Alcohol Use Disorder and Alcohol Withdrawal: Outpatient Management (Robledo 3/30/2022)

Thanks to Dr. Robledo for an excellent review of AUD and AWS at Grand Rounds this week. A link to a recording of the presentation is HERE.

Note: in place of male/female to discuss gender differences, Doctor Robledo used "assigned female at birth" (AFAB) and "assigned male at birth" (AMAB). These abbreviations are included in this summary.

Alcohol use

Appropriate alcohol use is considered no more than 1 standard drink/day (=7/week) for AFAB, 2/day (=14/week) for AMAB. Risky alcohol use is anything more than this amount. 

Risky alcohol use is drinking that can lead to health consequences and may develop into alcohol use disorder. 

Alcohol use disorder is a pattern of drinking that significantly impairs health and functioning. 

Binge drinking: drinking in a way that increases blood alcohol level >0.08 in 2 hours, generally >4 drinks at once for AFAB, >5 drinks at once for AMAB

Alcohol Use Disorder (by DSM-V Criteria)

https://creativecommons.org/licenses/by/4.0/

• mild 2-3 symptoms
• moderate 4-5 symptoms
• severe >6 symptoms

• early remission: abstinent between 3-12 months
• sustained remission: abstinent  >12 months

We all know that AUD is extremely prevalent in our society, but do you know how prevalent

29% lifetime prevalence

10.5% of children live with someone who has AUD

95K deaths/year

1/10 deaths in working age adults

$250 Billion/year in costs

COVID has been associated with alcohol use: 7.7x the odds ratio of getting COVID if you have AUD.

Screening tools for AUD 

The USPSTF recommends that all adults (>18) and all pregnant patients be screened annually for AUD. Here are some tools:

• SASQ: "How often in the past year have you had >4 drinks at one time (if AFAB), >5 drinks at home time (if AMAB)
• AUDIT-C: 3 questions, screening for at risk drinking (if +, should be followed by AUDIT-10)
• ADUIT-10: 10 questions
• CAGE questions: Cut down, Annoyed, Guilty, Eye opener (more looking at alcohol dependency)

https://www.aafp.org/afp/2013/1101/p596.html

https://www.aafp.org/afp/2002/0201/p441.html

Brief intervention for those who screen positive:

• be empathetic and caring
• state the medical findings in a non-judgemental way (e.g. signs of cirrhosis on exam, lab results, symptoms)
• educate patients regarding AUD
• advise patients to cut down/stop drinking
• assess their stage of change/readiness for change
• regular follow-up

Don't forget to use your motivational interviewing skills!

***

Alcohol Withdrawal Syndrome requires that someone 1) stopped after heavy/prolonged use and 2) two or more of the symptomsm describes in table 1 below:

https://www.clinicaladvisor.com/home/topics/psychiatry-information-center/alcohol-withdrawal-individualized-care-and-pharmacologic-treatment/

80% of patients will have totally uncomplicated withdrawal and do not need to be hospitalized

Higher risk folks include: those with hx withdrawal seizure or DTs, those with hx of numerous withdrawals, those with medical comorbidities (e.g. CHF, cirrhosis, traumatic brain injury)

You can use the PAWSS score or the CIWA-Ar score to predict who can safely withdraw in the outpatient setting.

• PAWWS score available here
• CIWA-Ar score
• mild (<8 just need rest and hydration, 8-10 may need some PRN meds)
• moderate 10-18 should receive standing meds iwth a taper
• severe/complicated: >19, to hospital for monitored withdrwawa
• SAWS score: patient self-assessment (mild <12, severe >12)

PAWSS, Maldonado 2015

CIWA-AR https://www.aafp.org/afp/2013/1101/p589.html

SAWS: https://www.aafp.org/afp/2013/1101/p589.html

Treatment of AWS should be based on your scoring, classically using the CIWA score plus/minus the SAWSS score to determine treatment

• Level 1: CIWA<10, SAWS <12: supportive care, prn gabapentin, carbamazepine
• Level 2: CIWA 10-18, SAWS>12: close follow-up (daily in person, daily video), benzodiazepine (chlordiazepoxide vs. valium/lorazepam) in fixed vs. PRN dosing
• For more information on specific drug dosing, you can refer to this paper in AAFP from 2016https://www.aafp.org/afp/2013/1101/p589.html

