Lymphadenectomy After Melanoma-A National Analysis of Recurrence Rates and Risk of Lymphedema.

INTRODUCTION: Treatment for melanoma after a positive sentinel lymph node biopsy includes nodal observation or lymphadenectomy. Important considerations for management, however, involve balancing the risk of recurrence and the risk of lymphedema after lymphadenectomy. METHODS: From the Merative MarketScan Research Databases, adult patients were queried from 2007 to 2021. International Classification of Disease, Ninth (ICD-9) and Tenth (ICD-10) Editions, diagnosis codes and Current Procedural Terminology codes were used to identify patients with melanoma diagnoses who underwent an index melanoma excision with a positive sentinel lymph node biopsy (SLNB). Main outcomes were completion lymph node dissection (CLND) utilization after a positive SLNB, developing lymphedema with or without CLND, and nodal basin recurrence 3 months or more after index excision. Subanalyses stratified by index excision year (2007-2017 and 2018-2021) and propensity score matched were additionally conducted. Demographics and comorbidities (measured by Elixhauser index) were recorded. RESULTS: A total of 153,085,453 patients were identified. Of those, 359,298 had a diagnosis of melanoma, and 202,456 patients underwent an excision procedure. The study cohort comprised 3717 patients with a melanoma diagnosis who underwent an excision procedure and had a positive SLNB. The mean age of the study cohort was 49 years, 57% were male, 41% were geographically located in the South, and 24% had an Elixhauser index of 4+. Among the 350 patients who did not undergo CLND, 10% experienced recurrence and 22% developed lymphedema. A total of 3367 patients underwent CLND, of which 8% experienced recurrence and 20% developed lymphedema. Completion lymph node dissection did not significantly affect risk of recurrence [odds ratio (OR), 1.370, P = 0.090] or lymphedema (OR, 1.114, P = 0.438). After stratification and propensity score matching, odds of experiencing lymphedema (OR, 1.604, P = 0.058) and recurrence (OR, 1.825, P = 0.058) after CLND were not significantly affected. Rates of CLND had significantly decreased (P < 0.001) overtime, without change in recurrence rate (P = 0.063). CONCLUSIONS: Electing for nodal observation does not increase the risk of recurrence or reduce risk of lymphedema. Just as CLND does not confer survival benefit, its decreased utilization has not increased recurrence rate.

Updated Trends and Outcomes in Autologous Breast Reconstruction in the United States, 2016-2019.

INTRODUCTION: Autologous breast reconstruction (ABR) has increased in recent decades, although concerns for access remain. As such, our goal is to trend national demographics and operative characteristics of ABR in the United States. METHODS: Using the National Inpatient Sample, 2016-2019, the International Classification of Disease , Tenth Edition codes identified adult female encounters undergoing ABR. Demographics and procedure-related characteristics were recorded. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate regression modeling. RESULTS: A total of 52,910 weighted encounters met the criteria (mean age, 51.5 ± 10.0 years). Autologous breast reconstruction utilization increased (Δ = +5%), 2016-2019, primarily driven by a rise in deep inferior epigastric perforator (DIEP) reconstructions (Δ = +28%; incidence rate ratio [IRR], 1.070; P < 0.001), which were predominant throughout the study period (69%). More recent surgery year, bilateral reconstruction, higher income levels, commercial insurance, and care in the South US region increased the odds of DIEP-based ABR ( P ≤ 0.036). Transverse rectus abdominis myocutaneous flaps, bilateral reconstructions, higher comorbidity levels, and experiencing complications increased the length of stay ( P ≤ 0.038). Most ABRs (75%) were privately insured. The rates of immediate reconstructions increased over the study period (from 26% to 46%; IRR, 1.223; P < 0.001), as did the rates of bilateral reconstructions (from 54% to 57%; IRR, 1.026; P = 0.030). The rates of ABRs performed at teaching hospitals remained high (90% to 93%; P = 0.242). CONCLUSIONS: As of 2019, ABR has become more prevalent, with the DIEP flap constituting the most common modality. With the increasing ABR popularity, efforts should be made to ensure geographic and financial accessibility.

Risk Factors for Hardware Removal Following Bimaxillary Surgery: A National Database Analysis.

