The value of microvascular breast reconstruction: Cost equivalence of TRAM and DIEP flaps implications in the era of CMS reforms.

BACKGROUND: Recent CMS billing changes have raised concerns about insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study compared the costs and utilization of transverse rectus abdominis myocutaneous (TRAM), DIEP, and latissimus dorsi (LD) flaps in breast reconstruction. METHOD: The study utilized the National Inpatient Sample database to identify female patients who underwent DIEP, TRAM, and LD flap procedures from 2016 to 2019. Key data such as patient demographics, length of stay, complications, and costs (adjusted to 2021 USD) were analyzed, focusing on differences across the flap types. RESULTS: A total of 17,770 weighted patient encounters were identified, with the median age being 51. The majority underwent DIEP flaps (73.5%), followed by TRAM (14.2%) and LD (12.1%) flaps. The findings revealed that DIEP and TRAM flaps had a similar length of stay (LOS), while LD flaps typically had a shorter LOS. The total hospital charges to costs using cost-to-charge ratio were also comparable between DIEP and TRAM flaps, whereas LD flaps were significantly less expensive. Factors such as income quartile, primary payer of hospitalization, and geographic region significantly influenced flap choice. CONCLUSION: The study's results appear to contradict the prevailing notion that TRAM flaps are more cost-effective than DIEP flaps. The total hospital charges to costs using cost-to-charge ratio and hospital stays associated with TRAM and DIEP flaps were found to be similar. These findings suggest that changes in the insurance landscape, which may limit the use of DIEP flaps, could undermine patient autonomy while not necessarily reducing healthcare costs. Such policy shifts could favor less costly options like the LD flap, potentially altering the landscape of microvascular breast reconstruction.

The Impact of Health Literacy on Trust in Online Plastic Surgery Content: A Nationwide Analysis.

INTRODUCTION: On most online platforms, just about anyone can disseminate plastic surgery (PS) content regardless of their educational or professional background. This study examines the general public's perceptions of the accuracy of online PS content and the factors that contribute to the discernment of credible information. METHODS: The Amazon Mechanical Turk crowdsourcing platform was used to survey adults in the United States. The survey assessed respondent demographics, health literacy (HL), and perceptions of online PS content accuracy. T-tests, Chi-square tests, and post hoc analyses with Bonferroni corrections assessed differences between HL groups. Multivariate linear regressions assessed associations between sociodemographic variables and perceptions of online content. RESULTS: In total, 428 (92.0%) of 465 complete responses were analyzed. The median age of respondents was 32 y (interquartile range: 29-40). Online sources were predominantly perceived to have a high degree of accuracy, with mean scores of various platforms ranging from 3.8 to 4.5 (1 = not accurate at all; 5 = extremely accurate). The low HL group perceived social media sites and review sites to be more accurate than the high HL respondents, particularly for Reddit (P = 0.004), Pinterest (P = 0.040), and Snapchat (P = 0.002). CONCLUSIONS: There is a concerning relationship between low HL and the perceptions of the accuracy of online PS sources. This study underscores the need for education campaigns, the development of trustworthy online resources, and initiatives to improve HL. By fostering a more informed public, individuals seeking PS can make better informed decisions.

Air Versus Saline in Tissue Expanders: A Systematic Review of the Literature.

BACKGROUND: There has been a greater focus in recent literature proposing air to be a superior medium to saline in tissue expanders. This study aims to review the literature and assess the quality of data on the efficacy and safety of air as an alternative medium to saline in tissue expanders, in the setting of postmastectomy two-stage reconstruction. METHODS: A systematic review regarding air inflation of tissue expanders was conducted using PubMed, Embase, Cochrane Library, and Web of Science. The methods followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three reviewers separately performed data extraction and comprehensive synthesis. RESULTS: A total of 427 articles were identified in our search query, of which 11 met the inclusion criteria. Three pertained to inflation with room air, and eight pertained to inflation with CO2 using the AeroForm device. They were comparable to decreased overall complication rates in the room air/CO2 cohort compared to saline, although statistical significance was only observed in one of five two-arm studies. Investigating specific complications in the five two-arm studies, significantly lower rates of skin flap necrosis were only observed in two CO2-based studies. Studies rarely discussed other safety profile concerns, such as the impacts of air travel, radiation planning, and air extravasation beyond descriptions of select patients within the cohort. CONCLUSION: There is insufficient evidence to suggest improved outcomes with room air inflation of tissue expanders. Further work is needed to fully characterize the benefits and safety profiles of air insufflation before being adopted into clinical practice.