Supportive care for AWS in addition to medication

• daily visits x at least 5 days
• education
• low stimulation home environment
• fluids
• 400mcg folic acid, 100mg Thiamine x 3 days

Treatment of AUD should involve CBT as well as  medication assisted therapy to help patients reduce and/or abstain from alcohol. The most commonly used option is Naltrexone (available in oral form 50-100 mg daily vs. injectable monthly form, aka Vivitrol). Additional medications to consider include acamprosate and disulfiram (less desirable, more punitive), as well as fluoxetine (if concomitant depression/anxiety and gabapentin, which has variable studies. More information in the chart below

https://www.aafp.org/afp/2016/0315/p457.html

The Sports Preparticipation Exam (Lukacic, 3/23/2022)

Thanks to Dr. Allison Lukacic for her excellent presentation this week on the Preparticipation Exam (aka the other PPE).

A recording of her presentation is available HERE. 

Summary notes:

• 30 million US adolescents participate in organized sports
• there is a legal requirement in all 50 states to have some form of preparticipation exam for student athletes, 29 states use a standardized form
• said form should be signed by parent if athlete is <18
• goal is to maximize safe participation for young athletes, to identify medical conditions that put athletes at risk, identify those that require treatment/rehab prior to participation
• PPE is potentially  the only interaction they have with a healthcare provider (50-90% of athletes do not have a PCP)

PPE. . .

• should occur 6 weeks prior to sports season
• most states require PPE annually 

A thorough history is the most important part of the PPE-- history detects 88% of important medical conditions affecting sports participation, 66% of injuries

• screening for cardiac conditions: have they ever passed out, do they have chest pain, chest pain w/exertion, SOB?
• family history: anyone in family with sudden death during activity, cardiac disease <50, anyone with Marfan's syndrome?
• history of prior injuries: treatment and f/u
• burning sensation in extremities (suggesting cervical spine injuries)
• history of concussion, timing, healing time
• primary care: medications, substance use, supplements, energy drinks, getting in car w/drunk drivers

Physical Exam, key components

• blood pressure>> caution if > 99percentile
• BP >160/100 is cutoff, should be treated prior to participation
• look for secondary causes (caffeine, supplements), work up as needed
• elevated BP contraindication for static exertion (e.g. weightlifting)
• Marfanoid body habitus?
• vision screen (20/40 in at least one eye if want to do archery, rifles)
• lung exam: asthma adequately treated? PFTs if exercise-induced asthma
• cardiac: rate, rhythm, listening for murmurs (supine, standing/sitting w/Valsalva maneuver), PMI
• grade 3 or greater?
• increase with Valsalva maneuver?
• diastolic?
• abdomen: hepatic or splenic enlargement
• genitalia: undescended/single testes (should wear cup), hernia (should be referred for repair), testicular mass
• no genital exam in female
•  musculoskeletal exam, including supplemental knee/shoulder/ankle exams if history of injury
• range of motion in all joints, pain through motions, symmetry
• duck walk quickly assesses all lower extremity joints
• skin: molluscum, scabies, ringworm, HSV, impetigo

EKG, labs, urine drug tests are NOT recommended in standard PPE

Preparticipation Assessment (reminder goal is to get as many kids actively engaged in sports as possible)

1. unrestricted clearance
2. clearance w/notification to coach/trainer (e.g. brace, inhaler)
3. clearance deferred for further evaluation (e.g. echo w/murmur)
4. disqualification (very rare)

Sudden Death

rare, 0.75 per 100K athletes (<35 cases per year in the US)

hypertrophic cardiomyopathy (HCM) is the most common cause of sudden death (36%)

HCM affects approximately 1/500 individuals 

sarcomere mutation in the heart muscle, autosomal dominant

clinical diagnosis: EKG>> echo>> cardiac MRI

exam findings: systolic murmur in left 2nd intercostal space, lateral displacement of apical pulse (PMI), murmur increases in intensity when lying to standing/sitting, w/Valsalva (due to increased venous return)

EKG: LVH, LV strain, deep q waves lateral/inferior leaves, T wave inversion, sometimes WPW (Current US recommendations there is not enough evidence for EKG for all athletes and risk>>benefit, though Italy does do EKG for all PPE because they have evidence it decreased HCM)

2016 California passed Eric Paredes Sudden Cardiac Prevention Act, which requires discussion of sudden cardiac death during the PPE, also specific coach/trainer responsibilities