Orthognathic surgery typically relies on the rigid fixation of fracture fragments using metal hardware. Though hardware is usually intended to be implanted permanently, the removal of hardware (ROH) is sometimes indicated for a variety of reasons. The authors sought to identify risk factors for ROH following orthognathic surgery. The authors conducted a retrospective analysis of the Merative MarketScan Research Databases, 2007-2021 using Current Procedural Terminology (CPT) and International Classification of Disease (ICD-9 and ICD-10) codes to identify patients who underwent an index Le Fort 1 osteotomy and bilateral sagittal split osteotomy operation on the same day. Statistical analysis involved χ 2 , Shapiro-Wilk, Wilcoxon-Mann-Whitney, Poisson regression, and multivariable logistic regression tests. 4698 patients met the inclusion criteria. The mean age at surgery was 25 years, and 57% were female. ROH occurred in 5.9% of patients. The mean time to hardware removal was 190.5±172.4 days. In a multivariate logistic regression, increased odds of ROH were associated with older patient age [OR: 1.02 (1.01-1.03), P =0.046], sleep apnea [OR: 1.62 (1.13-2.32), P =0.018], and craniofacial syndrome and/or cleft diagnoses [OR: 1.88 (1.14-2.55), P <0.001]. In the same model, postoperative oral antibiotic prophylaxis was not associated with ROH ( P =0.494). The incidence of all-cause complications [IRR: 1.03 (1.01-1.05), P <0.001] rose over the study period, while the incidence of ROH did not change significantly ( P =0.281). Patients at elevated risk should be counseled on the increased possibility of a second operation for ROH before having orthognathic surgery to ensure expectations and health care utilization decisions align with the evidence.

Reporting on Race and Racial Disparities in Breast Cancer: The Neglect of Racism as a Driver of Inequitable Care.

OBJECTIVE: This study reviews the surgical literature on racial disparities in breast cancer mortality, specifically evaluating the inclusion, justification, and discussion of race and ethnicity as a driver of disparities. SUMMARY OF BACKGROUND DATA: The volume of research on racial disparities has increased over the past 2 decades, but we hypothesize that there is considerable variation in how race is contextualized, defined, and captured in the disparities literature, leading to its questionable validity and relevance as a covariate. Recent guidelines for reporting have been suggested, but not yet applied. METHODS: A rubric was developed to evaluate the reporting of race and/or ethnicity. A systematic review (2010-2020) was performed to identify studies reporting on racial disparities in breast cancer surgery and mortality. We then evaluated these original articles based on key domains of race and/or ethnicity: justification for inclusion, formal definition, methodology used for classification, and type of racism contributing to disparity. RESULTS: Of the 52 studies assessed, none provided a formal definition for race and/or ethnicity. A justification for the inclusion of race and/or ethnicity was provided in 71% of the studies. Although 81% of studies discussed at least 1 potential driver of observed racial disparities, only 1 study explicitly named racism as a driver of racial disparities. CONCLUSIONS: Significant improvement in the reporting on racial disparities in breast cancer surgical literature is warranted. A more rigorous framework should be applied by both researchers and publishers in reporting on race, racial health disparities, and racism.

What Do Patients Look for When Scheduling Their Initial Elective Aesthetic Plastic Surgery Consultation?

BACKGROUND: Multiple factors influence patients when deciding on where to seek plastic surgery consultations. Our objective was to determine the most important factors when booking the initial consultation. METHODS: A 23 question survey was distributed online via Amazon Mechanical Turk targeting participants who had prior plastic surgery consultations or were planning to have one in the future. Participant demographic data were collected, and participants were asked to rank the importance of factors related to cost, surgeon reputation, social media, technology, amenities, accessibility, and appointment details on a 1-5 Likert scale. Rankings were reported by mean and standard deviation. RESULTS: A total of 593 responses were gathered. 48.1% of participants were 25-34 years of age, 54.6% were female, 66.3% identified as White, 78.4% were located in the U.S, and 54.5% had a bachelor's degree. Participants rated the importance of a surgeon's online reviews (mean 4.15, SD 0.81), surgeon presence at follow-up visits (mean 4.01, SD 0.91), and availability of pricing prior to appointment (mean 4.01, SD 0.91) the highest. The least important factors were waiting room amenities and social media advertising. Individuals younger than 45 were more likely to rate a surgeon's social media presence higher than those 45 years and older (OR 2.02; 95%CI [1.37-2.96]; p < 0.001). CONCLUSIONS: Patients considered surgeon's online reviews, presence at follow-up visits, and the availability of pricing information the most important when booking a plastic surgery consultation. These findings may assist physicians in structuring plastic surgery consultations based on factors important to patients. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Radiation dose benchmarks in pediatric cardiac catheterization: A prospective multi-center C3PO-QI study.

