The Impact of Food Insecurity Rate on Bariatric Surgery Outcomes.

INTRODUCTION: Various factors impact outcomes following bariatric surgery. Lack of access to healthy food options (food insecurity [FI]) is another potential factor affecting outcomes. No prior studies have directly explored the relationship between residing in a high FI zip code and patient outcomes relating to weight loss after bariatric surgery. We hypothesized that living in a high FI zip code would be associated with decreased weight loss postsurgery. METHODS: We conducted a retrospective study with 210 bariatric surgery patients at a tertiary referral center from January to December 2020. Patient weight and body mass index (BMI) were recorded at three time points: surgery date, 1 mo, and 12 mo postoperative. Residential addresses were collected, and FI rates for the corresponding Zip Code Tabulation Areas were obtained from the 2022 Feeding America Map the Meal Gap study (2020 data). RESULTS: The FI rate showed a negative correlation of -18.3% (95% confidence interval: -35% to -0.5%; P = 0.039) with the percentage of excess weight loss (%EWL) at 1 y. In multivariate analysis, preoperative BMI (P = 0.001), presence of diabetes mellitus (P = 0.008), and bariatric procedure type (P = 0.000) were significant predictors of %EWL at 1 y. After adjusting for confounding factors, including sex, preoperative BMI, insurance status, primary bariatric procedure, and emergency department visits, the increased FI rate (P = 0.047) remained significantly associated with a decreased %EWL at 1 y. CONCLUSIONS: Residing in a high FI, Zip Code Tabulation Areas correlated with a decreased %EWL at 1 y after bariatric surgery. These findings highlight the importance of assessing FI status in pre-bariatric surgery patients and providing additional support to individuals facing FI.

Preoperative comorbidities as a predictor of EBWL after bariatric surgery: a retrospective cohort study.

INTRODUCTION: The purpose of this study is to investigate the impact of preoperative comorbidities, including depression, anxiety, type 2 diabetes mellitus, obstructive sleep apnea, hypothyroidism, and the type of surgery on %EBWL (percent estimated body weight loss) in patients 1 year after bariatric surgery. Patients who choose to undergo bariatric surgery often have other comorbidities that can affect both the outcomes of their procedures and the postoperative period. We predict that patients who have depression, anxiety, diabetes mellitus, obstructive sleep apnea, or hypothyroidism will have a smaller change in %EBWL when compared to patients without any of these comorbidities. METHODS AND PROCEDURES: Data points were retrospectively collected from the charts of 440 patients from March 2012-December 2019 who underwent a sleeve gastrectomy or gastric bypass surgery. Data collected included patient demographics, select comorbidities, including diabetes mellitus, obstructive sleep apnea, hypothyroidism, depression, and anxiety, and body weight at baseline and 1 year postoperatively. Ideal body weight was calculated using the formula 50 + (2.3 × height in inches over 5 feet) for males and 45.5 + (2.3 × height in inches over 5 feet) for females. Excess body weight was then calculated by subtracting ideal body weight from actual weight at the above forementioned time points. Finally, %EBWL was calculated using the formula (change in weight over 1 year/excess weight) × 100. RESULTS: Patients who had a higher baseline BMI (p < 0.001), diabetes mellitus (p = 0.026), hypothyroidism (p = 0.046), and who had a laparoscopic sleeve gastrectomy rather than Roux-en-Y gastric bypass (p < 0.001) had a smaller %EBWL in the first year after bariatric surgery as compared to patients without these comorbidities at the time of surgery. Controversially, patients with anxiety or depression (p = 0.73) or obstructive sleep apnea (p = 0.075) did not have a statistically significant difference in %EBWL. CONCLUSION: A higher baseline BMI, diabetes mellitus, hypothyroidism, and undergoing laparoscopic sleeve gastrectomy may lead to lower %EBWL in the postoperative period after bariatric surgery. At the same time, patients' mental health status and sleep apnea status were not related to %EBWL. This study provides new insight into which comorbidities may need tighter control in order to optimize weight loss outcomes after bariatric surgery.

Endoscopic closure techniques of bariatric surgery complications: a meta-analysis.

