Breast reconstruction in the era of evidence-based medicine.
Ontology highlight
ABSTRACT:
SUBMITTER: Manrique OJ
PROVIDER: S-EPMC10477617 | biostudies-literature | 2023 Aug
REPOSITORIES: biostudies-literature
Publications
Breast reconstruction in the era of evidence-based medicine.
Manrique Oscar J OJ Escandón Joseph M JM
Annals of translational medicine 20230129 10
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Project description:Data are available such that choice of Helicobacter pylori therapy for an individual patient can be reliably predicted. Here, treatment success is defined as a cure rate of 90% or greater. Treatment outcome in a population or a patient can be calculated based on the effectiveness of a regimen for infections with susceptible and with resistant strains coupled with the knowledge of the prevalence of resistance (ie, based on formal measurement, clinical experience, or both). We provide the formula for predicting outcome and we illustrate the calculations. Because clarithromycin-containing triple therapy and 10-day sequential therapy are now only effective in special populations, they are considered obsolete; neither should continue to be used as empiric therapies (ie, 7- and 14-day triple therapies fail when clarithromycin resistance exceeds 5% and 15%, respectively, and 10-day sequential therapy fails when metronidazole resistance exceeds 20%). Therapy should be individualized based on prior history and whether the patient is in a high-risk group for resistance. The preferred choices for Western countries are 14-day concomitant therapy, 14-day bismuth quadruple therapy, and 14-day hybrid sequential-concomitant therapy. We also provide details regarding the successful use of fluoroquinolone-, rifabutin-, and furazolidone-containing therapies. Finally, we provide recommendations for the efficient development (ie, identification and optimization) of new regimens, as well as how to prevent or minimize failures. The trial-and-error approach for identifying and testing regimens frequently resulted in poor treatment success. The described approach allows outcome to be predicted and should simplify treatment and drug development.
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Project description:The concept of 'evidence-based medicine' dates back to mid-19th century or even earlier. It remains pivotal in planning, funding and in delivering the health care. Clinicians, public health practitioners, health commissioners/purchasers, health planners, politicians and public seek formal 'evidence' in approving any form of health care provision. Essentially 'evidence-based medicine' aims at the conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients. It is in fact the 'personalised medicine' in practice. Since the completion of the human genome project and the rapid accumulation of huge amount of data, scientists and physicians alike are excited on the prospect of 'personalised health care' based on individual's genotype and phenotype. The first decade of the new millennium now witnesses the transition from 'evidence-based medicine' to the 'genomic medicine'. The practice of medicine, including health promotion and prevention of disease, stands now at a wide-open road as the scientific and medical community embraces itself with the rapidly expanding and revolutionising field of genomic medicine. This article reviews the rapid transformation of modern medicine from the 'evidence-based medicine' to 'genomic medicine'.
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Project description:ImportanceBreast reconstruction is costly, and negotiated commercial rates have been hidden from public view. The Hospital Price Transparency Rule was enacted in 2021 to facilitate market competition and lower health care costs. Breast reconstruction pricing should be analyzed to evaluate for market effectiveness and opportunities to lower the cost of health care.ObjectiveTo evaluate the extent of commercial price variation for breast reconstruction. The secondary objective was to characterize the price of breast reconstruction in relation to market concentration and payer mix.Design, setting, and participantsThis was a cross-sectional study conducted from January to April 2022 using 2021 pricing data made available after the Hospital Price Transparency Rule. National data were obtained from Turquoise Health, a data service platform that aggregates price disclosures from hospital websites. Participants were included from all hospitals with disclosed pricing data for breast reconstructive procedures, identified by Current Procedural Terminology (CPT) code.Main outcomes and measuresPrice variation was measured via within- and across-hospital ratios. A mixed-effects linear model evaluated commercial rates relative to governmental rates and the Herfindahl-Hirschman Index (health care market concentration) at the facility level. Linear regression was used to evaluate commercial rates as a function of facility characteristics.ResultsA total of 69 834 unique commercial rates were extracted from 978 facilities across 335 metropolitan areas. Commercial rates increased as health care markets became less competitive (coefficient, $4037.52; 