OBJECTIVES: This study sought to update benchmark values to use a quality measure prospectively. BACKGROUND: Congenital Cardiac Catheterization Outcomes Project - Quality Improvement (C3PO-QI), a multi-center registry, defined initial radiation dose benchmarks retrospectively across common interventional procedures. These data facilitated a dose metric endorsed by the American College of Cardiology in 2014. METHODS: Data was collected prospectively by 9 C3PO-QI institutions with complete case capture between 1/1/2014 and 6/30/2015. Radiation was measured in total air kerma (mGy), dose area product (DAP) (µGy*M2 ), DAP per body weight, and fluoroscopy time (min), and reported by age group as median, 75th and 95th %ile for the following six interventional procedures: (1) atrial septal defect closure; (2) aortic valvuloplasty; (3) treatment of coarctation of the aorta; (4) patent ductus arteriosus closure; (5) pulmonary valvuloplasty; and (6) transcatheter pulmonary valve implantation. RESULTS: The study was comprised of 1,680 unique cases meeting inclusion criteria. Radiation doses were lowest for pulmonary valvuloplasty (age <1 yrs, median mGy: 59, DAP: 249) and highest in transcatheter pulmonary valve implantation (age >15 yrs, median mGy: 1835, DAP: 17990). DAP/kg standardized outcome measures across weights within an age group and procedure type significantly more than DAP alone. Radiation doses decreased for all procedures compared to those reported previously by both median and median weight-based percentile curves. These differences in radiation exposure were observed without changes in median fluoroscopy time. CONCLUSIONS: This study updates previously established benchmarks to reflect QI efforts over time. These thresholds can be applied for quality measurement and comparison. © 2017 Wiley Periodicals, Inc.

Late-term development of an atrial defect and thrombus formation after device fracture following successful transcatheter closure of an atrial septal defect with a STARFlex device.

Development of a new defect following transcatheter closure of an atrial septal defect has yet to be reported. In this study, we present an acutely successful atrial septal defect closure with a STARFlex device, resulting in surgical explantation after discovery of device fracture, thrombus formation, and a second atrial defect 5 years after catheterisation. This case highlights the need for ongoing device surveillance, even in late follow-up.

Implementation of Methodology for Quality Improvement in Pediatric Cardiac Catheterization: A Multi-center Initiative by the Congenital Cardiac Catheterization Project on Outcomes-Quality Improvement (C3PO-QI).

The Congenital Cardiac Catheterization Project on Outcomes (C3PO) launched in 2007 as a multi-center collaborative to establish standardized and comparable metrics for pediatric cardiac catheterization procedures. The limitations of larger registries at the time led to the development of the next phase in 2013, C3PO-Quality Improvement (C3PO-QI), focusing on instituting QI initiatives within the field. The objective of this manuscript is to provide a detailed overview of C3PO-QI and report data on case characteristics and outcome metrics being explored. C3PO-QI was designed to cultivate institutional collaboration during implementation of its initiatives. A database and website were developed to support data entry and on-demand reporting. The registry prospectively captures pediatric cardiac catheterization data among 15 hospitals. The present study includes case demographic data (n) and quality metric reporting by case type, age, and radiation dose variables. This dataset includes 13,135 cases entered into the database between 1/1/2014 and 12/31/2015. Interventional cases make up the highest percentage by case mix distribution (48 %), and patients <1 years make up the highest percentage by age distribution (26 %). The ratio of diagnostic and interventional procedures performed changes by age group. Application of QI metric shows all procedure types surpassing metric goals. Large volume data collection, such as in C3PO-QI, allows for meaningful interpretation of data. C3PO-QI is uniquely poised to deliver fast-paced changes in the field. Although the project initiatives are specific to pediatric cardiac catheterization, the implementation of the project and utilization of real-time reporting is generalizable to other specialties and multi-center collaboratives.

