Rinker, Brian

Introduction The Care Hotel is a virtual medicine hybrid model of care implemented at the Mayo Clinic to increase use of enhanced recovery protocols, address hospital capacity and reduce medical costs. This voluntary accommodation offers patients a comfortable environment to receive nursing care postoperatively with in-person daytime monitoring and 24-hour virtual telemonitoring in a hotel setting. This study aims to evaluate postoperative outcomes in patients admitted to the Care Hotel after mastectomy with immediate tissue expander reconstruction compared to standard overnight admission. Methods A retrospective review of the electronic medical record was conducted for patients who underwent mastectomy with immediate tissue expander reconstruction prior to (1/2019–1/2020) and after (7/2021–7/2023) the implementation of the Care Hotel. Postoperative outcomes, including 48-hour ED visit, 48-hour readmission, and 30-day infection, hematoma, seroma, admission, and return to operating room were collected. Results There were 61 patients with 108 tissue expander reconstructions in the hospital admission group and 122 patients with 212 tissue expander reconstructions in the Care Hotel group. The average length of hospital stay was 1.2 days while the average Care Hotel stay was 1.4 days. There were four 48-hour ED visits with 1 admission for 12 hours of observation in the Care Hotel group. There was no statistically significant difference in 30-day infection, seroma, hematoma, readmission, need for IR drain procedure or return to operating room between the groups. Conclusions This investigation demonstrates the safety of postoperative virtual telemonitoring and should encourage providers to utilize virtual visit technology in the immediate postoperative time-period.

Abstract Objective Peri-implant enhancement can be seen on contrast-enhanced breast MRI, but its association with malignancy has not been described, leading to considerable variability in assessment and recommendations by radiologists. This study evaluated imaging features, management, and outcomes of implant-related enhancement. Methods This multisite IRB-approved retrospective review queried all breast MRI reports for keywords describing peri-implant enhancement, fluid, and/or masses (plus synonymous descriptions) and implant-associated malignancies, with subsequent imaging and chart review. Peri-implant enhancement and implant features were characterized. Assessments and outcomes were evaluated via clinical and imaging follow-up, aspiration/biopsy, and/or capsulectomy to evaluate for association of peri-implant enhancement with implant-related malignancy. Results A total of 100 patients had peri-implant enhancement. Uniform thin peripheral enhancement was most common (79/100, 79%). Capsulectomy was performed in 31/100 (31%), with benign capsular fibrosis/inflammation discovered in 26/31 (83.9%). Breast implant–associated anaplastic large cell lymphoma was present in 2/100 (2%), both with textured implants, while 98/100 (98%) had no implant-related malignancy. MRI recommendations varied: resume routine imaging (26/100, 26%), clinical management (18/100, 18%), follow-up MRI (17/100, 17%), MRI-directed US (17/100, 17%), aspiration/biopsy (11/100, 11%), and surgical consultation (10/100, 10%). Conclusion Peri-implant enhancement is a nonspecific imaging finding with a low malignant association, especially when seen in isolation (no associated effusion, mass, or adenopathy). Implant surface texture should be considered in management recommendations; diagnostic capsulectomy is not recommended in patients with smooth implants. Additional studies are encouraged to validate nonoperative management recommendations.

AbstractBackgroundRecent 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.MethodThe 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.ResultsA 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.ConclusionThe 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.

Background Demographic characteristics are known to influence the treatment and outcomes of patients with invasive melanoma. Whether these characteristics influence treatment costs is unknown. We aimed to analyze whether patient demographics and tumor characteristics influence treatment costs for patients with invasive cutaneous melanoma in Florida. Methods This was a cross-sectional study in which the Florida Inpatient and Outpatient Dataset of the Agency for Health Care Administration was analyzed for patients with a diagnosis of invasive melanoma between January 1, 2013 and December 31, 2018. Categorical variables were assessed using Pearson χ2 tests, and continuous variables were evaluated using Kruskal-Wallis tests. Logistic regression analysis was conducted to identify the association between patient demographics and total costs. All analyses were done using SAS 9.4 statistical software (SAS Institute, Inc). Results Multivariate analysis showed that sex (P < 0.001), hospital setting (P < 0.001), race/ethnicity (P < 0.01), patient region (P < 0.01), Elixhauser Comorbidity Index score (P < 0.001), presence of metastasis (P < 0.01), total number of procedures (P < 0.001), and length of stay (P < 0.001) were correlated with the cost of treatment of invasive cutaneous melanoma. After stratification, the association between cost and race/ethnicity disappeared for inpatients but remained for Black patients in the outpatient setting (P < 0.001). The association between cost and patient residence regions also differed when the cohort was stratified. Conclusions Strategies addressing disparities in treatment cost of invasive melanoma should differ, depending on the hospital setting where the patient is being treated.

Background Radiation-induced skin injuries have been treated with different medical therapies and have shown diverse outcomes. We aim to evaluate the effect of adipose-derived stem cells (ADSCs) therapy on radiation-induced skin injury. Methods We performed a review by querying PubMed, Ovid MEDLINE, and EMBASE databases from inception to April 2020 following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. The MeSH terms “adipose-derived stem cells,” “wound healing,” “radiation,” and synonyms in combinations determined our search strategy. Experimental peer-reviewed articles describing the protocol and comparing the results with controls were included. Non-English studies were excluded. Results Our search recorded a total of 137 articles. Only 8 studies met our inclusion criteria and were included in this review. Five studies evaluated the use of ADSC alone, whereas the others evaluated the efficacy of ADSC seeded in scaffolds. Adipose-derived stem cell–based therapies, either alone or seeded in scaffolds, were shown to improve wound healing in most studies when compared with controls. Conclusions There is evidence supporting the positive benefits from ADSC-based therapies in radiation-induced skin injury. However, further studies are needed to standardize the method of ADSC extraction, radiation-induced skin injury experimental model, and increase the time of follow-up to evaluate the results accurately.