The impact of metabolic syndrome in breast reconstruction decision-making and postoperative outcomes: A nationwide analysis.

BACKGROUND: Metabolic syndrome (MetS) is a cluster of cardiometabolic abnormalities including hypertension, obesity, insulin resistance, and dyslipidemia. The safety profiles of patients with MetS undergoing breast reconstruction remain underreported. This study aims to evaluate the impact of MetS on the BR decision-making process and postoperative complication rates. METHODS: The ACS-NSQIP database was utilized to identify women who underwent BR between 2012 and 2021. Baseline characteristics were compared based on the presence of MetS, defined as patients receiving medical treatment for diabetes mellitus and hypertension, with a body mass index greater than 30 kg/m2. Group differences were assessed using t tests and Fisher's exact tests. Multivariate logistic regression models evaluated postoperative complications between the groups. RESULTS: A total of 160,115 patients underwent BR. A total of 4570 had a diagnosis of MetS compared to 155,545 without MetS. No statistically significant differences were observed in the type of BR patients received across cohorts. Logistic regression models demonstrated a higher likelihood of postoperative wound complications (OR 2.21; 95% CI 1.399, 3.478; p = 0.001), and readmission rates (OR 2.045; 95% CI 1.337, 3.128; p = 0.001) in the MetS group compared to the non-MetS patients. No significant differences were identified in other postoperative complications between groups. CONCLUSIONS: Patients with MetS appear to have an increased risk of postoperative wound complications and readmission after breast reconstruction. The synergistic effects of these comorbidities on postoperative outcomes underscore the importance of addressing MetS as a holistic condition and considering choosing Delayed breast reconstruction over Immediate Breast Reconstruction in this population. Thus, integrating MetS management and patient counseling at various stages of BR may improve outcomes and facilitate patient decision-making.

Geographic Variability of Genital Gender-Affirming Surgery Centers and Costs of Hospitalization.

PURPOSE: The cost of gender-affirming surgery (GAS) is an important component of healthcare accessibility for transgender patients. However, GAS is often prohibitively expensive, particularly as there are inconsistencies in insurance coverages. Variability in hospital costs has been documented for other types of nonplastic surgery procedures; however, this analysis has not been done for GAS. To better understand the financial barriers impairing access to equitable transgender care, this study analyzes the distribution of hospitals that perform genital GAS and the associated costs of inpatient genital GAS. METHODS: This is a study of the 2016-2019 National Inpatient Sample database. Transgender patients undergoing genital GAS were identified using International Classification of Diseases, Tenth Revision, diagnosis and procedure codes, and patients undergoing concurrent chest wall GAS were excluded. Descriptive statistics were done on patient sociodemographic variables, hospital characteristics, and hospitalization costs. χ2 test was used to assess for differences between categorical variables and Mood's median test was used to assess for differences between continuous variable medians. RESULTS: A total of 3590 weighted genital GAS encounters were identified. The Western region (50.8%) and Northeast (32.3%) performed the greatest proportion of GAS, compared with the Midwest (9.1%) and the South (8.0%) (P < 0.0001). The most common payment source was private insurance (62.8%), followed by public insurance (27.3%). There were significant differences in the variability of median hospital costs across regions (P < 0.0001). The South and Midwest had the greatest median cost for vaginoplasty ($19,935; interquartile range [IQR], $16,162-$23,561; P = 0.0009), while the West had the greatest median cost for phalloplasty ($26,799; IQR, $19,667-$30,826; P = 0.0152). Across both procedures, the Northeast had the lowest median cost ($11,421; IQR, $9155-$13,165 and $10,055; IQR, $9,013-$10,377, respectively). CONCLUSIONS: There is significant regional variability in the number of GAS procedures performed and their associated hospitalization costs. The identified disparities in insurance coverage present an area of possible future improvement to alleviate the financial burden GAS presents to gender-discordant individuals. The variability in cost suggests a need to evaluate variations in care, leading to cost standardization.