BACKGROUND: Leaks following bariatric surgery, while rare, are potentially fatal due to risk of peritonitis and sepsis. Anastomotic leaks and gastro-gastric fistulae following Roux-En-Y gastric bypass (RYGB) as well as staple line leaks after sleeve gastrectomy have historically been treated multimodally with surgical drainage, aggressive antibiotic therapy, and more recently, endoscopically. Endoscopic clipping using over-the-scope clips and endoscopic suturing are two of the most common approaches used to achieve full thickness closure. METHODS: A systematic literature search was performed in PubMed to identify articles on the use of endoscopic clipping or suturing for the treatment of leaks and fistulae following bariatric surgery. Studies focusing on stents, and those that incorporated multiple closure techniques simultaneously, were excluded. Literature review and meta-analysis were performed with the PRISMA guidelines. RESULTS: Five studies with 61 patients that underwent over-the-scope clip (OTSC) closure were included. The pooled proportion of successful closure across the studies was 81.1% (95% CI 67.3 to 91.7). The successful closure rates were homogeneous (I2 = 39%, p = 0.15). Three studies with 92 patients that underwent endoscopic suturing were included. The weighted pooled proportion of successful closure across the studies was shown to be 22.4% (95% CI 14.6 to 31.3). The successful closure rates were homogeneous (I2 = 0%, p = 0.44). Three of the studies, totaling 34 patients, examining OTSC deployment reported data for reintervention rate. The weighted pooled proportion of reintervention across the studies was 35.0% (95% CI 11.7 to 64.7). We noticed statistically significant heterogeneity (I2 = 68%, p = 0.04). One study, with 20 patients examining endoscopic suturing, reported rate of repeat intervention 60%. CONCLUSION: Observational reports show that patients managed with OTSC were more likely to experience healing of their defect than those managed with endoscopic suturing. Larger controlled studies comparing different closure devices for bariatric leaks should be carried out to better understand the ideal endoscopic approach to these complications.

Discontinuing semaglutide after weight loss: strategy for weight maintenance and a possible new side effect.

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) facilitate weight loss. Weight regain off therapy is concerning. We reported the case of a 35-year-old male prescribed oral semaglutide with 22.7 kg weight loss over 120 days. Herein, we describe the clinical course when discontinuing GLP-1 RA therapy, one approach to maintaining weight loss after discontinuation, and a possible new side effect. At day 120, we continued oral semaglutide 7 mg daily, down from 14 mg, for weight maintenance with subsequent weight regain. We re-increased semaglutide to 14 mg/day with weight re-loss within 1 month and weight maintance for a year. We then discontinued semaglutide; weight loss was maintained for 6 months. The patient reported lactose intolerance ∼13 months before starting semaglutide. During semaglutide therapy, the patient reported worsened lactose intolerance and new gluten intolerance. Food allergy/celiac testing were negative. Intolerances did not improve with semaglutide discontinuation. Six months after semaglutide discontinuation, the patient was diagnosed with small intestinal bacterial overgrowth, possibly worsened by semaglutide. Factors potentially supporting weight maintenance were early drug treatment for new-onset obesity, non-geriatric age, strength training, and diet modification. The case highlights tailoring approaches to maintain weight loss without GLP-1 RAs. Trials are needed to optimize weight maintenance strategies.

The emergence of MedTok: a qualitative analysis of popular medical TikTok videos.

Social media is increasingly being used by the public as a medium for health information. Unfortunately, misinformation has become widely available on these sites, often being provided using content that is designed to be more popular and engaging, and it is difficult for the public to differentiate between what is true and what is false. TikTok is one of these platforms and has been rapidly growing over the last few years. As an increasing number of people look to TikTok for their health information, it is important that quality information is accessible and popular on the platform. We conducted a review of TikTok videos using the top 10 videos to show when searching for 13 common conditions. Characteristics of both the creator and video were recorded and analyzed. Videos on conditions commonly diagnosed younger were commonly produced by younger creators with the condition, often based on their own experiences. Conversely, videos on conditions commonly diagnosed older were commonly produced by healthcare professionals providing educational information. Though for conditions affecting older individuals healthcare professionals may be able to create didactic, educational videos, for those affecting younger individuals, it may be beneficial to partner with younger creators, or "influencers," to produce more viral content. Further studies may expand on these ideas to encompass more facets of healthcare. As this study did not analyze the quality of the information in the videos, future research should also focus on determining the quality of popular content on TikTok and other social media platforms.