Diagnosis and Management of Orbital Compartment Syndrome in Burn Patients - a Systematic Review.

Orbital compartment syndrome is a poorly understood complication of acute burns. The purpose of this systematic review is to summarize the literature describing orbital compartment syndrome in burn patients to provide greater detail on risk factors and guide management of this morbid condition. A systematic review of the PubMed, Embase, and Cochrane Library databases was performed in June 2023 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality was assessed using two validated scoring systems. After removing duplicates, 303 unique articles were reviewed and 8 met inclusion criteria. All publications were retrospective. Most studies considered intraocular pressure >30-40mmHg as diagnostic for orbital compartment syndrome. Sixty unique cases of orbital compartment syndrome were reported. Orbital compartment syndrome occurred most frequently within 24 hours post-burn. The mean total body surface area of burn was 58.7%; the mean 24-hour resuscitation volume was 6.01 cc/kg/%total burn surface area; and 86.5% of cases had periorbital burns. Surgical decompression always started with lateral canthotomy. When pressures were not immediately reduced, cantholysis was performed. Study quality per Median Newcastle Ottawa Scores ranged from 38.9% to 94.4% (median 66.7%). A precise threshold for surgical decompression of OCS remains conflicted; however, IOP>30-40mmHg warrants intervention. Burn surgeons/intensivists should be aware of the risk factors for this vision-threatening complication and act appropriately.

A national analysis of burn injuries among homeless persons presenting to emergency departments.

INTRODUCTION: Burn injuries among the homeless are increasing as record numbers of people are unsheltered and resort to unsafe heating practices. This study characterizes burns in homeless encounters presenting to US emergency departments (EDs). METHODS: Burn encounters in the 2019 Nationwide Emergency Department Sample (NEDS) were queried. ICD-10 and CPT codes identified homelessness, injury regions, depths, total body surface area (TBSA %), and treatment plans. Demographics, comorbidities, and charges were analyzed. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate modeling. RESULTS: Of 316,344 weighted ED visits meeting criteria, 1919 (0.6%) were homeless. Homeless encounters were older (mean age 44.83 vs. 32.39 years), male-predominant (71% vs. 52%), and had more comorbidities, and were more often White or Black race (p < 0.001). They more commonly presented to EDs in the West and were covered by Medicaid (51% vs. 33%) (p < 0.001). 12% and 5% of homeless burn injuries were related to self-harm and assault, respectively (p < 0.001). Homeless encounters experienced more third-degree burns (13% vs. 4%; p < 0.001), though TBSA % deciles were not significantly different (34% vs. 33% had TBSA % of ten or lower; p = 0.516). Homeless encounters were more often admitted (49% vs. 7%; p < 0.001), and homelessness increased odds of admission (OR 4.779; p < 0.001). Odds of transfer were significantly lower (OR 0.405; p = 0.021). CONCLUSION: Homeless burn ED encounters were more likely due to assault and self-inflicted injuries, and more severe. ED practitioners should be aware of these patients' unique presentation and triage to burn centers accordingly.

Associations between prior COVID-19 infection and venous thromboembolism following common plastic surgery operations.

INTRODUCTION: SARS-CoV-2 (COVID-19) infection has been described as a cause of systemic hypercoagulability and a risk factor for the development of venous thromboembolism (VTE). Whereas some multispecialty studies have proposed a link between COVID-19 and postoperative thrombosis, other single-specialty studies have found no such association. We utilized a large national database to determine whether prior COVID-19 infection was associated with the incidence of VTE following common plastic surgery operations. METHODS: The Merative™ MarketScan® Research Databases were used to identify female patients who underwent index abdominal panniculectomy, breast reduction, autologous breast reconstruction, or implant-based breast reconstruction procedures between 2020 and 2021. International Classification of Disease, tenth edition (ICD-10) codes were used to identify patients diagnosed with COVID-19 preoperatively and those who experienced a VTE in the 90 days postoperatively. Propensity score matching and multivariable logistic regression were used to determine any independent association between COVID-19 and postoperative VTE. RESULTS: Twenty-four thousand two hundred and twenty-eight patients met inclusion criteria. Mean age at time of surgery was 44 years. Six percent carried a preoperative COVID-19 diagnosis, and postoperative VTE occurred in 1.3%. In a propensity-score-matched analysis of 2754 patients, COVID-19 did not significantly correlate with incidence of postoperative VTE (P = 0.463). Compared with a matched prepandemic cohort (14,151 patients), the incidence of VTE did not increase following any of the four studied procedures during the COVID-19 pandemic. CONCLUSION: This analysis of a national insurance claims database provides evidence against a link between resolved COVID-19 infection and VTE within 90 days of four common plastic surgery operations.

