric burn patients. METHODS: A retrospective review of pediatric patients who underwent TE placement for burn reconstruction from 2006 to 2019 was performed. Primary outcomes were major complications (TE explantation, extrusion, replacement, flap necrosis, unplanned reoperation, readmission) and wound complications (surgical site infection and wound dehiscence). Descriptive statistics were calculated. The association between primary outcomes, patient demographics, burn characteristics, and TE characteristics was assessed using the chi-squared, Fisher's exact, and Mann-Whitney U tests. RESULTS: Of 28 patients included in the study, the median [interquartile range (IQR)] age was 6.5 (3.3-11.8) years, with a follow-up of 12 (7-32) months. The majority were males [n = 20 (71%)], Black patients [n = 11 (39%)], and experienced burns due to flames [n = 78 (29%)]. Eleven (39%) patients experienced major complications, most commonly TE premature explantation [n = 6 (21%)]. Patients who experienced major complications, compared to those who did not, had a significantly greater median (IQR) % total body surface area (TBSA) [38 (27-52), 10 (5-19), P = 0.002] and number of TEs inserted [2 (2-3), 1 (1-2), P = 0.01]. Ten (36%) patients experienced wound complications, most commonly surgical site infection following TE placement [n = 6 (21%)]. Patients who experienced wound complications, compared to those who did not, had a significantly greater median (IQR) %TBSA [35 (18-45), 19 (13-24), P = 0.02]. CONCLUSION: Pediatric burn injuries involving greater than 30% TBSA and necessitating an increasing number of TEs were associated with worse postoperative complications following TE-based reconstruction.

The Impact of Surgical Timing in Orbital Fracture Repair: A New Paradigm.

PURPOSE: For decades, there has been an ongoing debate about the ideal timing of orbital fracture repair (OFR) in adults. METHODS: We conducted a retrospective review of patients who underwent OFR at two centers (2015-2019). Excluded were patients <18 years old and those with follow-up <2 weeks. Our primary outcome was the incidence/persistence of postoperative enophthalmos/diplopia at least 2 weeks following OFR. The association between surgical timing and postoperative ocular complications was assessed in patients with extraocular muscle (EOM) entrapment, enophthalmos and/or diplopia, and different fracture sizes. RESULTS: Of n=253 patients, n=13 (5.1%) had preoperative EOM entrapment. Of these, patients who had OFR within 2 days of injury were less likely to develop postoperative diplopia compared with patients who had OFR within 8-14 days (n=1/8 [12.5%], n=3/3 [100%]; P=0.018). Patients who had OFR for near-total defects within 1 week of injury were significantly less likely to have postoperative enophthalmos (n=0 [0.0%]) compared with those who had surgery after 2 weeks (n=2 [33.3%] after 15 to 28 days, n=8 [34.8%] after 28 days from injury, P<0.001). Patients who had delayed OFR for large fractures smaller than near-total defects, preoperative persistent diplopia, or enophthalmos were not at significantly greater likelihood of postoperative ocular complications compared with those who had early OFR. CONCLUSION: We recommend OFR within 2 days of injury for EOM entrapment and 1 week for near-total defects. Surgical delay up to at least 4 weeks is possible in case of less severe fractures, preoperative persistent diplopia, or enophthalmos.

The Role of the Fascia-Only Anterolateral Thigh Flap in Extremity Reconstruction: The Fascia-Only Anterolateral Thigh Flap.

BACKGROUND: Free flap selection in extremity reconstruction can be challenging. The ideal flap has to be thin and pliable to achieve optimal contour and function. We explore the role of the fascia-only anterolateral thigh (fALT) flap in extremity reconstruction. METHODS: We conducted a retrospective review of our experience using fALT-free flap for extremity reconstruction over a 2-year period. Patient demographics, mechanism of injury, flap characteristics, complications- and follow-up were recorded. Descriptive statistics were calculated. RESULTS: Twelve patients were included. The median (interquartile range [IQR]) age was 34 (28-52) years. One fALT flap was used for upper extremity reconstruction, while 11 flaps were used for lower extremity reconstruction (4 for lower third of the leg, 4 for dorsum of foot, and 3 for heel). The median (IQR) flap surface area was 90 (63-120) cm2 and time from injury to reconstruction was 10 (6-16) days. The postoperative course was uneventful for all flaps except for 1 flap failure and 1 delayed healing. The median (IQR) follow-up was 2 (1-4) months. In all cases, durable soft tissue reconstruction was achieved with no need for revisions. CONCLUSIONS: The fALT-free flap can be successfully used in extremity reconstruction. The ALT fascia has robust perfusion that allows for the harvest of a large flap that can be surfaced with a split thickness skin graft. Its thin pliable tissue provides excellent contour for the hand, distal leg, and foot that does not require future thinning, optimizing the cosmetic and functional result.