Exam findings in Marfan's

Female and Male Athlete Triad

in females: menstrual cycles, eating patterns, stress fractures (osteoporosis prevention)

male athlete triad (recently coined), but similar disordered eating, energy deficiency and reproductive dysfunction

athletes with these triad should not be cleared for participation until these issues are addressed

Concussions: important to document duration, frequency and recovery time

• in CA, athletes cannot return to play in less than 7 days from time of concussion (many athletes need a month to recover)
• Major goal to prevent second impact syndrome, chronic traumatic encephalopathy (football, 17+ injuries)
• balance error scoring and neuropsychological testing: all symptoms must resolve prior to return to play

Other medical conditions:

Asthma is a common diagnosis that may need to better controlled prior to clearance

Hemophilia or Von Willebrand's disease: no contact or collision

Sickle cell disease: no high exertion, contact, or collision sports

Sickle cell trait: cleared for ALL sports participation (though there have been deaths of NFL with just trait)

Epilepsy: any sport except w/ risk for fatal seizure (e.g. sky diving)

MSK injuries are the most common injury to have an athlete be restricted

Criteria for clearance: NO joint effusion, no decreased ROM, 80-90% of full strength

Resources:

• National Association of State High School Associations (NFHS)
• Standardized PPE form
• Pediatric Blood Pressure App

Wound Care (Cardenas, Cortez, Daly, 3/16/2022)

Many thanks to wound care nurse Wendy Cardenas, general surgeon Allen Cortez, and wound vac rep Kevin Daly for an informative talk this week on Wounds and Wound Care. I learned so much!

For a recording of their presentation click HERE (starting 11 minutes into the recording)

My notes:

• There are all kinds of wounds: surgical/traumatic, pressure, vascular, diabetic, infectious
• 1.3-3 million Americans are treated for pressure wounds each year
• 60,000 deaths per year are attributed to pressure wounds
• $9.1-11.6 billion dollars spent in the US on pressure wound are alone
• You only need 33 mmHg of pressure to create a pressure wound--> equivalent to a "gentle handshake"

Physician role in wound management

• decrease pressure
• decrease friction/shear forces
• manage incontinence (urinary, fecal>> indwelling/suprapubic catheters, ostomy)
• nutrition! nutrition! nutrition! (protein-calorie, blood sugar control, obesity)
• pain management
• managing comorbidities (DM, tobacco, drug addiction, venous stasis, etc)
• education (patient, caregiver, nursing staff, family)>> "you can tell people what to do, but if you give them the reason why, there is much more acceptance and compliance"

Initial management of wounds

• Identify and treat the cause
• Clean the wound--> tap water is just as good as sterile saline or any other wash (okay to shower day after surgery, no baths). Pulse evacuation (in OR) with fluid and pressure has been shown to improve outcomes. A simple syringe can also help w/debridement
• Keep wounds MOIST to allow capillary ingrowth (not too wet/not too dry)
• Debridement (wet to dry, enzymatic, surgical at bedside or in OR)
• you want to see bleeding
• Optimize nutrition (glucose control, protein)
• Optimize comorbidities (stop smoking!)
• Antibiotics if appropriate--> only if s/sx infection, "use common sense"
• Adjuncts (e.g. iodine/betadine-- can cause tissue damage, which can disrupt healthy granulation tissue. No evidence that adjuncts improve healing). 

Q: What is the perfect wound dressing?  A: Skin

Wound Vacs

3M Rep, Kevin Daly, then took us through the history of wound vacs (in hospitals since 1995, outside the hospital since 2000) and the range of products that are available, including silver-impregnated foam, special non-adherent dressings (silicone-based) designed to lay between wound and the wound vac (to prevent foam from sticking to the wound), the evolution of the instill vac 

What does a wound vac do?

reduces edema around wound

heals wound 60% faster than standard dressing

stretches cells--> leads to degranulation tissue

Contraindications to using a wound vac

No active cancer in the wound
Dead/necrotic tissue in the wound
Untreated osteomyelitis (if osteo is being treated, it is fine)

Who qualifies for a wound vac at home?

if wound vac was started in the hospital, generally patients can go home with the vac, but a wound vac isn't always the best thing for a patient

wound vacs weigh 8-11 pounds, too heavy for some

need to have home health care (dressing change 3x/week, 1x/week has to be licensed person who measures the wound to demonstrate healing)

must be able to keep wound vac on 22 hours/day 

• Of note, patients should be off their wound vac no more than 2 hours/day
• When vac dressings are used in skin grafts, you must use non-adherent dressing between the graft and the foam
• Vac instill: instills fluid (e.g. normal saline) into the wound. Protocol: dwell time 10 minutes, 2 hour suction. Vac instill leads to 40% more granulation tissue than regular wound vac. Only available in acute care (hospital, some LTAC/some SNF
• Prevena vac is used along closed clean incisions, helps approximate the wound. Not for everyone, only place in patients who are high risk for dehiscence (morbid obese, redo). Put on in the OR. Entire product is disposable. When stops holding suction, battery makes noise, it shoudl all get thrown away. No wound care needed, no home health required.