Monogenic early-onset lymphoproliferation and autoimmunity: Natural history of STAT3 gain-of-function syndrome.

BACKGROUND: In 2014, germline signal transducer and activator of transcription (STAT) 3 gain-of-function (GOF) mutations were first described to cause a novel multisystem disease of early-onset lymphoproliferation and autoimmunity. OBJECTIVE: This pivotal cohort study defines the scope, natural history, treatment, and overall survival of a large global cohort of patients with pathogenic STAT3 GOF variants. METHODS: We identified 191 patients from 33 countries with 72 unique mutations. Inclusion criteria included symptoms of immune dysregulation and a biochemically confirmed germline heterozygous GOF variant in STAT3. RESULTS: Overall survival was 88%, median age at onset of symptoms was 2.3 years, and median age at diagnosis was 12 years. Immune dysregulatory features were present in all patients: lymphoproliferation was the most common manifestation (73%); increased frequencies of double-negative (CD4-CD8-) T cells were found in 83% of patients tested. Autoimmune cytopenias were the second most common clinical manifestation (67%), followed by growth delay, enteropathy, skin disease, pulmonary disease, endocrinopathy, arthritis, autoimmune hepatitis, neurologic disease, vasculopathy, renal disease, and malignancy. Infections were reported in 72% of the cohort. A cellular and humoral immunodeficiency was observed in 37% and 51% of patients, respectively. Clinical symptoms dramatically improved in patients treated with JAK inhibitors, while a variety of other immunomodulatory treatment modalities were less efficacious. Thus far, 23 patients have undergone bone marrow transplantation, with a 62% survival rate. CONCLUSION: STAT3 GOF patients present with a wide array of immune-mediated disease including lymphoproliferation, autoimmune cytopenias, and multisystem autoimmunity. Patient care tends to be siloed, without a clear treatment strategy. Thus, early identification and prompt treatment implementation are lifesaving for STAT3 GOF syndrome.

Breastfeeding Ability After Breast Reductions: What does the Literature Tell us in 2023?

INTRODUCTION: Reduction mammaplasties are routinely performed on women of child-bearing age, yet there still exists some uncertainty regarding a patient's ability to breastfeed following the procedure. This is due to inconsistent definitions of "successful" breastfeeding, a variety of pedicles implemented, and inadequate follow-up in the published literature. Our aim was to summarize the current data and provide clear recommendations for counseling patients on expected breastfeeding outcomes following reduction mammaplasty. METHODS: A systematic review and meta-analysis in accordance with the PRISMA guidelines was conducted. We included papers that reported proportion of breastfeeding ability following reduction mammaplasty. RESULTS: We identified 33 papers that met our inclusion criteria. We found that women who undergo reduction mammaplasty are at a 3.5 times increased odds of not being able to breastfeed compared to controls. Overall, reduction mammaplasty patients have a breastfeeding success rate of 62%. The breastfeeding success rate for patients with inferior pedicles was 64%, superior pedicles was 59%, and lateral pedicles was 55%. No conclusions could be drawn regarding medial, central, vertical, and horizontal pedicles on breastfeeding ability. CONCLUSION: Current data suggest that women undergoing reduction mammaplasty have an increased odds of unsuccessful breastfeeding when compared to similar women who have not undergone the procedure. Based on the current literature, pedicle type does play a role in rate of breastfeeding success, although there is a need for further research on the aforementioned pedicles. Physicians should be aware of the likelihood of successful breastfeeding following reduction mammaplasty so that patients can be more thoroughly counseled prior to a decision for surgery. LEVEL OF EVIDENCE I: 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 .

Can we lower the platelet threshold of ≥ 50 × 109/L for performing a lumbar puncture safely in patients with hematological malignancies?

