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.

Hematospermia in a Transgender Woman with Evidence for Endometrial Tissue in the Prostate.

Background/Objective: The frequency of hematospermia in transgender women is unknown. This report aimed to describe the development of hematospermia in a transgender woman. Case Report: A 35-year-old transgender woman treated with estradiol valerate and leuprolide presented with painless rust-tinged ejaculate, urethral bleeding after ejaculation, and intermittent hematuria. Her medical history included gastroesophageal reflux disease, internal hemorrhoids, and attention deficit hyperactivity disorder with negative tobacco smoking and urologic history. Additional medications included emtricitabine-tenofovir disoproxil fumarate and fexofenadine. Physical examination did not reveal constitutional or genitourinary abnormalities. Urinalysis and culture disclosed rare white blood cells with gram-variable bacilli. The chlamydia, gonorrhea, and human immunodeficiency virus test results were negative. Abdominal computed tomography did not reveal bladder or prostate cancer, calcifications, inflammation, or cysts. She continued to have symptoms after this initial workup. One year after the initial symptom onset, transrectal ultrasound disclosed a 1.7-cm midline posterior prostatic cyst with hemorrhagic products, later revealed by magnetic resonance imaging as communicating with the left seminal vesicle. Two ultrasound-guided transperineal biopsy samples revealed benign prostatic tissue with a small focus of Müllerian or endometrial-type tissue, evidenced by immunopositivity for paired-box gene 8 and estrogen receptor in epithelium and cluster of differentiation 10 immunopositivity in stroma. After medical consultation, the patient underwent prostatic cyst aspiration, resection of the transurethral ejaculatory ducts, and orchiectomy. She did not experience any complications after these procedures. Discussion: The etiology of hematospermia may be idiopathic, iatrogenic, anatomic, or pathologic. Conclusion: Occult endometriosis or ectopic Müllerian epithelial tissue growth may occur in transgender women taking feminizing gender-affirming hormone therapy.

A New Start with HAART: Evaluating Breast Reconstruction in the Era of Highly Active Antiretroviral Therapy.

Background: As HIV-positive individuals utilizing highly active antiretroviral therapy live longer, the burden of breast cancer increases in the population. Breast reconstruction is an integral aspect of surgical treatment for many patients after a breast cancer diagnosis, prompting this examination of the characteristics and outcomes of breast reconstruction in this growing patient population. Methods: Using Merative MarketScan Research Databases, a large multipayer database, HIV-positive adult patients who underwent autologous or implant-based breast reconstruction between 2007 and 2021 were identified using International Classification of Disease codes and Common Procedural Terminology codes. In both HIV-positive and -negative cohorts, patient demographics, procedure-related complications, and postoperative revisions were recorded. Shapiro-Wilk, chi-square, Wilcoxon-Mann-Whitney, and multivariable logistic regression tests were used for statistical analysis. Results: Of 173,421 patients who underwent breast reconstruction, 1816 had an HIV diagnosis. HIV-positive patients were younger (P < 0.001), underwent surgery more recently (P < 0.001), more often underwent immediate breast reconstruction (P < 0.001), and had higher comorbidity levels (P < 0.001). There was a regional variation in which the patient cohorts underwent breast reconstruction. There was no significant difference in overall complication rates between patient groups, but HIV-negative patients more often underwent revision procedures (P = 0.009). Conclusions: When compared to their HIV-negative counterparts, breast reconstruction can be considered safe and efficacious in patients living with HIV. HIV-positive patients are a growing demographic who seek breast reconstruction, and surgeons must continue to further understand the unique implications of breast reconstruction in this population.

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.

The psychological impacts of post-mastectomy breast reconstruction: a systematic review.

Background: While it is often presumed that undergoing breast reconstruction (BR) after mastectomy has positive psychosocial effects, a comprehensive review of current knowledge on the topic is to date absent. The aim of this systematic review is to summarize the available literature on the effects of BR on postoperative psychological distress. Methods: A systematic review of the literature was performed using PubMed, Google Scholar, EMBASE, PSYCinfo, and Web of Science. Inclusion criteria included clinical studies of patients who underwent BR post-mastectomy with psychological distress assessments as primary outcomes. Articles were independently reviewed and assessed for bias and evidence quality. Analyses were performed among patients receiving mastectomy alone (MA) versus mastectomy with breast reconstruction (MBR), immediate versus delayed mastectomy, and implant-based versus autologous reconstruction. Results: Ninety-nine studies published from 1980-2021 met inclusion criteria and were reviewed. Twenty-six (26.3%) studies compared patients who underwent MBR to those who underwent MA. Of these, 18 (69.2%) found that MBR had superior effects on psychologic outcomes, 6 (23.1%) found no differences, and 2 (7.7%) found negative psychologic effects relative to MA. Fourteen (14.1%) studies compared immediate versus delayed BR, of which 4 (28.6%) found that immediate BR had superior psychologic outcomes while 10 (71.4%) found no significant differences. Sixteen (16.2%) studies compared autologous versus implant-based reconstruction. Eight (50.0%) of these reported patients with autologous BR were more satisfied with breast appearance. Conclusions: While findings are not uniform, the majority of studies found that BR following mastectomy improves psychologic outcomes, with a possible benefit of immediate over delayed BR. Future studies should determine if BR type has an effect on psychological distress.