• 

  Prevena vac

Our Wound Care Queen, Wendy Cardenas, finished off the presentation with these gems

Four stages of wound healing: hemostasis (immediate)>> inflammatory stage (6 days, WBCs/macrophages debride bioburden) >>proliferation (up to 3 weeks, this is where wounds get stuck, go from acute to chronic)>>maturation (can last up to a year, skin is never going to be exactly the same, always a place that can reopen, tensile strength permanently compromised)

How to approach a wound ala Wendy Cardenas

1) Figure out what happened

    chart review, look for all old notes pertaining to wound

    ask the patient, "How did this happen?"

    check for pressure points

2) Check for infection: is the surrounding tissue hot, red, indurated, painful?

    wound bed funky, milky, shiny, smell bad, creamy or copious fluid

3) Foot wounds: pressure, diabetic, venous vs. arterial ulcers

    venous: medial/lateral/posterior: irregularly shaped, shallow, yellow slough, not painful>> compress!

    arterial: medial/lateral: round, deep, pale bed, don't bleed easily, not much pulse>> no pressure!

4) Wound products you might use in the hospital

    foam dressings: prophylactic on sacrum or coccyx, heel + offloading boot

    plura-gel: adds hydration, cleans up wound

    silver-impregnated hydro-gel

    honey: better for superficial wounds

    zinc: moisture associated breakdown, good for venous stasis legs (use w/compression)

Additional pearls:

• do NOT ever do superficial cultures on wounds; superficial cultures will only reveal polymicrobial organisms and skin flora
• quantitative tissue cultures are gold standard
• silver is bacteriostatic 
• primary closure (clean wound), delayed primary closure (w/steristrips a day or two after), closure w/secondary intention
• skin graft wound vacs STINK when you first remove (5 days after a skin graft)
• if you have an abscess make a BIG BIG hole, making a tiny incision and packing will cause more pain. Big wounds are better

Management of GHB/GBL Drug Overdose and Withdrawal Syndrome (Steinberg 3/2022)

Thanks so much to Dr. Gabrielle Steinberg for her excellent presentation on Atypical Addictions: GHB/GBL Drug Overdose and Withdrawal

A recording of Dr. Steinberg's excellent presentation is available HERE. 

We know that addiction is a huge problem worldwide

• Globally, 33.6 million people suffer from substance use disorder (2019)
• In the US between 1999-2020, 841,000 people died  from drug-related overdose
• Synthetic opioids are main driver for SUD related deaths (esp. fentanyl right now)
• In 2011, Drug Abuse Warning Network (DAWN 2011) reported 2.5 million drug use/misuse related ER visits, more than half from multiple drugs: alcohol, cocaine, marijuana, opioids, methamphetamines
• Atypical/uncommon drugs comprise about 5% of ER visits
• GHB/GBL was associated with 2, 406 ER visits in 2011 (US)
• Other "atypical substances": inhalants/solvents, bath salts, Khat, K2/spice, Kratom, U47770, Rohypnol, DMT, MPTP

GHB=gamma hydroxybutyrate

GBL= gamma butyrolactone 

GBL is a precursor to >> GHB is a precursor to>> GABA

GHB is a CNS depressant, also has effect on mesolimbic pathway (rapid reward, abuse potential)

Initially developed in  France as general anesthetic (not in US), can be prescribed in salt form (prescription rx approved to tx narcolepsy, cataplexy). In 1980s, marketed as supplement for body builders, removed from the market due to fatal intoxications/overdose

GHB= schedule 1 (no current recognized medical use, high potential for abuse)

When used illicitly, GHB is used for calming, euphoric effects, aphrodisiac (increases libido).

Considered similar to MDMA/alcohol. 

