ABSTRACT
Orthoplastic surgery is a multidisciplinary approach that is well-studied for extremity trauma, but not for musculoskeletal oncologic reconstruction. Here, the authors describe the application of a collaborative orthoplastic approach for the management of primary musculoskeletal neoplasms and evaluate its impact. The collaboration protocol, implemented in July 2019, comprises specific checkpoints of interdisciplinary co-management, which span the pre-, intra-, and postoperative treatment period. This involves direct communication between attending surgeons and their respective clinical teams. Patients who underwent resection of a primary musculoskeletal neoplasm between March 2014 and April 2022 were retrospectively categorized into conventional or collaboration groups. Of the 136 total patients, there were 63.2% (nâ =â 86) conventional and 36.8% (nâ =â 50) collaboration; 31.6% (nâ =â 43) had reconstruction and 68.4% (nâ =â 93) did not. Compared with the conventional group, the collaboration group had significantly higher rates of diabetes (18% versus 7%, P = 0.048) and radiation treatment (68% versus 43%, P = 0.005). The collaboration group was significantly more likely to have plastic surgery involvement in their care than the conventional group (38% versus 14%, P = 0.001), and to undergo reconstruction (42% versus 26%, P = 0.047). The groups showed no difference in rates of hematoma, seroma, delayed healing, infection, 30- or 90-day reoperation, or partial or complete flap/graft failure. The collaborative approach described here is feasible and associated with increased plastic surgery involvement and reconstructive surgery. Complications were equivalent despite evidence suggesting increased case complexity in the collaboration group. These early results are promising and could inspire wider adoption of structured orthoplastic protocols for care of these patients.
ABSTRACT
The United States (US) opioid epidemic is a persistent and pervasive public health emergency that claims the lives of over 80,000 Americans per year as of 2021. There have been sustained efforts to reverse this crisis over the past decade, including a number of measures designed to decrease the use of prescription opioids for the treatment of pain. This study analyzed the changes in federal production quotas for prescription opioids and the distribution of prescription opioids for pain and identified state-level differences between 2010 and 2019. Data (in grams) on opioid production quotas and distribution (from manufacturer to hospitals, retail pharmacies, practitioners, and teaching institutions) of 10 prescription opioids (codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, oxymorphone, and tapentadol) for 2010 to 2019 were obtained from the US Drug Enforcement Administration. Amounts of each opioid were converted from grams to morphine milligram equivalent (MME), and the per capita distribution by state was calculated using population estimates. Total opioid production quotas increased substantially from 2010 to 2013 before decreasing by 41.5% from 2013 (87.6 MME metric tons) to 2019 (51.3). The peak year for distribution of all 10 prescription opioids was between 2010 and 2013, except for codeine (2015). The largest quantities of opioid distribution were observed in Tennessee (520.70 MME per person) and Delaware (251.45) in 2011 and 2019. There was a 52.0% overall decrease in opioid distribution per capita from 2010 to 2019, with the largest decrease in Florida (-61.6%) and the smallest in Texas (-18.6%). Southern states had the highest per capita distribution for eight of the ten opioids in 2019. The highest to lowest state ratio of total opioid distribution, corrected for population, decreased from 5.25 in 2011 to 2.78 in 2019. The mean 95th/5th ratio was relatively consistent in 2011 (4.78 ± 0.70) relative to 2019 (5.64 ± 0.98). This study found a sustained decline in the distribution of ten prescription opioids during the last five years. Distribution was non-homogeneous at the state level. Analysis of state-level differences revealed a fivefold difference in the 95th:5th percentile ratio between states, which has remained unchanged over the past decade. Production quotas did not correspond with the distribution, particularly in the 2010-2016 period. Future research, focused on identifying factors contributing to the observed regional variability in opioid distribution, could prove valuable to understanding and potentially remediating the pronounced disparities in prescription opioid-related harms in the US.
ABSTRACT
BACKGROUND: Textured implants and expanders are associated with an increased risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). As a result, plastic surgeons are utilizing smooth expanders, but many perceive these produce undesirable outcomes including infection, seroma, and lateral displacement. OBJECTIVES: The aim of this study was to compare clinical outcomes of smooth and textured expanders. METHODS: Breast reconstruction patients from January 2018 to May 2021 were retrospectively reviewed. Included patients underwent placement of tissue expanders at the time of mastectomy. Primary outcomes included postoperative seroma, infection, malposition, days to final reconstruction, explantation, and the need for capsulorrhaphy. RESULTS: In total, 233 patients were reviewed, of whom 167 met both inclusion and exclusion criteria. There was no statistically significant difference in poor outcomes comparing smooth and textured expanders. Days to final reconstruction was lower with smooth expanders per breast (P = .0424). The subpectoral group was associated with an increased likelihood of undergoing capsulorrhaphy (P = .004). Prepectoral placement was associated with more seromas (P = .0176) and infections (P = .0245). Demographic factors included older age as a protective factor for undergoing capsulorrhaphy (odds ratio [OR] = 0.962, P = .038), obesity increased the risk of infection (OR = 5.683, P = .0279) and malposition (OR = 6.208, P = .0222), and radiation was associated with malposition (OR = 3.408, P = .0246). CONCLUSIONS: There was no significant difference in poor outcomes between smooth and textured expanders. Patient demographics and anatomical plane placement had greater effects on infection, seroma, and the need for capsulorrhaphy compared with tissue expander texturing.