Lumbar punctures (LP) are routinely used to administer intrathecal chemotherapy for children and adults with hematologic malignancies. The current guidelines suggest a platelet threshold of ≥ 50 × 109/L prior to LP for intrathecal chemotherapy (ITC). This can be challenging in patients with hematological malignancies who are thrombocytopenic. We conducted a retrospective chart review of 900 LPs for ITC and compared adverse events in patients with a platelet count of ≥ 50 × 109/L and < 50 × 109/L. Cohort 1 included 682 LPs (75.8%) with a pre-procedure platelet count ≥ 50 × 109/L, and cohort 2 included 218 LPs (24.2%) with a pre-procedure platelet count < 50 × 109/L. Cohort 2 was further subdivided into pre-procedure platelet counts of 41 × 109/L-49 × 109/L (n = 43), 31 × 109/L-40 × 109/L (n = 77), 21 × 109/L-30 × 109/L (n = 84), and 11 × 109/L-20 × 109/L (n = 14). Among 900 LP procedures, a pre-procedure platelet count < 50 × 109/L did not demonstrate a higher rate of post-procedure adverse events (6.5% vs 6.8%, p = 0.8237). When cohort 2 was further stratified, the cohort with a pre-procedure platelet count of 21 × 109/L-30 × 109/L had the highest percentage of complications from LP (9.5%) and the highest rates of traumatic taps with observed LP RBC count > 200 (35.7%, p = 0.0015). The rate of red blood cells (RBC) in the CSF was significantly higher in the group with platelets < 50 × 109/L with observed LP RBC count ≥ 200 (31.2% vs 20.5%, p = 0.0016), ≥ 500 (27.1% vs 14.6%, p < 0.0001), and ≥ 1000 (23% vs 11.6%, p < 0.0001). No instances of epidural hematomas were seen. We found no significant difference in bleeding complications between patients undergoing LPs for ITC with a platelet count above or below 50 × 109/L.

Radioembolization with Yttrium-90 Glass Microspheres as a First-Line Treatment for Unresectable Intrahepatic Cholangiocarcinoma-A Prospective Feasibility Study.

PURPOSE: To evaluate the safety and effectiveness of yttrium-90 (90Y) radioembolization as first-line treatment for unresectable intrahepatic cholangiocarcinoma (ICC). MATERIALS AND METHODS: This prospective study enrolled patients who had never received chemotherapy, liver embolization, and radiation therapy. The tumors were solitary in 16 patients, multiple in 8 patients, unilobar in 14 patients, and bilobar in 10 patients. Patients underwent transarterial radioembolization with 90Y-labeled glass microspheres. The primary end point was hepatic progression-free survival (HPFS). Secondary end points were overall survival (OS), tumor response, and toxicity. RESULTS: Twenty-four patients (age, 72.3 years ± 9.3; 12 women) were included in the study. The median delivered radiation dose was 135.5 Gy (interquartile range, 77.6 Gy). The median HPFS was 5.5 months (95% CI, 3.9-7.0 months). Analysis failed to identify any prognostic factor associated with HPFS. Imaging response at 3 months showed 56% disease control, and the best radiographic response was 71% disease control. The median OS from the radioembolization treatment was 19.4 months (95% CI, 5.0-33.7). Patients with solitary ICC had significantly longer median OS than patients with multifocal ICC: 25.9 months (95% CI, 20.8-31.0 months) versus 10.7 months (95% CI, 8.0-13.4 months) (P = .02). Patients with progression on the 3-month imaging follow-up had significantly shorter median OS than patients who had stable disease at 3 months: 10.7 months (95% CI, 0.7-20.7 months) versus 37.3 months (95% CI, 16.5-58.1 months) (P = .003). Two (8%) Grade 3 toxicities were reported. CONCLUSIONS: First-line treatment of ICC with radioembolization showed promising OS and minimal toxicity, especially in patients with solitary tumor. Radioembolization may be considered as a first-line treatment option for unresectable ICC.

Robotic-assisted foregut surgery is associated with lower rates of complication and shorter post-operative length of stay.

BACKGROUND: Two of the most common foregut operations are laparoscopic Heller myotomy and laparoscopic Nissen fundoplication. Robotic assistance, compared to standard laparoscopic approach, may potentially grant surgeons advantages such as enhanced visualization and dexterity. This study compares patient outcomes for Heller myotomy (HM) and Nissen fundoplication (NF) when performed laparoscopically versus robotically. METHODS: A retrospective review of patients at a single institution who underwent laparoscopic or robotic-assisted HM or NF from January 2019 to July 2022 was conducted. 123 HM (72 laparoscopic, 51 robotic-assisted) and 92 NF (62 laparoscopic, 30 robotic-assisted) were performed by three surgeons. Outcomes investigated were operative time, hospital length of stay, pre- and post-operative imaging, resolution of symptoms at 30 days, resolution of symptoms at 90 days, and complications. RESULTS: In the HM cohorts, the average operative time was longer in the robotic cohort (127 min robotic versus 108 min laparoscopic, p < 0.01). However, overall complication rates (p < 0.05) were lower, and hospital length of stay was shorter in the robotic group (1.5 days compared to 2.7 days, p < 0.001). In the NF cohorts, there was no significant difference in operative time. However, hospital length of stay was shorter in the robotic group (1.54 days compared to 2.7 days, p < 0.001) with otherwise similar outcomes. There was no difference in the rate of post-operative resolution of symptoms or need for additional interventions in either HM or NF. CONCLUSION: Robotic-assisted HM and NF are associated with shorter hospital stays compared to their respective laparoscopic approaches. Robotic-assisted HM also has a lower rate of complications. Our findings suggest that robotic assistance may be beneficial for shortening hospital length of stay and decreasing complications for certain surgeries specific to Foregut surgery.