The Association Between Craniofacial Fracture Patterns and Traumatic Optic Neuropathy.

Traumatic optic neuropathy (TON) is a rare but potentially devastating complication of craniofacial trauma. Approximately half of patients with TON sustain permanent vision loss. In this study, we sought to identify the most common fracture patterns associated with TON. We performed a retrospective review of craniomaxillofacial CT scans of trauma patients who presented to the R Adams Cowley Shock Trauma Center from 2015 to 2017. Included were adult patients who had orbital fractures with or without other facial fractures. Patients diagnosed with TON by a formal ophthalmologic examination were analyzed. Craniofacial fracture patterns were identified. Bivariate analysis and multivariate logistic regression were performed to identify craniofacial fracture patterns most commonly associated with TON. A total of 574 patients with orbital fractures who met inclusion criteria [15 (2.6%)] were diagnosed with TON. The median [interquartile range (IQR)] age was 44 (28-59) years. Patients with optic canal fractures and sphenoid sinus fractures had greater odds of TON compared with patients who did not have these fracture types [adjusted odds ratio (aOR) 95% confidence interval (CI) 31.8 (2.6->100), 8.1 (2.7-24.4), respectively]. Patients who sustain optic canal and sphenoid sinus fractures in the setting of blunt facial trauma are at increased odds of having a TON. Surgeons and other physicians involved in the care of these patients should be aware of this association.

Orbital Fracture Characteristics and Outcomes in Baltimore.

Fracture characteristics and postoperative outcomes of patients presenting with orbital fractures in Baltimore remain poorly investigated. The purpose of our study was to determine the fracture patterns, etiologies, and postoperative outcomes of patients treated for orbital fractures at 2 level I trauma centers in Baltimore. A retrospective cohort study was conducted on patients who underwent orbital fracture repair at the R Adams Cowley Shock Trauma Center and the Johns Hopkins Hospital from January 2015 to December 2019. Of 374 patients, 179 (47.9%) had orbital fractures due to violent trauma, 252 (67.4%) had moderate to near-total orbital fractures, 345 (92.2%) had orbital floor involvement, and 338 (90.4%) had concomitant neurological symptoms/signs. Almost half of the patients had at least one postoperative ocular symptom/sign [n = 163/333 (48.9%)]. Patients who had orbital fractures due to violent trauma were more likely to develop postoperative ocular symptoms/signs compared with those who had orbital fractures due to nonviolent trauma [n = 88/154 (57.1%), n = 75/179 (41.9%); P = 0.006]. After controlling for factors pertaining to injury severity, there was no significant difference in patient throughput or incidence of any postoperative ocular symptom/sign after repair between the two centers. Timely management of patients with orbital fractures due to violent trauma is crucial to mitigate the risk of postoperative ocular symptoms/signs.

Surgical techniques and outcomes of thyroid chondroplasty in transfeminine individuals: A systematic review.

Thyroid chondroplasty (TC) in facial gender-affirming surgery (FGAS) is aimed at modifying the thyroid cartilage to achieve a more feminine laryngeal appearance. This study evaluated open versus endoscopic techniques to TC and associated outcomes and complications. A systematic review (SR) of articles pertaining to TC was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twelve articles representing 368 patients were included for analysis. Nine articles described open approaches, and three articles described endoscopic techniques. The rate of total complications was 4.3% (n = 12) in the open approach compared to 15% (n = 13) in the endoscopic approach. Positive esthetic results were reported in 92% of cases performed with the open approach and 90% with the endoscopic approach. In the open approach, seven (2.5%) patients requested additional removal of cartilage, and three (1.1%) requested scar revision. In the endoscopic approach, three (3.7%) patients requested additional cartilage removal. In addition, data of individuals who underwent "cervical tracheoplasty" for gender dysphoria from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was reviewed, and there was no incidence of wound or major complications among patients who underwent tracheoplasty alone. Although the advantage of the endoscopic approach is a scarless neck incision, the rate of complications is higher with the open approach. Endoscopic approaches are still not widely used, and continued investigations are warranted to improve familiarity with this approach and reduce postoperative complications.