95% CI, $700.12 to $7374.92; P = .02; for Herfindahl-Hirschman Index [HHI] 1501-2500, coefficient $3290.21; 95% CI, $878.08 to $5702.34; P = .01; both compared with HHI ≤1500). Commercial rates demonstrated economically insignificant associations with Medicare and Medicaid rates (Medicare coefficient, -$0.05; 95% CI, -$0.14 to $0.03; P = .23; Medicaid coefficient, $0.14; 95% CI, $0.07 to $0.22; P < .001). Safety-net and nonprofit hospitals reported lower commercial rates (coefficient, -$3269.58; 95% CI, -$3815.42 to -$2723.74; P < .001 and coefficient, -$1892.79; -$2519.61 to -$1265.97; P < .001, respectively). Extra-large hospitals (400+ beds) reported higher commercial rates compared with their smaller counterparts (coefficient, $1036.07; 95% CI, $198.29 to $1873.85, P = .02).Conclusions and relevanceStudy results suggest that commercial rates for breast reconstruction demonstrated large nationwide variation. Higher commercial rates were associated with less competitive markets and facilities that were large, for-profit, and nonsafety net. Privately insured patients with breast cancer may experience higher premiums and deductibles as US hospital market consolidation and for-profit hospitals continue to grow. Transparency policies should be continued along with actions that facilitate greater health care market competition. There was no evidence that facilities increase commercial rates in response to lower governmental rates.
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Project description:The side effects of mastectomy can be significant. Breast reconstruction may alleviate some distress; however, there are currently no provincial recommendations regarding the integration of reconstruction with breast cancer therapy. The purpose of the present article is to provide evidence-based strategies for the management of patients who are candidates for reconstruction. A systematic review of meta-analyses, guidelines, clinical trials and comparative studies published between 1980 and 2013 was conducted using the PubMed and EMBASE databases. Reference lists of publications were manually searched for additional literature. The National Guidelines Clearinghouse and SAGE directory, as well as guideline developers' websites, were also searched. Recommendations were developed based on the available evidence. Reconstruction consultation should be made available for patients undergoing mastectomy. Tumour characteristics, cancer therapy, patient comorbidities, body habitus and smoking history may affect reconstruction outcomes. Although immediate reconstruction should be considered whenever possible, delayed reconstruction is acceptable when immediate is not available or appropriate. The integration of reconstruction and postmastectomy radiotherapy should be addressed in a multidisciplinary setting. The decision as to which type of procedure to perform (autologous or alloplastic with or without acellular dermal matrices) should be left to the discretion of the surgeons and the patient after providing counselling. Skin-sparing mastectomy is safe and appropriate. Nipple-sparing is generally not recommended for patients with malignancy, but could be considered for carefully selected patients. Immediate reconstruction requires resources to coordinate operating room time between the general and plastic surgeons, to provide supplies including acellular dermal matrices, and to develop the infrastructure needed to facilitate multidisciplinary discussions.
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Project description:Sphingolipids are bioactive lipids that participate in a wide variety of biological mechanisms, including cell death and proliferation. The myriad of pro-death and pro-survival cellular pathways involving sphingolipids provide a plethora of opportunities for dysregulation in cancers. In recent years, modulation of these sphingolipid metabolic pathways has been in the forefront of drug discovery for cancer therapeutics. About two decades ago, researchers first showed that standard of care treatments, e.g., chemotherapeutics and radiation, modulate sphingolipid metabolism to increase endogenous ceramides, which kill cancer cells. Strikingly, resistance to these treatments has also been linked to altered sphingolipid metabolism, favoring lipid species that ultimately lead to cell survival. To this end, many inhibitors of sphingolipid metabolism have been developed to further define not only our understanding of these pathways but also to potentially serve as therapeutic interventions. Therefore, understanding how to better use these new drugs that target sphingolipid metabolism, either alone or in combination with current cancer treatments, holds great potential for cancer control. While sphingolipids in cancer have been reviewed previously (Hannun & Obeid, 2018; Lee & Kolesnick, 2017; Morad & Cabot, 2013; Newton, Lima, Maceyka, & Spiegel, 2015; Ogretmen, 2018; Ryland, Fox, Liu, Loughran, & Kester, 2011) in this chapter, we present a comprehensive review on how standard of care therapeutics affects sphingolipid metabolism, the current landscape of sphingolipid inhibitors, and the clinical utility of sphingolipid-based cancer therapeutics.
