Invasive Meningococcal Disease Among People Experiencing Homelessness-United States, 2016-2019.

BACKGROUND: Recently, several invasive meningococcal disease (IMD) outbreaks caused by Neisseria meningitidis have occurred among people experiencing homelessness (PEH). However, overall IMD risk among PEH is not well described. We compared incidence and characteristics of IMD among PEH and persons not known to be experiencing homelessness (non-PEH) in the United States. METHODS: We analyzed 2016-2019 IMD data from the National Notifiable Diseases Surveillance System and enhanced meningococcal disease surveillance. Incidence was calculated using US census data and point-in-time counts from the US Department of Housing and Urban Development. RESULTS: Of cases from states participating in enhanced surveillance during 2016-2019 (n = 1409), 45 cases (3.2%) occurred among PEH. Annual incidence was higher among PEH (2.12 cases/100 000) than non-PEH (0.11 cases/100 000; relative risk, 19.8; 95% confidence interval [CI], 14.8-26.7). Excluding outbreak-associated cases (PEH n = 18, 40%; non-PEH n = 98, 7.2%), incidence among PEH remained elevated compared to incidence in non-PEH (relative risk, 12.8; 95% CI, 8.8-18.8). Serogroup C was identified in 68.2% of PEH cases compared to 26.4% in non-PEH (P < .0001). CONCLUSIONS: PEH are at increased risk for IMD. Further assessment is needed to determine the feasibility and potential impact of meningococcal vaccination for PEH in the United States.

Meningococcal Disease in Persons With HIV Reported Through Active Surveillance in the United States, 2009-2019.

Persons with HIV (PWH) are at increased risk for bacterial infections, and previous publications document an increased risk for invasive meningococcal disease (IMD) in particular. This analysis provides evidence that PWH face a 6-fold increase in risk for IMD based on Active Bacterial Core surveillance data collected during 2009-2019.

Outcomes of Nipple-sparing Mastectomy with Reconstruction after Recent Oncoplastic Wise-pattern Reduction.

For patients with large and/or ptotic breasts, a planned staged approach to nipple-sparing mastectomy (NSM) has been described. Less is known about surgical outcomes of unplanned staged NSM for management of positive margins after partial mastectomy with oncoplastic reduction. It is not clear from earlier studies whether an interval of less than 10 weeks between oncoplastic reduction and NSM is feasible, when a shorter interval is important for oncologic reasons. Methods: This is a single institution analysis of patients from 2018 to 2021 with a diagnosis of invasive cancer or ductal carcinoma in situ who underwent NSM after oncoplastic breast reduction for positive margins or nodes. The primary endpoint measured was nipple loss. Secondary outcomes were need for operative re-intervention and wound complications. Results: Nine patients (14 breasts) underwent partial mastectomy with oncoplastic Wise-pattern breast reduction, followed by NSM. Three patients underwent intersurgery chemotherapy. The average interval between oncoplastic reduction and NSM was 11.3 weeks when excluding patients undergoing chemotherapy (range 8-13 weeks). Thirteen breasts (93%) underwent pre-pectoral direct-to-implant reconstruction. One breast (7%) received autologous reconstruction. One breast required reoperation for seroma. The rate of partial or total nipple loss was 0%, with an average follow-up of 1.6 years. Conclusions: Our experience demonstrates excellent outcomes from NSM after oncoplastic breast reduction, with the majority of patients undergoing single-stage pectoral direct-to-implant breast reconstruction. Overall, patients had a shorter intersurgery interval, compared with prior studies, with no cases of nipple loss. An intersurgery interval of 8 weeks may be feasible when avoiding delays is important for oncologic reasons.

Is Sentinel Lymph Node Biopsy Reliable After Recent Oncoplastic Breast Reduction?

An oncoplastic breast reduction may disrupt normal lymphatic drainage and make subsequent identification of the sentinel lymph nodes (SLNs) unreliable. There are little data on the success rate of sentinel lymph node biopsy (SLNB) after recent oncoplastic breast reduction, and there is no agreement on whether SLNB should be done at the time of the partial mastectomy and reduction for ductal carcinoma in situ (DCIS). The primary goals of this study were to evaluate the identification rate of SLNB after recent oncoplastic or functional breast reduction and to examine recurrence rates in this setting. Results reveal SLNB is feasible in this setting. At least one SLN was found in all patients, and there were no recurrences with an average follow-up of 34 months.