Sources of Facial Injury Across Age Groups: A Nationwide Overview Using the National Electronic Injury Surveillance System Database.

BACKGROUND: Facial trauma comprises a significant portion of injuries that occur each year in the United States, with injuries ranging from lacerations to complex facial fractures. This study aims to provide a broad epidemiologic overview of facial trauma in the United States to direct preventative safety measures. METHODS: A cross-sectional study was conducted utilizing the National Electronic Injury Surveillance System database to identify the weighted national incidence of facial injuries from 2017 to 2021. Descriptive and inferential statistical analysis was used to compare the demographics of patients, the settings where the injury occurred, and the products resulting in the injury. RESULTS: A total of 8,465,538 out of 64,312,132 weighted encounters involved facial injuries. Less than 10 years was the highest-represented age group (36.8%). The most frequent disposition was treated and released (91.1%), with increasing age associated with higher rates of hospitalization (odds ratio: 1.04, P < 0.001). Cases predominantly occurred at home (49.0%), and the most common type of injury was laceration (36.5%). At-home injuries increased with age, comprising 39.2% of facial injuries for 21 to 40 years, 52.0% for 41 to 64 years, and 58.0% for older than 65 years. Building structures (21.4%) were the most prevalent source of injury, composed predominantly of floors (58.3%) and ceilings and walls (10.4%). CONCLUSIONS: There is an understated burden of at-home facial injuries across all age groups, beyond the pediatric and geriatric population. Fall prevention and home environmental hazards education could benefit all ages, reducing the incidence of facial trauma.

Severe Neuroinvasive West Nile Virus in Association With Anti-CD20 Monotherapy for Multiple Sclerosis.

OBJECTIVES: The objective of this study was to report on the development of neuroinvasive West Nile virus (WNV) infection in the context of anti-CD20 monotherapy for multiple sclerosis (MS). METHODS: This is a case series study. RESULTS: In 2021-2022, we observed 4 cases of neuroinvasive WNV infection in our patient population of 2009 patients with MS on ocrelizumab, compared with a total of 46 cases of neuroinvasive WNV infection reported in Pennsylvania and 40 in New Jersey. Odds were 258 times that of the general population (95% confidence interval 97-691), χ2 p < 0.0001). All were women aged 41-61 years with variable disease duration, level of disability, and duration of anti-CD20 therapy. All presented in summer/early fall with fever, headache, and encephalopathy consistent with meningoencephalitis. Three patients had acute cerebellitis. Two had anterior nerve root involvement progressing to quadriparesis, and 1 developed refractory nonconvulsive status epilepticus. All required intubation and experienced significant morbidity. All had CSF pleocytosis. Two patients were WNV IgM positive in both the serum and CSF, 1 patient had positive serum IgM and CSF metagenomic next-generation sequencing (mNGS), while 1 had positive CSF mNGS with negative serum and CSF antibodies. DISCUSSION: Neuroinvasive WNV infection can develop with anti-CD20 monotherapy in the absence of additional immunosuppression. WNV serologies may be negative in the setting of anti-CD20 treatment; in the appropriate clinical context, one should consider direct detection methods such as PCR or mNGS-based testing.

Impact of financial well-being on gender affirmation surgery access and hospital course.