Facial Feminization: Middle Third of the Face.

Facial feminization surgery (FFS) as applied to the midfacial region targets modifications to the nasal and malar esthetic complexes. Although a global assessment is paramount in achieving desired functional results, most patients benefit from malar feminization in the form of bony and soft tissue augmentation, and nasal feminization in the form of reductive rhinoplasty. For patients with signs of aging, additional interventions in the form of rhytidectomy are powerful adjuncts to feminization. As with FFS techniques directed toward the upper and lower thirds, the overarching goal is to obtain complementary outcomes that enhance facial harmony and beauty.

Development and validation of a risk calculator for postoperative diplopia following orbital fracture repair in adults.

Postoperative diplopia is the most common complication following orbital fracture repair (OFR). Existing evidence on its risk factors is based on single-institution studies and small sample sizes. Our study is the first multi-center study to develop and validate a risk calculator for the prediction of postoperative diplopia following OFR. We reviewed trauma patients who underwent OFR at two high-volume trauma centers (2015-2019). Excluded were patients < 18 years old and those with postoperative follow-up < 2 weeks. Our primary outcome was incidence/persistence of postoperative diplopia at ≥ 2 weeks. A risk model for the prediction of postoperative diplopia was derived using a development dataset (70% of population) and validated using a validation dataset (remaining 30%). The C-statistic and Hosmer-Lemeshow tests were used to assess the risk model accuracy. A total of n = 254 adults were analyzed. The factors that predicted postoperative diplopia were: age at injury, preoperative enophthalmos, fracture size/displacement, surgical timing, globe/soft tissue repair, and medial wall involvement. Our predictive model had excellent discrimination (C-statistic = 80.4%), calibration (P = 0.2), and validation (C-statistic = 80%). Our model rules out postoperative diplopia with a 100% sensitivity and negative predictive value (NPV) for a probability < 8.9%. Our predictive model rules out postoperative diplopia with an 87.9% sensitivity and a 95.8% NPV for a probability < 13.4%. We designed the first validated risk calculator that can be used as a powerful screening tool to rule out postoperative diplopia following OFR in adults.

Association of High Body Mass Index With Postoperative Complications After Chest Masculinization Surgery.

PURPOSE: Body mass index (BMI) requirements for transgender and nonbinary patients undergoing chest masculinization surgery (CMS) are not standardized and based on small sample sizes. This is the largest and first national retrospective study to determine the association between BMI and postoperative complications. METHODS: The National Surgical Quality Improvement Program 2012-2020 was queried for CMS patients. The primary outcome was incidence of at least one complication within 30 days. Secondary outcomes were incidence of major and minor complications. Body mass index (in kilograms per square meter) was categorized as category 0 (<30), 1 (30-34.9), 2 (35-39.9), 3 (40-44.9), 4 (45-49.9), and 5 (≥50). Logistic regression was used to evaluate the association between BMI and outcomes. RESULTS: Of 2317 patients, median BMI was 27.4 kg/m 2 (interquartile range, 23.4-32.2 kg/m 2 ). Body mass index range was 15.6 to 64.9 kg/m 2 . While increasing BMI was significantly associated with greater odds of at least one complication, no patients experienced severe morbidity, regardless of BMI. Patients with BMI ≥50 kg/m 2 had an adjusted odds ratio [aOR, 95% confidence interval (CI)] of 3.63 (1.02-12.85) and 36.62 (2.96->100) greater odds of at least one complication and urinary tract infection compared with nonobese patients, respectively. Patients with BMI ≥35 kg/m 2 had an adjusted odds ratio (95% CI) of 5.06 (1.5-17.04) and 5.13 (1.89-13.95) greater odds of readmission and surgical site infection compared with nonobese patients, respectively. CONCLUSIONS: Chest masculinization surgery in higher BMI patients is associated with greater odds of unplanned readmission. Given the low risk for severe complications in higher BMI individuals, we recommend re-evaluation of BMI cutoffs for CMS patients.