OncotypeDX Testing Does Not Benefit Patients with Estrogen and Progesterone Receptor Positive Grade 1 Breast Cancers: A TAILORx Validated Study.

BACKGROUND & OBJECTIVES: We previously described a predictive AAMC model that identifies patients (grade 1, hormonepositive) who would not benefit from OncotypeDX testing. The purpose of this study was to validate the AAMC model by assessing distant recurrence-free interval (DRFI) and invasive disease-free survival (IDFS) using TAILORx clinical trial data. MATERIALS & METHODS: We retrospectively analyzed TAILORx trial data and categorized patients based on the AAMC model. AAMC low-risk patients are those with grade 1 and hormone-positive tumors. Kaplan-Meier curves examined DRFI and IDFS. RESULTS: Of the 9195 cases, 2246 (24.4%) were identified by AAMC as low-risk. Among these AAMC low-risk patients, 55.2% had Recurrence Score (RS) 0-15, 42.3% had RS 15-25, and 2.4% had RS > 25. The 10-year DRFI did not differ for those who received adjuvant chemotherapy versus those who did not (98% vs. 96%, log-rank p = 0.46). Similarly, IDFS was comparable between those who received adjuvant chemotherapy and those that did not (86% vs. 86%, log-rank p = 0.66). Only 2.4% of AAMC low-risk patients were categorized as high-risk (RS > 25). A sensitivity analysis of this discordant group, wherein those with RS > 25 were re-classified into the no-chemotherapy group and assumed to have experienced recurrences at the rate expected without chemotherapy, did not find any difference in DRFI between those who received adjuvant chemotherapy and those who did not (log-rank p = 0.16). CONCLUSION: OncotypeDX testing does not benefit AAMC low-risk patients with hormone-positive grade 1 tumors. Based on these data, 1 in 4 TAILORx participants would not need OncotypeDX testing.

Outcomes of Margin Reexcision after Oncoplastic Breast Reduction.

Tissue rearrangement after an oncoplastic breast reduction may complicate identification of margins during reexcision. Little is known about outcomes of reoperation in this setting. Methods: This is a single-institution, retrospective analysis of outcomes of margin reexcisions after lumpectomy with concurrent oncoplastic Wise-pattern reduction from 2015 to 2020. Outcomes assessed were the rate of successful breast conservation, in-breast recurrence, wound issues or complications, effect on cosmesis, and delay to onset of adjuvant therapy. Results: From 2015 to 2020, 649 patients underwent lumpectomy with oncoplastic Wise-pattern reduction. Forty-seven patients (7.2%) had greater than or equal to one positive margin(s); of these, 28 went directly to mastectomy, and 19 underwent margin reexcision. Residual disease was found in seven of 19 patients (37%) at reexcision. The rate of successful breast-conserving therapy was 95% with a mean follow-up of 31 months. There was one (5%) in-breast recurrence (invasive ductal carcinoma [IDC] occurring 30 months after the original operation); this patient had a mastectomy for treatment of her recurrence. The overall complication rate was 37%. Radiation was administered to 18 patients (95%), and two patients (11%) had delay of radiation past 6 weeks due to wound complications. Of the 14 patients with photographs available, 12 of 14 patients (86%) were blindly assessed to have equivalent or better cosmesis after margin reexcision (versus initial lumpectomy). Conclusion: Margin reexcision after oncoplastic breast reduction with Wise-pattern is feasible and effective, and can be done without compromising the initial cosmetic results.

Umbilical Hernia Repair: Overview of Approaches and Review of Literature.

Umbilical hernias are ubiquitous, and surgery is indicated in symptomatic patients. Umbilical hernia defects can range from small (<1 cm) to very large/complex hernias, and treatment options should be tailored to the clinical situation. Open, laparoscopic, and robotic options exist for repair, with each having its advantages and disadvantages. In general, mesh should be used for repair, because it has been shown to decrease recurrence rates, even in small hernias. Although outcomes are generally favorable after umbilical hernia repairs, some patients have chronic complaints that are mostly related to recurrences.