BACKGROUND: Although gender affirmation surgery (GAS) can effectively treat gender dysphoria, it remains one of the most expensive components of gender affirming care. This study aims to identify the impact of financial well-being on GAS access and hospital course in the United States. METHODS: The National Inpatient Sample database was queried from 2012 to 2019. US transgender patients undergoing GAS were identified. Predictors included patient sociodemographic variables. Outcomes included hospitalization course variables. Regression modeling was used to assess the relationship between predictor and outcome variables. Significance was set at α = 0.05. RESULTS: A total of 5620 weighted GAS encounters were identified (genital surgery 92.3%, chest surgery 16.6%). 1825 (32.5%) patients were in the highest income bracket, compared with 1120 (19.9%) patients in the lowest bracket. Higher income was associated with younger age at the time of GAS. Patients in the highest income quartile were also 3.7 times more likely to be funded by private insurance and self-pay options than those in the lowest income quartile (95% confidence interval [CI]: 3.1-4.4, p < 0.0001). Additionally, patients in the lowest income quartile were 4.2 times more likely to require either home healthcare or transfer to a nursing facility post discharge than those in the highest income quartile (95% CI: 3.1-5.8, p < 0.001). CONCLUSIONS: To promote equitable care to transgender patients, efforts to reduce financial barriers to healthcare access are much needed, particularly through broader insurance coverage of GAS procedures. Broadly, our results highlight the impact of socioeconomic variables on healthcare access and outcomes.

Age-dependent differences and similarities in the plasma proteomic signature of postoperative delirium.

Delirium is an acute confusional state and a common postoperative morbidity. Prevalent in older adults, delirium occurs at other ages but it is unclear whether the pathophysiology and biomarkers for the condition are independent of age. We quantified expression of 273 plasma proteins involved in inflammation and cardiovascular or neurologic conditions in 34 middle-aged and 42 older patients before and one day after elective spine surgery. Delirium was identified by the 3D-CAM and comprehensive chart review. Protein expression was measure by Proximity Extension Assay and results were analyzed by logistic regression, gene set enrichment, and protein-protein interactions. Twenty-two patients developed delirium postoperatively (14 older; 8 middle-aged) and 89 proteins in pre- or 1-day postoperative plasma were associated with delirium. A few proteins (IL-8, LTBR, TNF-R2 postoperatively; IL-8, IL-6, LIF, ASGR1 by pre- to postoperative change) and 12 networks were common to delirium in both age groups. However, there were marked differences in the delirium proteome by age; older patients had many more delirium-associated proteins and pathways than middle-aged subjects even though both had the same clinical syndrome. Therefore, there are age-dependent similarities and differences in the plasma proteomic signature of postoperative delirium, which may signify age differences in pathogenesis of the syndrome.

The Relationship of Postoperative Pain and Opioid Consumption to Postoperative Delirium After Spine Surgery.

Purpose: To examine the relationship between postoperative pain and opioid use and the development of postoperative delirium (POD), with attention to the preoperative opioid use status of patients. Methods: This was a secondary analysis of data from a prospective observational study of patients (N = 219; ≥70 years old) scheduled to undergo elective spine surgery. Maximal daily pain scores (0-10) and postoperative morphine milligram equivalents per hour (MME/hr) were determined for postoperative days 1-3 (D1-3). POD was assessed by daily in-person interviews using the Confusion Assessment Method and chart review. Results: Patients who reported regular preoperative opioid use (n = 58, 27%) reported significantly greater maximal daily pain scores, despite also requiring greater daily opioids (MME/hr) in the first 3 days after surgery. These patients were also more likely to develop POD. Interestingly, while postoperative pain scores were significantly higher in patients who developed POD, postoperative opioid consumption was not significantly higher in this group. Conclusion: POD was associated with greater postoperative pain, but not with postoperative opioid consumption. While postoperative opioid consumption is often blamed for delirium, these findings suggest that uncontrolled pain may actually be a more important factor, particularly among patients who are opioid tolerant. These findings underscore the importance of employing multimodal perioperative analgesic management, especially among older patients who have a predilection to developing POD and baseline tolerance to opioids.

Use of provider-to-provider telemedicine in Kenya during the COVID-19 pandemic.