Evaluating the Spanish readability of American Society for Metabolic and Bariatric Surgery (ASMBS) Centers of Excellence (COE) websites.

BACKGROUND: Healthcare disparities continue to be an ongoing struggle in Bariatrics. Limited availability of Spanish online material may be a correctible barrier for accessibility to Hispanic patients. We sought to evaluate accredited Bariatric Centers of Excellence (COE) for Spanish readability via their websites to determine accessibility for Spanish speakers. METHODS: This was an internet research study. 103 COE accredited by American Society for Metabolic and Bariatric Surgery (ASMBS) and the American College of Surgeons (ACS) were evaluated and assigned one of five Spanish Visibility Categories. The United States was divided into 4 regions. Regional Spanish visibility was calculated by dividing each category count by the number of institutions in each region. County Spanish-speaking populations were obtained from the US Census Bureau's 2009-2013 American Community Survey. Differences in their distributions across the Spanish Visibility Categories were investigated using the Mann-Whitney U test. RESULTS: 25% of websites were translatable to Spanish, and a regional discrepancy was found with 61% translatable in the West, 19% in Northeast, 19% in Midwest, and 15% in South. Median Spanish-speaking population was higher in counties where websites were translatable to Spanish than where websites were not translatable. CONCLUSION: Healthcare disparities in Bariatrics continue to be an ongoing struggle. We suggest that Spanish readability for ASMBS ACS COE websites should be improved regardless of geographic differences in Spanish-speaking populations. We believe it would be valuable for these websites to have standards for readability of Spanish and other languages.

Mental health status as a predictor of emergency department visits and hospital readmissions post bariatric surgery: a retrospective cohort study.

BACKGROUND: This retrospective cohort study aims to investigate emergency department (ED) visits and readmission after bariatric surgery among patients with a history of anxiety and/or depression. We predict that patients with a reported history of anxiety and/or depression will have more ED visits in the year following surgery than patients without a history of mental illness. METHODS: Data were collected from the charts of all consecutive patients who underwent sleeve gastrectomy or gastric bypass surgery between March 2012 and December 2019. Data on baseline body mass index, mental health diagnosis and treatment and emergency department visits and hospital readmissions were retrospectively reviewed over the first year following surgery. RESULTS: One thousand two hundred ninety-seven patients were originally included in this study and 1113 patients were included in the final analysis. Patients with a history of depression (OR 1.23; 95% CI 0.87-1.73), anxiety (OR 1.14; 95% CI 0.81-1.60), or both (OR 1.17; 95% CI 0.83-1.65) did not have a statistically significant increase in ED visits compared to patients without these disorders. Patients with a history of depression (OR 1.49; 95% CI 0.86-2.61), anxiety (OR 1.45; 95% CI 0.80-2.65) or both (OR 1.47; 95% CI 0.94-2.29) did not have a statistically significant increase in hospital readmissions in the first year after surgery compared to patients without these disorders. Patients treated with a sleeve gastrectomy were readmitted due to postoperative complications less frequently than those treated with other surgeries (OR 0.20; 95% CI 0.05-0.83). CONCLUSION: Patients with a history of anxiety, depression or both did not have an increased rate of emergency department visits and hospital readmissions within the first year following bariatric surgery. This contradicts current literature and may be due to the multidisciplinary program patients undergo at this study's home institution.

Spanish-language bariatric surgery patient education materials fail to meet healthcare literacy standards of readability.