Subject(s)
Breast Implantation , Breast Implants , Breast Neoplasms , Mammaplasty , Humans , Female , Tissue Expansion Devices/adverse effects , Mastectomy , Retrospective Studies , Breast Neoplasms/etiology , Breast Neoplasms/surgery , Seroma/epidemiology , Seroma/etiology , Mammaplasty/adverse effects , Breast Implants/adverse effects , Breast Implantation/adverse effectsABSTRACT
BACKGROUND: Lymphedema (LE) is the most notable complication of axillary surgery. The axillary reverse mapping (ARM) technique was created to decrease LE. This study aims to evaluate a single surgeon's experience with ARM in patients undergoing sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) for breast cancer. METHODS: We retrospectively analyzed patients who underwent SLNB or ALND. Tumor characteristics and treatments received were evaluated. Surgical intervention and use of ARM were compared to assess LE rates. A subgroup analysis was also performed of patients who underwent NAC. RESULTS: LE was initially reported in 7.1% (n = 10) of patients; 3.3% (n = 4) with SLNB and 35% (n = 6) with ALND. At initial follow-up, LE was reported 16.4% more often in patients who underwent ALND with no ARM, and 38.8% more often in patients who underwent ALND plus ARM. An increased risk of LE was found in patients treated with ALND (OR = 16.0, P < .001). All patients who underwent ARM were 12.75% more likely to develop LE if they received NAC (P < .05). Patients in the ALND group who also received NAC were more likely to undergo ARM as compared with patients in the SLNB group (P < .01). DISCUSSION: Our study showed that ARM failed to decrease the incidence of LE. Until better surgical outcomes are shown for the prevention of LE using ARM, other approaches should be utilized. However, larger prospective studies are needed to evaluate ARM.
Subject(s)
Breast Neoplasms , Lymphedema , Humans , Female , Retrospective Studies , Lymph Node Excision/adverse effects , Lymph Node Excision/methods , Lymphedema/etiology , Lymphedema/prevention & control , Lymphedema/pathology , Sentinel Lymph Node Biopsy/adverse effects , Sentinel Lymph Node Biopsy/methods , Lymph Nodes/pathology , Breast Neoplasms/surgery , Breast Neoplasms/pathology , Axilla/surgeryABSTRACT
BACKGROUND: The COVID-19 pandemic has disproportionately impacted Hispanics in the USA with increased rates of SARS-CoV-2 infections, hospitalizations, and deaths. The objective of this report was to characterize the demographics and beliefs of unvaccinated Hispanics to help address their concerns that lead to vaccine hesitancy. METHODS: Of 1,011 potential participants from a national online panel, 22.3% (N = 225, 51.6% female, age = 40.5) met inclusion criteria of Hispanic adults and not receiving at least one dose of the COVID-19 vaccine. The 30-item survey included items about demographics, political affiliations, sources of news (e.g., Fox vs. CNN), reasons for being unvaccinated, and ratings (0 = strongly disagree, 100 = strongly agree) of 10 controversial statements regarding COVID-19. RESULTS: Over three-fifths (62.6%) identified side effects and safety concerns, while almost one-third (30.5%) cited a lack of efficacy as their top reasons for being unvaccinated. Agreement to "The developers of the COVID-19 vaccine rushed the development and cut corners" was rated the highest (63.22) which was significantly (p < .001) higher than the other nine statements (e.g., "The COVID-19 vaccine does not work"). Many vaccine attitudes differed significantly by political party affiliation and some by gender and news source. Republicans (59.9 ± 4.2) scored higher than Democrats (38.5 ± 4.2, p ≤ .001) to "If I've already had COVID-19, I don't need the vaccine." CONCLUSIONS: This study identified the heterogeneity in COVID-19 vaccine attitudes among Hispanics. Further research is needed to determine if the subgroups identified are differentially receptive to interventions to facilitate reconsideration of prior vaccination decisions.