Introduction: According to the World Health Organization (WHO), about 90 percent of countries continue to report COVID-related disruptions to their health systems. The use of telemedicine has been especially common among high-income countries to safely deliver and access health services where enabling infrastructure like broadband connectivity is more widely available than low- and middle-income countries (LMICs). The Addis Clinic implements a provider-to-provider (P2P) asynchronous telemedicine model in Kenya. We sought to examine the use of the P2P telemedicine platform during the second year of COVID-19. Methods: To assess sustainability, we compared the data for two 12-month calendar periods (period A = year 2020, and period B = year 2021). To examine performance, we compared the data for two different 12-month periods (period C = pandemic period of February 2021 to January 2022, and period D = baseline period of February 2019 to January 2020). Results: Sustainability of the P2P telemedicine platform was maintained during the pandemic with increased activity levels from 2,604 cases in 2020 to 3,525 cases in 2021. There was an average of 82 specialists and 5.9 coordinators during 2020, and an average of 81 specialists and 6.0 coordinators during 2021. During 2020, there were 444 cases per coordinator, and 587 cases per coordinator in 2021(P = 0.078). During 2020, there were 32 cases per specialist, and 43 cases per specialist in 2021(P = 0.068). Performance decreased with 99 percent of cases flagged as "answered" during the baseline period (period D), and 75 percent of cases flagged as "answered" during the pandemic period (period C). Conclusion: Results suggest that despite a decline in certain sustainability and performance indicators, The Addis Clinic was able to sustain a very high level of activity during the second year of the pandemic, as shown by the continued use of the system. Furthermore, despite some of the infrastructure challenges present in LMICs, the P2P telemedicine platform was a viable option for receiving clinical recommendations from medical experts located remotely. As health systems in LMICs grapple with the effects of the pandemic, it is worthwhile to consider the use of telemedicine to deliver essential health services.

Motivations and Barriers Associated With Physician Volunteerism for an International Telemedicine Organization.

Introduction: The Addis Clinic uses volunteer physicians to implement an international humanitarian telemedicine program. We sought to identify motivations and barriers that may contribute to physician volunteerism in international telemedicine. Methods: We surveyed active and inactive volunteers working with The Addis Clinic. Descriptive statistics were used to examine closed-ended questions, while a qualitative approach identified overarching themes for open-ended questions. The Volunteer Functions Inventory framework was also applied. Results: Among 69 active and 25 inactive volunteers, survey response rates of 74 and 72%, respectively, were attained. Volunteer cohorts exhibited comparable distributions across sex, marital status, and children. Active, as compared with inactive, participants were significantly more likely to be <40 years old (51 vs. 39%, p = 0.01), have prior experience with international/global health (67 vs. 39%, p = 0.04), and express an interest in international/global health work (82 vs. 50%, p = 0.008). Active volunteers were predominantly concerned with challenges regarding patient care: they more often reported the asynchronous nature of communication with frontline health workers as a significant barrier (37 vs. 6%, p = 0.047), and increased patient follow-up significantly drove their enthusiasm (64 vs. 35%, p = 0.05). Conversely, active volunteers were less likely to cite commitment/availability as a significant barrier for participation (33 vs. 72%, p = 0.002), less likely to be incentivized by opportunities to fulfill professional obligations (14 vs. 59%, p = 0.001), and more likely to be satisfied with the telemedicine experience (86 vs. 0%, p < 0.0001). Opportunities to receive remuneration or recognition did not increase the likelihood of volunteering for either cohort. Malpractice concerns were cited in a comparable minority across cohorts (20 vs. 17%). Conclusions: Age and global health experience/interest were significant predictors of physician volunteerism. While inactive volunteers reported time commitment as a barrier, active participants were concerned with challenges regarding patient care and motivated by increased methods to connect with patients. Financial considerations and recognition were infrequently reported as a barrier. With advances in telemedicine globally, results from this study can be used by organizations involved in international telemedicine to develop effective volunteer recruitment and retention strategies.