BACKGROUND: The Hispanic population is the fastest growing ethnic minority in the United States, contributing to nearly half of the population growth over the last decade. Unfortunately, this population suffers from lower-than-average health literacy rates, leading to poorer health outcomes. Per the American Medical Association and National Institutes of Health, patient education materials (PEMs) should be written at no higher than a 6th grade reading level. Given that US Hispanic adults have the second-highest obesity prevalence, this study aims to analyze the readability of Spanish-language PEMs regarding bariatric surgery available in US-based academic and medical centers. METHODS: A total of 50 PEMs were found via the query ""cirugía de pérdida de peso" site: (edu OR.org)" on the Google search engine. Thirty-nine sources met the inclusion criteria of belonging to a US-based academic or medical center and containing information regarding the indications for bariatric surgery, descriptions of the types of bariatric surgery, what to expect before and after surgery, or the risks and benefits of bariatric surgery. The excerpts were analyzed according to three readability formulas designed specifically for the Spanish language and evaluated for their reading grade level. RESULTS: All 39 sources were at the college reading level per the Fry graph corrected for Spanish. Per the Spaulding formula, 37 sources were "Grade 12 + " and two sources were "Grade 8-10." Per the Fernandez-Huerta formula, 16 sources were at the 8th/9th grade reading level, 22 sources were at the 7th grade reading level, and one was at the 6th grade reading level. CONCLUSION: The Spanish-language bariatric surgery PEMs available online from US-based academic and medical centers are generally above the recommended 6th grade reading level. Failure to meet the recommended sixth-grade reading level decreases health care literacy for Spanish-speaking patients within the United States seeking bariatric surgery.

Patient perceptions of urgency of their pelvic floor disorders during the COVID-19 pandemic.

INTRODUCTION AND HYPOTHESIS: During the COVID-19 pandemic, many surgical societies released guidelines that included cancellation of elective cases. The aim of this study was to better understand our patients' perceptions of the severity of their pelvic floor disorders (PFDs) and to determine what factors influenced this perception. We also aimed to better understand who might be amenable to telemedicine visits and what factors influenced this decision. METHODS: This is a cross-sectional quality improvement study that included women at least 18 years of age diagnosed with a pelvic floor disorder being evaluated within a university Female Pelvic Medicine and Reconstructive Surgery clinic during the COVID-19 pandemic. Patients whose appointments and procedures were being cancelled were queried on whether they would be willing to answer a telephone questionnaire developed by the clinical and research teams. We gathered descriptive data from 97 female patients with PFDs using a primary phone questionnaire. The data were analyzed using proportions and descriptive statistics. RESULTS: Of the 97 patients, the majority (79%) viewed their conditions as non-urgent. Factors that influenced patients' perception of urgency included race (p=0.037), health status (p≤0.001), a history of diabetes (p=0.011), and willingness to attend an in-person appointment (p=0.010). Further, 52% of respondents were willing to attend a tele-health appointment. Statistically significant factors influencing this decision were ethnicity (p=0.019), marital status (p=0.019), and willingness to attend an in-person appointment (p=0.011). CONCLUSION: The majority of women did not view their conditions as urgent during the COVID-19 pandemic and were amenable to a telehealth appointment.

An Electronic Medical Record Pocket Guide for Incoming Internal Medicine Interns: Perceptions and Impact on Patient Information Gathering.

OBJECTIVES: The transition from medical student to intern is associated with a significant increase in workloads and responsibilities. This includes using the electronic medical record (EMR), which can lead to challenges in information gathering and patient care; however, no formal residency interventions exist in the use of an EMR for information gathering, with most EMR training occurring in the clinical setting. The present study aimed to improve information gathering on patient care and enhance the confidence of Internal Medicine interns in information gathering. METHODS: We performed a pre- and postprospective study in July 2021. All of the Internal Medicine interns at our community hospital were included. A pre- and postassessment to evaluate interns' confidence was distributed to participants during orientation week and at the end of the inpatient Internal Medicine rotation. A pre- and postconfidence assessment was collected at the beginning and end, respectively, of each intern's inpatient Internal Medicine rotation. RESULTS: Seventeen (85%) interns completed both the preassessment and postassessment. Use of an EMR guide led to a significant increase in completeness of patient information gathering (preassessment: 73.2% ± 18.4% vs post-EMR guide: 94.7% ± 7.4%, P < 0.001) and in intern confidence (P = 0.001). CONCLUSIONS: The use of an EMR guide was well received among Internal Medicine interns and led to increased completeness in patient information gathering. Residency programs may benefit from developing an EMR guide to improving the transition of interns during residency.

