Nuvance Health was formed in 2019 when Health Quest and Western Connecticut Health Network merged. It employs approximately 2,600 physicians and 12,000 ancillary staff, and serves approximately 1.5 million residents.
Importance:The management of infectious and inflammatory lesions of the breast remains controversial. The expert panel focused on management recommendations for 3 of the most common infectious breast conditions, as very few evidence-based guidelines for the management of these conditions exist. Observations:Clinicians should distinguish between infectious and noninfectious lactational mastitis (LM) because the former often requires interventions whereas the latter requires supportive care only. Patients with infectious LM often have thick fluid collections that are not amenable to aspiration and usually require a stab incision with drain placement (but no packing) to resolve the infection. Operative drainage is only required if the patient cannot tolerate an office procedure. If a phlegmon is present, antibiotics should be prescribed for at least 10 days. The diagnosis of granulomatous mastitis (GM) requires pathology confirmation with characteristic findings on core biopsy. Cystic neutrophilic granulomatous mastitis (CNGM) is a specific form of GM associated with a granulomatous reaction to Corynebacterium infection and should be empirically treated with doxycycline. For patients without findings characteristic of CNGM and no other associated bacterium identified, there is no role for empiric antibiotic use. Granulomatous mastitis cases often recur and can take up to 18 months to resolve. Patients who have GM cases with worsening symptoms should be treated with repeated intralesional steroid injections; surgical excision or repeated aspirations should be avoided. Cases refractory to intralesional steroid injection may require oral steroids or even advanced biologic agents such as methotrexate or azathioprine. Periductal mastitis with squamous metaplasia of lactiferous ducts (PDM-SMOLD) is a distinct entity from other periductal mastitis cases that can present with recurrent abscesses and should be treated with antibiotics and aspiration for fluid collections. Operative excision for PDM-SMOLD is required for those patients who present with a fistula or recurrent episodes typically using a radial incision to remove the diseased ducts within and below the nipple. Conclusions and Relevance:Evidence-informed, consensus-, and expert opinion-based guidelines for the management of infectious and inflammatory conditions of the breast were developed. Clinicians can use these guidelines to appropriately manage these conditions for which clinical care often varied in the past.
OBJECTIVE:Previous studies have suggested unique challenges in treating women with thoracoabdominal aortic aneurysms (TAAAs) compared with their male counterparts. We sought to examine the real-world outcomes of complex endovascular aneurysm repair (cEVAR) for TAAA in women and men. METHODS:Patients undergoing cEVAR for type I to IV TAAAs between 2014 and 2020 were identified using the Vascular Quality Initiative database. Demographic, preoperative, and intraoperative variables, as well as postoperative outcomes, were compared between women and men. One-year survival after cEVAR was compared between women and men using the long-term follow-up data from the Vascular Quality Initiative. RESULTS:A total of 1128 patients underwent cEVAR for type I to IV TAAAs during the study period, of whom 417 (37%) were females. Women had more extensive aneurysms (84.7% vs 72.4% type I-III TAAA; P < .001) and were more likely to present with symptomatic aneurysm (26.1% vs 18.4%; P = .002) compared with men. Women were less likely to be on secondary cardiovascular preventative medications, including aspirin (59.4% vs 67.4%; P = .019) and statins (65.1% vs 73.1%; P = .012), more likely to be current smokers (36.1% vs 30.7%; P = .052), and treated at higher maximum diameter threshold (7.7 mm vs 4.6 mm above the recommended repair size; P < .001). Although there were no differences in operative time, women were more likely to have undergone a staged repair (22.3% vs 16.6%; P = .018) and have complicated iliofemoral access (19.2% vs 10.3%; P < .001) with a higher incidence of access complications (8.9% vs 5.2%; P = .016) compared with men. Thirty-day rates of mortality (11.8% vs 6.6%; P = .003) and overall complications (35.7% vs 25.7%; P < .001), including permanent spinal cord ischemia (5.5% vs 2.8%; P = .022) primarily among patients with type II TAAAs (7.8 vs 3.0%; P = .025), were all higher for women compared with men. One-year survival after cEVAR for TAAAs was significantly lower for women compared with men (74 vs 82%; P = .001), driven by the higher 30-day mortality rate in women. Female sex was an independent risk factor for both 30-day and 1-year mortality. CONCLUSIONS:This study demonstrated that women had higher 30-day morbidity and mortality and lower 1-year survival rates after cEVAR for type I to IV TAAAs compared with men. There were significant differences in presentation, anatomical features, and implementations of secondary cardiovascular preventative management, all likely affecting the differences in outcomes between women and men. Future studies are warranted to better understand these differences and optimize sex-specific approaches to management of TAAAs in women.
Definitive radiation therapy is the backbone of treatment in the management of primary vaginal cancer. The use of modern treatment techniques, such as intensity-modulated radiotherapy (RT) and image-guided adaptive brachytherapy, allows for the precise delivery of higher radiation doses to the tumor with reduced exposure to surrounding normal tissues compared with older, conventional 2D techniques. These advances in treatment planning have resulted in a nearly 10% absolute improvement in survival, along with a significant reduction in severe treatment-related toxicity. Accurate target volume delineation based on the tumor location and extent at presentation is crucial and is achieved with greater precision due to advances in imaging, including the routine incorporation of MRI into treatment planning. The brachytherapy target volume concepts used in the management of vaginal cancers largely mirror the adaptive approaches established for cervical cancers, incorporating tumor response following external-beam RT. Additionally, the expanding array of brachytherapy applicators, including both hybrid and custom options, has improved the ease and conformality of tumor implantation compared with standard template-based approaches. This review summarizes modern RT concepts and techniques in the management of primary vaginal cancer.