Postoperative Regret Among Transgender and Gender-Diverse Recipients of Gender-Affirming Surgery.

This Viewpoint examines prevalence of and factors associated with surgical regret among transgender and gender-diverse individuals who undergo gender-affirming surgery.

Performance and oncologic safety of sentinel lymph node biopsy after neoadjuvant chemotherapy: Results from a tertiary care center in Lebanon.

BACKGROUND: The feasibility of sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NACT) in initially node-positive patients is still controversial. We aim to evaluate the oncologic outcomes of SLNB after NACT and further compare the results between those who were initially node-negative and node-positive. METHODS: This is a retrospective cohort that included patients diagnosed with invasive breast cancer and had surgical management between January 2010 and December 2016. Survival and recurrence data after 3-5 years were collected from patients' records. We divided patients into Group A who were initially node-negative and had SLNB ± axillary lymph node dissection (ALND) and Group B who were node-positive and had SLNB ± ALND. RESULTS: Among initially node-negative patients, 43 out of 63 patients did SLNB (Group A). However, among initially node-positive patients only 28 out of 123 patients did SLNB (Group B). Out of the 71 patients who did SLNB after NACT, 26 patients had positive SLNs with only 14 patients who further underwent ALND. The identification rate of SLNB was 100% in Group A and 96.4% in Group B. The survival curves by nodal status showed no significant difference between overall survival and recurrence-free survival at 5 years between patients in Group A versus Group. CONCLUSION: The results suggest that in properly selected patients, SLNB can be feasible after NACT. Our results resemble the reported literature on accuracy of SLNB after NACT and adds to the growing pool of data on this topic.

Predictors of Postoperative Diplopia Following Orbital Fracture Repair in Adults.

PURPOSE: Postoperative diplopia is reported in up to 52% of orbital bone fracture (OBF) repair. Evidence on these risk factors is based on low-quality data, single-institution studies, and small sample sizes. Our study is the largest and first multi-center study to determine the predictors of postoperative diplopia following OBF repair. METHODS: We conducted a retrospective review of patients who underwent OBF repair at two centers from 2015 to 2019. Our primary outcome was the incidence or persistence of postoperative diplopia at least 2 weeks following OBF repair. Descriptive statistics were calculated. Multivariable logistic regression was performed to determine significant predictors of postoperative diplopia. RESULTS: Of 254 patients, the median (interquartile range [IQR]) age was 36.1 (27.8-50.7) years, and the median (IQR) follow-up was 79.5 (40.3-157.3) days. The most common postoperative ocular symptom was diplopia [n=51/254 (20.1%)]. Patients who had preoperative limited ocular motility or enophthalmos had adjusted odds ratio [aOR] (95% confidence interval [CI]) 2.33 (1.03-5.24) and 2.35 (1.06-5.24) the odds of developing postoperative diplopia, compared to patients who did not have these preoperative symptoms, respectively. Patients who had combined orbital floor and medial wall and moderate OBF (>2 cm2 defect or >3 mm displacement) on preoperative CT scan had aOR (95% CI) 2.16 (1.04-4.46) and 3.77 (1.44-9.83) the odds of developing postoperative diplopia, compared to patients without these preoperative CT findings, respectively. CONCLUSION: During primary assessment of the patient with OBF, preoperative ocular signs and symptoms, fracture severity, and location of OBF are key predictors of postoperative diplopia.

Temporal Trends in Gender Affirmation Surgery Among Transgender and Non-Binary Minors.