Reverse Abdominoplasty for Mastectomy Defect Closure in Advanced Breast Cancer.

BACKGROUND: Breast cancer patients with locally advanced breast cancer who require radical mastectomy are left with large chest wall defects. This poses a significant reconstructive challenge as many high-risk patients require timely postmastectomy adjuvant therapy. While the reverse abdominoplasty technique is commonly used for aesthetic improvement of the anterior trunk, it can be also be effectively used for closure of extensive mastectomy defects in this patient population. METHODS: We conducted a retrospective cohort study of all consecutive patients who underwent an extensive radical mastectomy followed by immediate closure with the reverse abdominoplasty technique at a single tertiary cancer center from June 2017 to July 2022. Patients who had concurrent skin grafting or breast mound flap reconstruction were excluded. Demographic, medical, oncologic, and reconstructive data were collected. RESULTS: Six patients were treated with reverse abdominoplasty for 9 chest wall defects after surgical excision of locally advanced breast cancer. The median tumor size was 10.7 cm (range, 6.7-10 cm) and the median mastectomy weight was 865.7 g (range, 356.4-1247.7 g). On average, the operation length was 191 minutes (range, 86-257 minutes) and the postoperative length of stay was 2.2 days (range, 1-5 days). All patients underwent systemic adjuvant therapy and the median time from surgery to initiation of therapy was 44.5 days (range, 32-75 days). CONCLUSIONS: Reverse abdominoplasty is a simple and safe technique to reliably close large defects after locally advanced breast cancer excision. It has a short operative time, hospital stay, and turnaround time to initiation of adjuvant therapy.

Preventative Cancer Screening Rates Among Uninsured Patients in Free Clinics: A Retrospective Cohort Study of Cancer Survivors and Non-cancer Survivors.

BACKGROUND: There is limited research on screening rates among uninsured cancer survivors. Uninsured cancer survivors are at higher risk of poorer health outcomes than the insured due to limited access to preventative screening for secondary cancers. This study examines the rates of surveillance and screening of uninsured cancer survivors and compares to uninsured patients without a cancer history seen in free clinics. METHODS: Data were collected retrospectively from electronic medical records and paper charts of patients from 10 free clinics between January 2016 and December 2018 in the Tampa Bay area. The prevalence of socioeconomic characteristics, cancer diagnoses, and screening practices were compared for cancer survivors and free clinic patients without a history of cancer. Study participants were determined to be eligible for cancer screenings based on the United States Preventive Services Task Force guidelines. RESULTS: Out of 13 982 uninsured patients frequenting free clinics between 2016 and 2018, 402 (2.9%) had a documented history of cancer. Out of the 285 eligible cancer survivors, 44 (15.4%) had completed age-appropriate colon cancer screening. Among the 170 female cancer survivors, 75 (44.1%) had completed breast cancer screenings, and only 5.9% (59/246) had completed cervical cancer screenings. After adjusting for age, gender, race, salary, employment status, and household size, cancer survivors were more likely to undergo colorectal cancer screening (OR: 3.59, 95% CI: 2.10-6.15) and breast cancer screening (OR: 2.13, 95% CI: 1.30-3.84) than patients without a cancer history. This difference was not seen for cervical cancer screening (OR: 0.99, 95% CI: .62-1.58). CONCLUSIONS: Uninsured cancer survivors frequenting free clinics represent a unique population that is underrepresented in the medical literature. Our results suggest that uninsured survivors use screening services at higher rates when compared to uninsured patients without a reported cancer diagnosis. However, these rates are suboptimal when compared to national screening rates of insured cancer survivors.

nPEP protocol implementation and evaluation at a local US Crisis Center.

