Utilizing the Frailty Index to Predict Long-term Mortality in Patients Undergoing Major Lower Extremity Amputation.

The 5-factor modified Frailty Index (mFI-5) is a risk-stratification tool utilized to predict complications and mortality following major lower extremity (LE) amputation. However, its prognostic value for long-term mortality is unknown. The study aim was to assess whether a high mFI-5 score relates to long-term mortality following major LE amputation for chronic wounds. Patients ≥60 years who underwent major LE amputation from 2017 to 2021 were retrospectively reviewed. Data regarding demographics, comorbidities, perioperative factors, amputation type, and postoperative complications was collected and mFI-5 was calculated. Survival analysis was performed with Kaplan-Meier curves and differences were assessed with Log-Rank test. A total of 172 patients were identified. Mean age was 70.7 ± 8.0 years. Median time to ambulation was 3.7 months (IQR 4.0). By final follow-up of 17.5 ± 15.9 months, ambulatory rate was 51.7% (n = 89), overall mortality 36.0% (n = 62), 1-year mortality 14.0% (n = 24), and 3-year mortality 27.9% (n = 48). Patients with an mFI-5 of ≥4 (26.7%, n = 46) compared with patients with mFI-5 <4 (73.3%, n = 126) had a higher rate of prolonged postoperative LOS (34.8% vs 19.8%, p = .042), overall mortality (52.2% vs 30.2%, p = .008), 1-year mortality (23.9% vs 10.3%, p = .023), and 3-year mortality (45.7% vs 21.4%, p = .002). Multivariate analysis demonstrated mFI-5 was an independent predictor of 3-year mortality (OR 2.35, p = .043). At a threshold ≥4, the mFI-5 demonstrated utility in predicting long-term mortality. The value of this prognostic indicator is in its preoperative application of assessing risk of mortality, which should be utilized in conjunction with other measures.

Factors influencing intraoperative conversion from double- to single-incision mastectomy with free nipple grafts in 352 transgender and non-binary patients.

BACKGROUND: Double-incision mastectomy (DIM) with free nipple grafts (FNG) is a common technique employed in gender-affirming mastectomy (GAM), but is associated with a high scar burden. Intraoperatively, the surgeon may opt for a single-incision mastectomy (SIM) along the inframammary folds (IMF) to optimize aesthetic outcomes. This study sought to identify factors predictive of intraoperative conversion. METHODS: From February 2018 to November 2022, TGNB patients who underwent GAM at a single institution were retrospectively reviewed. Data regarding patient characteristics, perioperative details, postoperative complications, and aesthetic satisfaction were collected. RESULTS: A total of 352 patients were identified. Median age and body mass index (BMI) were 25.0 years (IQR: 9.0) and 28.5 kg/m2 (IQR: 8.5), respectively. Most patients received IMF incisions (n = 331, 94.0%); of whom, 66 (19.9%) underwent intraoperative conversion from DIM to SIM with FNG. Larger breast cup-size (p < 0.001) and a greater degree of ptosis (p = 0.002) preoperatively were significantly associated with intraoperative conversion to SIM. There was no significant association between intraoperative conversion and the ratio of intermammary distance to the width of the chest wall (p = 0.086). Overall complication rates were significantly higher among patients with diabetes mellitus (p = 0.015) and a greater degree of ptosis (p = 0.018). 77.8% (n = 274) of patients were satisfied with their aesthetic outcome. NPWT usage was associated with higher rates of aesthetic satisfaction (83.6% vs. 77.8%; p = 0.005). CONCLUSION: Patients with larger breast cup size and greater degree of ptosis should be counseled preoperatively that they may be at a higher risk of conversion to a singular incision.

A Qualitative Study of Factors Influencing Hospital Participation in the Healthcare Equality Index.

ABSTRACT: Gender and sexual minority individuals experience higher rates of mistreatment and discrimination in healthcare compared with their non-lesbian, gay, bisexual, transgender, queer, and other nonheterosexual (LGBTQ+) peers. The Healthcare Equality Index (HEI) aims to create more inclusive environments and to provide metrics for quality improvement. Currently, only one adult hospital in the District of Columbia has earned the highest recognition from the HEI. Our institution is part of the same regional health system as this hospital, yet has never been evaluated by the HEI. This study explores the knowledge, attitudes, and perceptions surrounding the HEI at our institution to assess the feasibility of its participation. During the study period of July 2021 to June 2022, a total of 12 physicians, administrators, and educators from both hospitals and our affiliated school of medicine were interviewed. All participants expressed support after HEI requirements and improving inclusivity for LGBTQ+ patients. Participants at the other hospital cited unanimous support amongst hospital administrators as key for successful HEI implementation. Participants also mentioned cost, staff shortages, and the school of medicine's religious affiliation as potential barriers to this goal. Ultimately, hospital implementation of HEI guidelines is feasible despite shifting institutional priorities and resource limitations through greater stakeholder buy-in and streamlining a systemwide approach.

Age is just a number: The role of advanced age in predicting complications following ventral hernia repair with component separation.

BACKGROUND: While advanced age is often considered a risk factor for complications following abdominal surgery, its impact on outcomes after complex open ventral hernia repair (VHR) with component separation technique (CST) remains unclear. METHODS: A single-center retrospective review of patients who VHR with CST from November 2008 to January 2022 was performed and cohorts were stratified by presence of advanced age (≥60 years). RESULTS: Of 219 patients who underwent VHR with CST, 114 patients (52.1 â€‹%) were aged ≥60 years. Multivariate analysis demonstrated BMI to be an independent predictor for any complication (OR 1.1, p â€‹= â€‹0.002) and COPD was positively associated with seroma development (OR 20.1, p â€‹= â€‹0.012). Advanced age did not independently predict postoperative outcomes, including hernia recurrence (OR 0.8, p â€‹= â€‹0.766). CONCLUSIONS: VHR with CST is generally safe to perform in patients of advanced age. Every patient's comorbidity profile should be thoroughly assessed preoperatively for risk stratification regardless of age.