BACKGROUND: Over the last decade, a greater number of transgender or non-binary (TGNB) minors have been seeking gender affirmation surgery (GAS). Given the recent concerns about the potential harm of GAS in TGNB minors, we sought to determine the incidence and postoperative outcomes of GAS among TGNB minors. METHODS: We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric database, 2018-2021, for minors aged 17 years or younger. The primary outcome was the frequency and type of GAS plotted over time. The secondary outcome was the incidence of postoperative complications within 30 days following GAS. Descriptive statistics were calculated. Linear regression was performed to assess the association between the incidence of GAS and time in years. RESULTS: A total of 108 TGNB minors were identified. The mean (SD) age was 16.9 (0.8) years without significant variation over time. There was a significant increase in the number of GAS per year over four years (P<.001). Nevertheless, only two (1.9%) patients underwent GAS below the age of 15 (13.9 and 14.5 years). Chest masculinization surgery (CMS) was the predominant procedure type among TGNB minors (n=102, 94.4%). There was no incidence of major complications (mortality, bleeding, sepsis, unplanned intubation) except for unplanned reoperation for hematoma evacuation (n=3, 2.8%). The incidence of minor complications (surgical site infection, wound dehiscence) was low (n=1, 0.9%), each). CONCLUSIONS AND RELEVANCE: GAS in minors, primarily in the form of CMS, has been increasing over time. CMS in minors is a safe procedure with rare complications.

Conflict of interest in the peer review process: A survey of peer review reports.

OBJECTIVES: To assess the extent to which peer reviewers and journals editors address study funding and authors' conflicts of interests (COI). Also, we aimed to assess the extent to which peer reviewers and journals editors reported and commented on their own or each other's COI. STUDY DESIGN AND METHODS: We conducted a systematic survey of original studies published in open access peer reviewed journals that publish their peer review reports. Using REDCap, we collected data in duplicate and independently from journals' websites and articles' peer review reports. RESULTS: We included a sample of original studies (N = 144) and a second one of randomized clinical trials (N = 115) RCTs. In both samples, and for the majority of studies, reviewers reported absence of COI (70% and 66%), while substantive percentages of reviewers did not report on COI (28% and 30%) and only small percentages reported any COI (2% and 4%). For both samples, none of the editors whose names were publicly posted reported on COI. The percentages of peer reviewers commenting on the study funding, authors' COI, editors' COI, or their own COI ranged between 0 and 2% in either one of the two samples. 25% and 7% of editors respectively in the two samples commented on study funding, while none commented on authors' COI, peer reviewers' COI, or their own COI. The percentages of authors commenting in their response letters on the study funding, peer reviewers' COI, editors' COI, or their own COI ranged between 0 and 3% in either one of the two samples. CONCLUSION: The percentages of peer reviewers and journals editors who addressed study funding and authors' COI and were extremely low. In addition, peer reviewers and journal editors rarely reported their own COI, or commented on their own or on each other's COI.

Pediatric Orbital Fractures.

The unique anatomy and physiology of the growing craniofacial skeleton predispose children to different fracture patterns as compared to adults. Diagnosis and treatment of pediatric orbital fractures can be challenging. A thorough history and physical examination are essential for the diagnosis of pediatric orbital fractures. Physicians should be aware of symptoms and signs suggestive of trapdoor fractures with soft tissue entrapment including symptomatic diplopia with positive forced ductions, restricted ocular motility (regardless of conjunctival abnormalities), nausea/vomiting, bradycardia, vertical orbital dystopia, enophthalmos, and hypoglobus. Equivocal radiologic evidence of soft tissue entrapment should not withhold surgery. A multidisciplinary approach is recommended for the accurate diagnosis and proper management of pediatric orbital fractures.

Predictors of surgical site infection following reconstructive flap surgery: A multi-institutional analysis of 37,177 patients.

