Factors Affecting Prescribing of Type 2 Diabetes Medications in Older Adults within an Integrated Healthcare System.

BACKGROUND: Despite type 2 diabetes guidelines recommending against the use of sulfonylureas in older adults and for the use of sodium-glucose cotransporter-2 inhibitors (SGLT2) and glucagon-like peptide-1 agonists (GLP1s) in patients with atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), and heart failure (HF), real-world guideline-concordant prescribing remains low. While some factors such as cost have been suggested, an in-depth analysis of the factors associated with guideline-concordant prescribing is warranted. OBJECTIVE: To quantify the extent of guideline-concordant prescribing in an integrated health care delivery system and examine provider and patient level factors that influence guideline-concordant prescribing. DESIGN: We performed a cross-sectional study. PARTICIPANTS: Participants were included if they had a diagnosis of type 2 diabetes, were prescribed a second-line diabetes medication between January 1, 2018 and December 31, 2020 and were at least 65 years old at the time of this second-line prescription. MAIN MEASURES: Our outcome of interest was guideline-concordant prescribing. The definition of guideline-concordant prescribing was based on American Diabetes Association and American Geriatric Society recommendations as well as expert consensus. Factors affecting guideline concordant prescribing included patient demographics and provider characteristics among others. KEY RESULTS: We included 1,693 patients of which only 50% were prescribed guideline-concordant medications. In a subgroup of 843 patients with cardiorenal conditions, only 30% of prescriptions were guideline concordant. Prescribing of guideline-concordant prescriptions was more likely among pharmacists than physicians (RR 1.34, 95% CI 1.19-1.51, p<0.001) and in endocrinology practices compared to primary care practices (RR 1.41 95% CI 1.16-1.72, p=0.007). Additionally, guideline concordant prescribing increased over time (42% in 2018 vs 53% in 2019 vs 53% in 2020, p<0.001). CONCLUSIONS: Guideline-concordant prescribing remains low in older adults, especially among those with cardiorenal conditions. Future studies should examine barriers to prescribing guideline-concordant medications and interventions to improve guideline-concordant prescribing.

Evaluation of pharmacist-led transition of care program in patients with acute coronary syndrome.

BACKGROUND: Guideline-directed medical therapies (GDMTs), initiated in-hospital and continued during the transition to outpatient care, are paramount to successful outcomes for patients with acute coronary syndrome (ACS). Incomplete discharge medication prescribing and delayed follow-up lead to worse cardiovascular outcomes. OBJECTIVES: We investigated a system of care using inpatient and outpatient clinical pharmacists to close GDMT gaps, ensure seamless transition to outpatient care, improve patient education, and optimize therapies. METHODS: We conducted a pre-post cohort analysis of patients with ACS pre- versus post-intervention to compare process metrics and key outcomes using electronic health record data. RESULTS: There were 181 and 135 patients in the pre- and post-intervention cohorts, respectively. Patients post-intervention were significantly more likely to have appropriately-timed follow-up visits scheduled with cardiology (79% vs. 51%, P < 0.0001) and primary care (57% vs. 43%, P = 0.01), to be discharged with prescriptions for P2Y12 inhibitors (87% vs. 64%, P < 0.0001), high dose statins (86% vs. 70%, P = 0.001), and beta blockers (87% vs. 76%, P = 0.01), and significantly less likely to have 30-day all-cause hospital readmissions (4% vs. 12%, P = 0.02) and emergency department (ED) visits (10% vs. 18%, P = 0.04). CONCLUSIONS: The integration of advanced practicing pharmacists into a cardiology team at transition and post-hospitalization resulted in improved rates of posthospital follow-up visits, optimization of GDMT medications, and significantly lower 30-day hospital readmission and ED utilization.

Preferences for Shigellosis-Related Health Promotion Materials for Gay, Bisexual, and Other Men Who Have Sex With Men: Results From a Qualitative Assessment, Atlanta, GA.