Prophylactic Local Antibiotics for Tissue Expansion (PLATE) Improve Breast Reconstruction Outcomes.

INTRODUCTION: Infection following tissue expander (TE) breast reconstruction is frequent and impactful. Preliminary reports demonstrate value of local antibiotic delivery for implant salvage and prophylactic potential. Herein is a multi-institutional retrospective study employing surgeon-crafted tobramycin-vancomycin PMMA plates (PLATE) during TE implantation for infection prophylaxis. The authors hypothesized the intervention would be associated with fewer infections compared to historical practice. METHODS: In 2021, surgeons at three institutions began independently offering PLATE for primary TE breast reconstructions. After independent IRB approvals, data were retrospectively collected for PLATE subjects and pre-intervention cohorts of equivalent sizes. Subjects were followed for seven months, or to second stage removal. The primary outcome, complication requiring readmission/reoperation, was compared between aggregated cohorts. Analysis included logistic modeling and Kaplan-Meyer survival. RESULTS: The aggregate sample included 183 intervention subjects (292 breasts) and 183 controls (301 breasts), each with 5+/-2-month follow-up. Overall, complications were significantly less frequent with PLATE (13.1% vs 21.9%, p<0.01*). This was driven by significantly fewer infections (4.8% vs 12.6%, p<0.01*) with no difference in rates of tissue necrosis, seroma, or other complications (p>0.05). In multivariable regression, the intervention was associated with significantly reduced odds of any complication (OR=0.53, 95%CI: [0.3-0.93]) and infection (OR=0.22, 95%CI: [0.08-0.50]). Kaplan-Meyer curves demonstrated significant longitudinal reduction in complication and infection (p<0.01*) without notable rebound throughout dissipation of the antibiotic eluent. CONCLUSION: Prophylactic employment of intraoperatively-crafted PLATE during TE implantation was associated with significant infection reduction without increase in local or systemic complications. This reproducible tool may be highly valuable in alloplastic breast reconstruction.

Decreased Use of Anti-Inflammatory Medications in Autoimmune Connective Tissue Disease Patients Following Breast Implant Removal: A National Analysis.

Background: Recent case studies demonstrate resolution of rheumatologic symptoms following implant explantation, raising concern around breast implant illness and associated inflammatory symptomatology. In patients with connective tissue disorders (CTD) and breast implants, we quantified the number of anti-inflammatory medications as a proxy for inflammation and disease burden before and after implant removal. Methods: Using the Clinformatics Data Mart Database, adult female patients from 2003 to 2021 were queried. Current Procedural Terminology codes were used to identify patients who underwent implant-based reconstruction and subsequent implant removal. International Classification of Diseases, Ninth (ICD-9) and Tenth Revision (ICD-10) codes identified patients with CTD. Filled prescriptions of anti-inflammatory drugs were quantified for each patient during the preoperative, perioperative, and postoperative windows surrounding breast implant removal. Results: Of 1015 patients meeting criteria (mean age 56 ± 12 years), 821 (81%) filled prescriptions during the preoperative window, 753 (74%) filled during the perioperative window, and 735 (73%) filled during the postoperative window. Patients filled significantly fewer postoperative prescriptions than preoperative prescriptions (P < .001).Statistically significant predictors of the number of anti-inflammatory prescriptions filled in the postoperative window included additional anti-inflammatory prescriptions filled in the preoperative (P < .001) and perioperative (P < .001) windows. Experiencing a complication was not associated with the number of prescriptions filled in the postoperative window (P = .935). Conclusions: We found a significant decrease in filled anti-inflammatory prescriptions in patients with known CTD following implant removal, suggesting that breast implant removal may help diminish inflammatory symptomology in predisposed patients.