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Project description:BackgroundThe COVID-19 pandemic posed significant challenges to traditional simulation education. Because simulation is considered best practice for competency-based education, emergency medicine (EM) residencies adapted and innovated to accommodate to the new pandemic normal. Our objectives were to identify the impact of the pandemic on EM residency simulation training, to identify unique simulation adaptations and innovations implemented during the pandemic, and to analyze successes and failures through existing educational frameworks to offer guidance on the use of simulation in the COVID-19 era.MethodsThe Society for Academic Emergency Medicine (SAEM)'s Simulation Academy formed the SimCOVID task force to examine the impact of COVID-19 on simulation didactics. A mixed-methods approach was employed. A literature search was conducted on the subject and used to develop an exploratory survey that was distributed on the Simulation Academy Listserv. The results were subjected to thematic analysis and examined through existing educational frameworks to better understand successes and failures and then used to generate suggestions on the use of simulation in the COVID-19 era.ResultsThirty programs responded to the survey. Strategies reported included adaptations to virtual teleconferencing and small-group in situ training with a focus on procedural training and COVID-19 preparedness. Successful continuation or relaunching of simulation programs was predicated on several factors including willingness for curricular pivots through rapid iterative prototyping, embracing teleconferencing software, technical know-how, and organizational and human capacity. In specific instances the use of in situ simulation for COVID-19 preparedness established the view of simulation as a "value add" to the organization.ConclusionsWhereas simulation educator's responses to the COVID-19 pandemic can be better appreciated through the lens of iterative curricular prototyping, their successes and failures depended on existing expertise in technological, pedagogical, and content knowledge. That knowledge needed to exist and synergize within a system that had the human and organizational capacity to prioritize and invest in strategies to respond to the rapidly evolving crisis in a proactive manner. Going forward, administrators and educators will need to advocate for continued investment in human and organizational capacity to support simulation-based efforts for the evolving clinical and educational landscape.
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Project description:Over the last years, prepectoral implant-based breast reconstruction has undergone a renaissance due to several technical advancements regarding mastectomy techniques and surgical approaches for the placement and soft tissue coverage of silicone implants. Initially abandoned due to the high incidence of complications, such as capsular contraction, implant extrusion, and poor aesthetic outcome, the effective prevention of these types of complications led to the prepectoral technique coming back in style for the ease of implant placement and the conservation of the pectoralis muscle function. Additional advantages such as a decrease of postoperative pain, animation deformity, and operative time contribute to the steady gain in popularity. This review aims to summarize the factors influencing the trend towards prepectoral implant-based breast reconstruction and to discuss the challenges and prospects related to this operative approach.
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Project description:PurposeThe aim of the study is to evaluate the level of sensible impairment after mastectomy or implant-based breast reconstruction (IBBR). In addition, factors influencing breast sensibility were evaluated.MethodsA cross-sectional study was performed in Maastricht University Medical Center between July 2016 and August 2018. Women with unilateral mastectomy with or without IBBR were included. Objective sensory measurements were performed using Semmes-Weinstein monofilaments. Their healthy breast served as control, using a paired t test. Differences between mastectomy with and without IBBR were evaluated using the independent t test. Linear regression was performed to evaluate the association between patient characteristics on breast sensibility. The paired t test was used to evaluate in which part of the breast the sensibility is best preserved.ResultsFifty-one patients were eligible for inclusion. Sixteen patients underwent IBBR after mastectomy. Twenty-three patients received radiotherapy and 35 patients received chemotherapy. Monofilament values were significantly higher in the operated group compared to the reference group (p < 0.001). Linear regression showed a statistically significant association between IBBR and objectively measured impaired sensation (p = 0.008). After mastectomy, the cutaneous protective sensation is only diminished. After IBBR, it is lost in the majority of the breast. The medial part of the breast was significantly more sensitive than the lateral part in all operated breasts (p < 0.001).ConclusionIBBR has a significantly negative impact on the breast sensibility compared to mastectomy alone. This study shows that the protective sensation of the skin in the breast is lost after IBBR. To our knowledge, this is the first study to evaluate the level of sensible impairment after mastectomy or IBBR. More research is necessary to confirm these results.
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