Also "date rape drug" because of effects on memory and consciousness

• colorless odorless liquid, or white powder that can be dissolved
• mostly ingested orally as liquid, sometimes pill form
• onset: high 15-30 minutes, duration 3-6 hours, doses vary
• tolerance and dependence does build quickly
• death has been associated with overdose, withdrawal and intoxication 

Demographic & use patterns: majority male, majority white, late 20s/30s (same in ED overdose data, though increasing rates GHB overdoses in women), commonly co-ingested with alcohol

GBL now becoming more common than GHB, cheaper, easier to access: found in solvents, greater potency, faster onset

GHB/GBL intoxication

CNS depression, agitation, seizures

Hypothermia, bradypnea, bradycardia (hypotension less common), urinary and fecal incontinence

death from intoxication/overdose can be caused respiratory depression and/or respiratory arrest, aspiration (due to risk for vomiting)

Common to see alternating ABRUPT onset somnolence and agitation

Toxicity can come on and resolve abruptly, effects last 2-5 hours

Hospital stays can be often short because of short half life (managed out of ER and then discharged)

Most of the time GHB/GBL used with other drugs (ETOH, methamphetamines)

Not detected on typical urine drug screen, do have a send out confirmation test (urine test takes 9-10 days to result)

Key to management GHB intoxication: supportive care, airway support (intubation to protect airway when sedated), use of sedation due to abrupt alertness that can occur (midazolam, propofol), best effects with benzos (lorazepam or diazepam) or Haldol

There is no antidote, no effect from naloxone or flumazenil

GHB/GBL withdrawal

Happens quickly, as early as 6 hours after last dose

Mild/mod: anxiety, tremor, diaphoresis, tachycardia

Severe: agitated delirium, seizures, hypothermia, rhabdomyolysis

Preferred treatment: benzodiazepine (PO valium for longer duration), baclofen TID has been studied (shown to reduce withdrawal, reduce cravings, GABA b receptor agonist, small studies)

For severe withdrawal: intubation, IV valium benzo of choice. Can get benzo resistance (acts more on GABA-A receptors). Add on Propofol, Precedex.

Vitamins: magnesium, folate (some Wernicke's like syndrome)

Fluid resuscitation: vomiting, diaphoresis

No validated withdrawal scale, most literature uses CIWA scores

Netherlands study (450 patients): giving GHB taper in the hospital, taper down and off, relatively effective

Belgium tried similar protocol with benzos (less effective)

Outpatient management of GHB/GBL

GHB/GBL use is associated with high risk of abuse, rapid onset of euphoric and calming effects

outpatient labs: GHB urine drug screen is available via Quest labs/ECW (send out, takes some time)

GHB/GBL addiction hard to treat outpatient

Study from Netherlands (596 pts): high rates of relapse with GHB use, withdrawal severity, ER visits, duration of time in treatment programs

Baclofen has been found to be helpful w/detox, but also in maintaining abstinence, no RCTs; one non-RCT found baclofen 45-60mg/day  (10-20mg TID, titrate by patient) PLUS CBT more effective in reducing craving, anxiety, and relapse (than CBT alone). Baclofen decreases need for benzos

Key to outpatient management is wrap around support with interdisciplinary team: more success with patients with lower daily dose. 

Outpatient Rx should include: baclofen PLUS valium/diazepam (symptom guided) PLUS close follow-up PLUS simultaneous behavioral therapy

For help/assistance with these atypical drugs, consider reaching out to the UCSF Substance Use Disorder Warmline https://nccc.ucsf.edu/clinical-resources/substance-use-resources/

855-300-3595.

Big thank you to new-to-town-plastic surgeon, Dr. Melissa Mueller, for an excellent Grand Rounds presentation this week on Breast Reconstruction. I learned so much from her, and I look forward to working with her in our Sonoma County community. 

A recording of Dr. Mueller's excellent presentation is available HERE. If you care for women in Sonoma County, you should definitely watch this.