US air pollution is associated with increased incidence of non-syndromic cleft lip/palate.

Maternal cigarette use is associated with the fetal development of orofacial clefts. Air pollution should be investigated for similar causation. We hypothesize that the incidence of non-syndromic cleft lip with or without palate (NSCLP) and non-syndromic cleft palate (NSCP) would be positively correlated with air pollution concentration. METHODS: The incidence of NSCLP and NSCP per 1000 live births from 2016 to 2020 was extracted from the Centers for Disease Control and Prevention Vital Statistics Database and merged with national reports on air pollution using the Environmental Protection Agency Air Quality Systems annual data. The most commonly reported pollutants were analyzed including benzene, sulfur dioxide (SO2), particulate matter (PM) 2.5, PM 10, ozone (O3), and carbon monoxide (CO). Multivariable negative binomial and Poisson log-linear regression models evaluated the incidence of NSCLP and NSCP as a function of the pollutants, adjusting for race. All p-values are reported with Bonferroni correction. RESULTS: The median NSCLP incidence was 0.22/1000 births, and isolated NSCP incidence was 0.18/1000 births. For NSCLP, SO2 had a coefficient estimate (CE) of 0.60 (95% CI [0.23, 0.98], p < 0.007) and PM 2.5 had a CE of 0.20 (95% CI [0.10, 0.31], p < 0.005). Among isolated NSCP, no pollutants were found to be significantly associated. CONCLUSION: SO2 and PM 2.5 were significantly correlated with increased incidence of NSCLP. The American people and perinatal practitioners should be aware of the connection to allow for risk reduction and in utero screening.

The Best Under Stress: An Analysis of Breast Tissue Expander Response to External Forces.

Background: The use of breast tissue expanders (TEs) in breast reconstruction is accompanied by undesired changes to the chest wall and lateral plane. Breast TEs are designed to create a naturally formed breast pocket by capitalizing on the ductile response of skin tissue; however, in practice, the use of expanders is accompanied by undesired changes to the chest wall and lateral plane. Objectives: The authors of this study compared 3 comparably sized and commercially available breast TEs to assess the mechanical profile and functionality of each design. Methods: Authors compared MENTOR Artoura PLUS Smooth (Irvine, CA), Allergan 133 Smooth (Irvine, CA), and Sientra AlloX2 Smooth (Santa Barbara, CA) filled to 100% of their label volume. The mechanical profile of TEs was assessed via vertical compression. Dimensions were recorded at baseline and percent changes were calculated at each compressive load (5-35 lbf intervals of 5 lbf). Results: Base width and projection were recorded at compressive loads of 10, 20, and 35 lbs. For percent changes of base width, MENTOR had 0.98%, 2.09%, 3.84%; Allergan 4.21%, 9.15%, 15.52%; and Sientra 4.72%, 10.19%, 19.15%. For percent changes of projection, MENTOR had -19.06%, -25.44%, -30.88%, Allergan -35.53%, -42.90%, -50.09%, and Sientra -29.64%, -37.68%, -44.69%. For percent change of height, MENTOR had 1.44%, 2.62%, 4.27%, Allergan 10.26%, 16.49%, 22.97%, and Sientra 6.99%, 11.93%, 16.90%. MENTOR's TE had the most pronounced lower pole with volume expansion. Conclusions: The MENTOR TE demonstrated the least lateral deformation and projection loss across the range of compressive loads, as well as the highest force resistance compared with the other models.

Is Plastic Surgery Training Equitable? An Analysis of Health Equity across US Plastic Surgery Residency Programs.