Purpose: Rates of surgical site infection (SSI) following reconstructive flap surgeries (RFS) vary according to flap recipient site, potentially leading to flap failure. This is the largest study to determine predictors of SSI following RFS across recipient sites. Methods: The National Surgical Quality Improvement Program database was queried for patients undergoing any flap procedure from years 2005 to 2020. RFS involving grafts, skin flaps, or flaps with unknown recipient site were excluded. Patients were stratified according to recipient site: breast, trunk, head and neck (H&N), upper and lower extremities (UE&LE). The primary outcome was the incidence of SSI within 30 days following surgery. Descriptive statistics were calculated. Bivariate analysis and multivariate logistic regression were performed to determine predictors of SSI following RFS. Results: 37,177 patients underwent RFS, of whom 7.5% (n = 2,776) developed SSI. A significantly greater proportion of patients who underwent LE (n = 318, 10.7%) and trunk (n = 1,091, 10.4%) reconstruction developed SSI compared to those who underwent breast (n = 1,201, 6.3%), UE (n = 32, 4.4%), and H&N (n = 100, 4.2%) reconstruction (p < .001). Longer operating times were significant predictors of SSI following RFS across all sites. The strongest predictors of SSI were presence of open wound following trunk and H&N reconstruction [adjusted odds ratio (aOR) 95% confidence interval (CI) 1.82 (1.57-2.11) and 1.75 (1.57-1.95)], disseminated cancer following LE reconstruction [aOR (CI) 3.58 (2.324-5.53)], and history of cardiovascular accident or stroke following breast reconstruction [aOR (CI) 16.97 (2.72-105.82)]. Conclusion: Longer operating time was a significant predictor of SSI regardless of reconstruction site. Reducing operating times through proper surgical planning might help mitigate the risk of SSI following RFS. Our findings should be used to guide patient selection, counseling, and surgical planning prior to RFS.

ACTH-secreting metastatic prostate cancer with neuroendocrine differentiation.

Cushing's syndrome (CS) due to ectopic adrenocorticotropic hormone (ACTH) secretion (EAS) can result from a variety of tumours and rarely from those of prostatic origin. We present a male patient in his early 60s with ACTH-secreting metastatic prostate adenocarcinoma with neuroendocrine differentiation (ICD-O code 8574/3) years after prostatectomy and androgen-deprivation therapy, initially presenting with Cushingoid features. After open radical prostatectomy and bilateral orchiectomy for disease recurrence, the patient was found to have metastatic liver and bone lesions highly suggestive of metastatic prostatic cancer. About 10% of cells on liver biopsy expressed ACTH, a finding consistent with EAS as the cause of CS. His stay was complicated with multiple infections and ultimate death. Hence, we report a case of metastatic prostate adenocarcinoma with neuroendocrine differentiation who presented with CS. We also emphasize the importance of adequate and timely treatment.

Menstrual health and period poverty in Lebanon during economic crisis: A qualitative analysis of the challenges and recommendations.

Objective: Recently, severe period poverty has had a dramatic spread throughout Lebanon as a result of several crises: the COVID-19 pandemic, the Beirut explosion, and the economic collapse. Period poverty is the lack of access to menstrual hygiene materials, comfortable environments, and adequate education about menstrual health. Due to the great implications of period poverty on Lebanese women's health, our study aims to explore stakeholder's perspective on the Lebanese public health policy regarding menstrual health, the evolving challenges it faces in the context of the current economic collapse, and to suggest recommendations for solutions. Methods: Our study is qualitative in nature, where data collection was done via online semi-structured interviews with stakeholders from the public and private sectors of the Lebanese healthcare system in addition to non-governmental organizations (NGOs) and physicians. Data were then analyzed based on themes and subthemes that emerged from the interviews. Results: Nine stakeholders were interviewed: five from NGOs, two obstetrics and gynecology physicians, and two public sector representatives. The challenges to menstrual health were subcategorized into previously existing and new ones. The consequences of poor menstrual health were tackled on the mental, physical, and social levels. Stakeholders suggested both short-term and long-term recommendations. Short-term recommendations included decreasing the monetary burden by subsidizing menstrual products or via a coupon system. Long-term recommendations included proper education on multiple levels, cooperation between key players in the private and public sectors, and encouragement of local production to ensure future sustainability. Conclusion: Menstrual health is a neglected public health issue in Lebanon, causing detrimental effects on girls and women residing in the country. Proper planning and collaboration between the private and public sectors are required to address this human rights issue.

Everyone Is Harmed When Clinicians Aren't Prepared.

War and conflict are now common, lingering like an endemic disease in most countries of the Global South. Population displacement, infectious disease outbreaks, food and water shortages, damage to infrastructure, anxiety, and posttraumatic stress are among the phenomena to which clinicians are expected to respond as professionals. Yet curricula in health professions do not prepare trainees to cultivate the skills needed to develop intervention pathways to meet the needs of populations in conflict zones. This article argues that decolonization of curricula in health professions is key to preparing clinicians to respond with care and competence to vulnerabilities and disease burden exacerbated by conflict.