Here are my notes:

• 1 in 8 women will develop breast cancer in their lifetime
• 80% of women w/breast cancer have breast conserving therapy (i.e. lumpectomy)
• of 20% of patients who undergo mastectomies, 40% get breast reconstruction, the majority implant based
• in SoCo, less than the national average of patients get reconstruction, likely due to lack of access to modern breast reconstruction in the area
• Breast reconstruction after cancer treatment is associated with improved self-image, decreased depression and anxiety, better body image, improved self esteem,  and overall improved emotional, social and sexual functioning
• Some studies showing highest satisfaction with autologous reconstruction
• The 1998 Women's Rights and Cancer Rights Act guaranteed reconstruction for women getting mastectomy (national)
• California state law goes further and requires that ALL insurers (including Medi-Cal) must cover reconstructive surgeries (initial and subsequent) after breast cancer treatment, initial and subsequent implants (if patient needs an exchange)
• includes mastectomy AND lumpectomy
• includes contralateral breast symmetry procedures
• Breast reconstruction may be a "silver lining" to getting cancer

Type of breast reconstruction after breast cancer depends on type of surgery.

After Lumpectomy (i.e. Breast Conserving Therapy or Partial Mastectomy)

All women in CA are eligible for oncoplastic reconstruction as well as contralateral breast symmetry

To be eligible for a lumpectomy (vs. mastectomy), the size of breast cancer must be small in relation to the size of breast. After the lump is removed, there will be a hole in the breast, which needs to be filled. This can be done in two different ways:

• volume displacement: uses surrounding breast tissue to fill that hole--> that breast will be smaller and may require tissue rearrangement, reduction, lift/mastopexy
• volume replacement: brings adjacent tissue outside the breast to restore the original breast size (e.g. back, side wall/bra fat, implants)
• the contralateral breast will need to undergo symmetry procedure either immediately or delayed fashion 
• this can happen at same time and/or after radiation
• radiation causes collateral damage and decreased breast volume by 10-15%, tightening of the skin, nipple uplift
• if reconstruction is happening before radiation, the breast that will be irradiated will be left slightly larger to allow for radiation changes

After Mastectomy, there are two categories of reconstruction

• implant based: most commonly performed with tissue expander placed at time of mastectomy. Expander is inflated q1-2 weeks until desired size is achieved, then is replaced with implant (saline, silicone)
• autologous: using patient's own tissue, make a breast mound with patient's own tissue, from abdomen/thigh/buttock/back (abdomen most common)

Reconstruction Timing 

post-mastectomy reconstruction also can happen immediately (at time of mastectomy) vs. delayed

    overall anesthesia time is less if doing delayed (in two parts)

    if done delayed, another advantage is that final pathology is received (margins) to know if radiation will be required

of note, breast skin cannot be expanded after radiation treatment, so if a patient wants an implant-based reconstruction, they need to have fully inflated before radiation tx

in advanced cancer, pts should focus on adjuvent therapy prior to reconstruction

but for patients who have the choice, more immediate reconstruction is associated with better outcomes

Implant-based reconstruction

under vs. over pectoralis mm

historically, implant has been placed under the muscle because the tissue makes implant less visible

however, recently prepectoral breast reconstruction is gaining in popularity-- less pain, no animation deformity (doesn't move when pectoralis moves)

fat grafting (i.e. liposuction) can help make the implant less visible in both cases

for some women, surgeons can place implant at time of mastectomy--> fewer total surgeries

    -have to have small breasts (A/B cup), want to stay same size, pts with nipple in correct place

    -mastectomy is stressor to breast skin, so heavy implants can create a second stressor to the skin which can compromise blood flow to the skin

Autologous reconstruction: 

create a breast mound using patient's own tissue (so you don't need an implant)

most common and most popular donor site is abdomen (deep inferior epigastric perforator flap)-- surgery similar to tummy tuck, kept alive by suturing to internal artery and vein in the chest

Fat grafting (ie liposuction--> injected with syringes after implant or autologous ( to disguise)

Counseling women for cosmetic results they may expect w/mastectomy

• chest wall can be concave after surgery
• lateral chest adiposity is not removed
• dog ears (standing cone deformity)

BIA-ALCL

A word on very rare condition/complication from breast implants called Breast Implant Associated Anaplastic Large Cell Lymphoma

associated between textured devices-- both textured tissue expanders and implants (these are no longer used)

Incidence of association: 1/30K implants placed--> 949 total cases worldwide

On average 8-10 years after implant (at least 1 year)

Sudden fluid collection (collecting within a matter of days) or a new mass associated with the capsule around the implant

There has been a recall on all textured implants

FDA doesn't currently recommend removing the devices because it is unknown if removing them decreases lymphoma risk, but if patients feel uncomfortable having the device in their body, insurance will cover their replacement or removal

Ultrasound vs. MRI to evaluate, aspirate 50cc of fluid should be sent for pathology and immunochemistry