Achieving health equity includes training surgeons in environments exemplifying access, treatment, and outcomes across the racial, ethnic, and socioeconomic spectrum. Increased attention on health equity has generated metrics comparing hospitals. To establish the quality of health equity in plastic and reconstructive surgery (PRS) residency training, we determined the mean equity score (MES) across training hospitals of US PRS residencies. Methods: The 2021 Lown Institute Hospital Index database was merged with affiliated training hospitals of US integrated PRS residency programs. The Lown equity category is composed of three domains (community benefit, inclusivity, pay equity) generating a health equity grade. MES (standard deviation) was calculated and reported for residency programs (higher MES represented greater health equity). Linear regression modeled the effects of a program's number of training hospitals, safety net hospitals, and geographical region on MES. Results: The MES was 2.64 (0.62). An estimated 5.9% of programs had an MES between 1-2. In total, 56.5% of programs had an MES between 2 and 3, and 37.7% had an MES of 3 or more. The southern region was associated with a higher MES compared with the reference group (Northeast) (P = 0.03). The number of safety net hospitals per program was associated with higher MES (P = 0.02). Conclusions: Two out of three programs train residents in facilities failing to demonstrate high equity healthcare. Programs should promote health equity by diversifying care delivery through affiliated hospitals. This will aid in the creation of a PRS workforce trained to provide care for a socioeconomically, racially, and ethnically diverse population.

Breast reconstruction after mastectomy in patients with obesity: a narrative review.

Background and Objective: Breast reconstruction in patients with obesity presents numerous challenges, both in terms of surgical technique and post-operative complication management. As breast reconstruction techniques continue to evolve, the armamentarium of reconstructive options for patients with obesity has vastly expanded. Options now include immediate or delayed, implant-based, autologous, or hybrid reconstruction. Determining the optimal breast reconstruction in this complex population requires nuanced and experienced decision-making. Methods: A literature search was conducted to identify studies assessing breast reconstruction considerations in patients with obesity. The search was performed on PubMed and was limited to English language studies published between 1990 and 2023. Primary studies, case reports, chart reviews, and qualitative studies were included. Additional articles were identified for inclusion based on a review of references, as well as a web-based search, to identify additional studies that were not captured with the primary search strategy. Key Content and Findings: This narrative review article summarizes the current literature available to guide surgeons in breast reconstruction in patients with obesity. Conclusions: The advancements in oncologic surgery and breast reconstruction techniques have expanded available surgical options, including immediate or delayed implant-based, autologous, or hybrid breast reconstruction. Each approach has its unique advantages, disadvantages, and surgical considerations. Despite the challenges, patients with obesity can achieve favorable aesthetic outcomes through careful assessment of comorbidities and expectation management.

Longitudinal Improvements in Radiation Exposure in Cardiac Catheterization for Congenital Heart Disease: A Prospective Multicenter C3PO-QI Study.

BACKGROUND: The C3PO-QI (Congenital Cardiac Catheterization Project on Outcomes - Quality Improvement), a multicenter registry launched in 2015, instituted quality improvement (QI) initiatives to reduce patient radiation exposure. Through regular collaboration, this initiative would allow for harmony among active participants, maximizing efforts and efficiency at achieving radiation best practices. This study sought to report these efforts with a detailed methodology for which institutions can target initiatives, reducing radiation exposure, and increasing patient safety. METHODS: Data were collected prospectively by 8 C3PO-QI institutions between January 1, 2015 and December 31, 2017. Radiation exposure was measured in dose area product per body weight (dose area product/kg; µGy*m2/kg) and reported by expected radiation exposure categories (REC) and institution for 40 published unique procedure types. Targeted interventions addressing selected strategic domains for radiation reduction were implemented in the pediatric catheterization labs of the C3PO-QI institutions. RESULTS: The study consisted of 15 257 unique cases. Median exposure (dose area product/kg) was decreased by 30% for all procedures. Dose area product/kg was reduced in all 3 REC, with the greatest improvement observed in REC I (REC I, -37%; REC II, -23%; REC III, -27%). Although the baseline radiation exposures and exact percent decrease varied across all C3PO-QI sites, each institution demonstrated improvements in radiation dose over time. These improvements occurred with the implementation of institution-specific QI interventions accelerated by participation in the C3PO-QI multicenter collaborative. CONCLUSIONS: Substantial radiation dose reductions can be achieved using targeted QI methodology and interventions. Participation in a multicenter QI collaborative may accelerate improvement across all centers due to enhanced engagement and shared learning between sites.