Examining the unmet needs of chronic wound patients with common mental disorders.

BACKGROUND: Common mental disorders (CMD) are highly morbid conditions not routinely screened for in chronic wound care. A comorbid psychiatric condition's influence on a patient with chronic wounds' quality of life (QoL) is unknown. This study investigates the implications of CMD on QoL in patients with chronic lower extremity (LE) wounds. METHODS: This cross-sectional study surveyed patients with chronic LE wounds evaluated in our multidisciplinary clinic between June-July 2022. Surveys included validated physical and social QoL questionnaires, including the Lower Extremity Functional Scale (LEFS), Patient-Reported Outcomes Measurement Information System (PROMIS-3a) Scale v2.0, 12-Item Short-Form (SF-12), and a screening tool for common mental disorders, the Self-Reporting Questionnaire 20 (SRQ-20). Data regarding patient demographics, comorbidities, psychiatric diagnoses, and wound care history were retrospectively collected. RESULTS: Of the 265 identified patients, 39 (14.7%) had documented psychiatric diagnoses, most often depression or anxiety. The diagnosed cohort had higher median SRQ-20 scores (6, IQR: 6 vs. 3, IQR: 5; P < 0.001) and a higher proportion of positive screens for CMD (30.8% vs. 15.5%; P = 0.020) than non-diagnosed patients. There were no differences in physical or social QoL in patients with and without a psychiatric diagnosis. However, individuals screening positively for CMD experienced significantly more pain (T-score 60.2 vs. 51.4, P = 0.0052) and reduced function (LEFS 26.0 vs. 41.0, P < 0.0000). CONCLUSION: This study illustrates that patients with chronic LE wounds experience potentially meaningful psychologic distress. Further, symptoms of a CMD (SRQ-20 ≥8), rather than a previous diagnosis, may influence pain and functional outcomes. These findings emphasize the potential relevance of psychological distress in this population and reinforce the need for further investigation of actionable responses to this apparent need.

Trends in Craniofacial Fellowship Career Outcomes: A Call for Expanding Professional Opportunities in Craniofacial Surgery.

PURPOSE: Limited available pediatric plastic surgery positions fail to accommodate the increasing number of craniofacial fellows trained annually. However, many adult indications have increased the demand for craniofacial expertise. Given new opportunities available to craniofacial surgeons, the authors aim to evaluate career prospects for recent craniofacial graduates and explore additional career opportunities. METHODS: Upon approval from the American Society of Craniofacial Surgeons (ASCFS), an anonymous online survey invitation was sent to craniofacial fellows who graduated from 2016 to 2021. Respondents were queried regarding their craniofacial fellowship and subsequent career prospects. RESULTS: A total of 124 eligible participants were identified, of which 30 (24.2%) responded. Craniomaxillofacial case distribution at respondents' current practices varied, with 42.3% reporting a 50% to 75% craniofacial caseload and 38.5% reporting less than 25%. Craniofacial trauma reconstruction was performed most at current positions (92.3%), followed by general reconstruction (92.3%) and breast surgery (69.2%); the least commonly performed was facial feminization (23.1%). Most respondents desired an increased craniomaxillofacial caseload (65.4%). However, 26.9% were unable to secure their current position before fellowship completion, and 80.0% cited limited craniofacial job availability. Recommendations to improve fellowship comprehensiveness and increase candidate competitiveness included increased facial feminization, facial esthetic, and microsurgical experience. CONCLUSION: To adapt to trends in craniomaxillofacial surgery, ASCFS should encourage developing fellowships that increase exposure to gender-affirming, adult craniofacial reconstruction, orthognathic, and skeletal facial esthetic surgery. Expanding training beyond congenital deformities can provide additional employment opportunities while maintaining excellence and innovation in facial plastic surgery.

A qualitative analysis of factors influencing health-seeking behavior of people living with HIV, hypertension and diabetes in an urban area of Ghana.

Non-communicable diseases are rising globally and lower-middle-income countries are now facing a double-burden of communicable and non-communicable diseases like hypertension and diabetes. Patients with HIV/AIDS are at increased risk of developing hypertension and diabetes. Understanding how this double-burden influences persons living with HIV health-seeking behavior (HSB) is critical to identifying successful interventions and policies. To explore the factors that influence the health-seeking behavior of HIV patients with hypertension and diabetes in an urban setting of Ghana, we undertook a qualitative study consisting of sixteen in-depth interviews (five healthcare providers [HCP] and eleven patients); all recruited from Antiretroviral Therapy (ART) clinics in the Techiman South Municipality of Ghana. Interview questions were designed to explore cognitive, affective, social, and environmental factors that influence an individual's decision-making process and behavior. All interviews were audio-recorded, transcribed, and analyzed thematically. Participants raised unique challenges while seeking treatment services for HIV, hypertension, and diabetes. Frequent appointments, increased pill burden, food restrictions, alternate sources of care (herbalist and pastors), and negative psychological wellbeing were some of the challenges noted for seeking treatment services. Challenges with the health facility, including separate clinic days for comorbid conditions, high costs of medications and transportation, and long waiting hours were also cited as influencing health-seeking behavior. Results indicate greater challenges for HIV patients living with hypertension and diabetes in accessing treatment services. Understanding this is critical to removing barriers and making treatment more accessible. Further integration of treatment for hypertension and diabetes into HIV care is essential to ensuring patient engagement in continuous care.