Non-occupational Post-Exposure Prophylaxis for HIV (nPEP) is recommended by the CDC for isolated exposures that pose "substantial risk" for HIV transmission. To combat multiple barriers to nPEP utilization, a comprehensive program was developed through the local community sexual assault provider. The purpose of this study was to evaluate nPEP protocol implementation. A retrospective chart review was conducted of all sexual assault victims seen during a six-month period, and all patients who accepted nPEP were selected for follow-up phone interviews. 157 patients presented during the study period. Mean time to care was 32.4hrs, with 126/157 (80%) presenting ≤72hrs. 114/157 (73%) patients were offered nPEP by providers. 67/114 (59%) patients accepted, with the most common reason for declining being needing more time to decide. 10/13 (77%) patients able to be contacted reported completing nPEP, with side-effects cited as the most common noncompletion reason. 9 reported side effects and 4 received recommended follow-up HIV testing. 83/99 (84%) patients clearly eligible by chart review were offered nPEP, suggesting good adherence to CDC guidelines. Most patients contacted completed nPEP despite side-effects, suggesting good adherence. Our findings demonstrated multiple points status post-sexual assault to potentially improve the nPEP process.

Novel biomarkers of inflammation in heart failure with preserved ejection fraction: analysis from a large prospective cohort study.

BACKGROUND: Heart failure with preserved ejection fraction (HFpEF) is a syndrome with a heterogeneous cluster of causes, including non-resolving inflammation, endothelial dysfunction, and multi-organ defects. The present study's objective was to identify novel predictors of HFpEF. METHODS: The study analyzed the Multi-Ethnic Study of Atherosclerosis (MESA) to assess the association of specific markers of inflammation with new onset of HFpEF (interleukin-2 [IL-2], matrix metalloproteinase 3 [MMP3], large low-density lipoprotein cholesterol [LDL-C], and medium high-density lipoprotein cholesterol [HDL-C]). The study included men and women 45 to 84 years of age without cardiovascular disease at baseline. The primary outcome was the multivariate association of the hypothesized markers of inflammation with new-onset of HFpEF versus participants without new-onset heart failure. Participants with missing data were excluded. RESULTS: The present analysis included 6814 participants, 53% female, with a mean age of 62 years. Among the entire cohort, HFpEF was diagnosed in 151 (2.2%) participants and heart failure with reduced ejection fraction (HFrEF) was diagnosed in 146 (2.1%) participants. Participants were followed for the outcome of heart failure for a median 13.9 years. Baseline IL-2 was available for 2861 participants. The multivariate analysis included 2792 participants. Of these, 2668 did not develop heart failure, 62 developed HFpEF, 47 developed HFrEF, and 15 developed unclassified heart failure. In the multivariate regression model, IL-2 was associated with new-onset HFpEF (OR, 1.00058; 95% confidence interval, 1.00014 to 1.00102, p = 0.009) but not new-onset HFrEF. In multivariate analysis, MMP3, large LDL-C, and medium HDL-C were not associated with HFpEF or HFrEF. CONCLUSION: These findings portend IL-2 as an important component of suboptimal inflammation in the pathogenesis of HFpEF.

Treatment of early-stage mycosis fungoides with oral bexarotene and phototherapy: A systematic review and meta-analysis.

Mycosis fungoides (MF) is a rare subtype of non-Hodgkin lymphoma, for which no standard treatment exists. The objective of this study is to provide evidence-based recommendations for adult patients with early-stage MF treated with oral bexarotene and phototherapy. A systematic review and meta-analysis was conducted utilizing studies identified via Embase, Pubmed, Web of Science, and the Cochrane Library from inception to April 2020 to evaluate the clinical efficacy and adverse events of oral bexarotene and phototherapy. Of 645 abstracts retrieved, 17 full-text articles with 143 subjects were included for analysis. There were nine case reports, five retrospective cohort studies, two prospective cohort studies, and one randomized controlled trial. Most subjects were men (24.48%) with stage IB disease (54.4%), and the mean age at presentation was 63. One patient had folliculotropic disease. The retrospective studies' analysis included 67 subjects and indicated that the partial response was 40.36% (95% CI 18.24-64.92), complete response was 34.06% (95% CI 10.73-62.56), and overall response was 64.48% (95% CI 48.56-78.89). Side effects from bexarotene were hypertriglyceridemia (54%), hypothyroidism (50%), and hypercholesterolemia (46%). Similar results were noted in the prospective studies. The literature consists mostly of uncontrolled studies, which suggest that combination therapy with oral bexarotene and phototherapy is a therapeutic option. Future randomized control studies with longer follow-up and standardized definitions of treatment responses and dosages are needed to support the development of evidence-based approaches for the treatment of early-stage MF.