BACKGROUND: Shigellosis, an acute diarrheal disease, is the third most common bacterial infection in the United States. Shigellosis most commonly affects children younger than 5 years; however, clusters and outbreaks of shigellosis have been reported among gay, bisexual, and other men who have sex with men (MSM). Evidence suggests that knowledge of shigellosis among MSM is low, indicating health promotion outreach is needed for this population. METHODS: To inform the development of shigellosis-related health communication materials and strategies, 6 focus groups were conducted in 2017, in Atlanta, GA among 24 self-identified gay and bisexual men. Participants were asked about their preferences and recommendations for health communication materials. RESULTS: Participants indicated they would prefer a range of physical and virtual materials placed in diverse locations where the community would see them. Respondents recommended health messages be simple, quick to read, and concise with limited word counts. Participants also advised the use of diverse images that were inclusive of couples of varying sexual orientations to reduce stigma. Participants advocated for the use of humor and provocative images to increase user engagement. CONCLUSIONS: The results emphasize the potential benefits of conducting formative research when designing health communication materials. Incorporating messaging preferences of MSM in the development of shigellosis-related health communication materials could enhance their relevance for the target population while also avoiding unintended consequences associated with stigmatizing MSM.

Accelerating prediction of chemical shift of protein structures on GPUs: Using OpenACC.

Experimental chemical shifts (CS) from solution and solid state magic-angle-spinning nuclear magnetic resonance (NMR) spectra provide atomic level information for each amino acid within a protein or protein complex. However, structure determination of large complexes and assemblies based on NMR data alone remains challenging due to the complexity of the calculations. Here, we present a hardware accelerated strategy for the estimation of NMR chemical-shifts of large macromolecular complexes based on the previously published PPM_One software. The original code was not viable for computing large complexes, with our largest dataset taking approximately 14 hours to complete. Our results show that serial code refactoring and parallel acceleration brought down the time taken of the software running on an NVIDIA Volta 100 (V100) Graphic Processing Unit (GPU) to 46.71 seconds for our largest dataset of 11.3 million atoms. We use OpenACC, a directive-based programming model for porting the application to a heterogeneous system consisting of x86 processors and NVIDIA GPUs. Finally, we demonstrate the feasibility of our approach in systems of increasing complexity ranging from 100K to 11.3M atoms.

Identifying requirements for RSK2 specific inhibitors.

Identifying isoform-specific inhibitors for closely related kinase family members remains a substantial challenge. The necessity for achieving this specificity is exemplified by the RSK family, downstream effectors of ERK1/2, which have divergent physiological effects. The natural product, SL0101, a flavonoid glycoside, binds specifically to RSK1/2 through a binding pocket generated by an extensive conformational rearrangement within the RSK N-terminal kinase domain (NTKD). In modelling experiments a single amino acid that is divergent in RSK3/4 most likely prevents the required conformational rearrangement necessary for SL0101 binding. Kinetic analysis of RSK2 association with SL0101 and its derivatives identified that regions outside of the NTKD contribute to stable inhibitor binding. An analogue with an n-propyl-carbamate at the 4" position on the rhamnose moiety was identified that forms a highly stable inhibitor complex with RSK2 but not with RSK1. These results identify a SL0101 modification that will aid the identification of RSK2 specific inhibitors.

Informing collaborative relationships between community pharmacists and health care professionals in primary care practices.

BACKGROUND: Collaborative relationships between community pharmacists and health care professionals in primary care practices can assist with the provision of medication and disease management services in community pharmacy settings. OBJECTIVES: The objective was to describe the attitudes of providers working in primary care practices with on-site pharmacist collaborators to understand how to facilitate similar collaborations with pharmacists in community pharmacy settings. METHODS: This qualitative study was conducted among physicians, nurse practitioners, and nurses of 3 primary care practice sites in the Commonwealth of Pennsylvania. A demographic survey and a semistructured interview were conducted to elicit feedback on participant perceptions about building relationships with community pharmacists. Interviews were audio-recorded and transcribed. A qualitative analysis was performed to identify emerging themes using an inductive approach. Demographic data were summarized using descriptive statistics. This study was approved by the University's Institutional Review Board. RESULTS: Nineteen interviews were conducted. Fifty-eight percent of participants were physicians and 68% were female with a mean age of approximately 46 years. Five themes were identified: (1) Pharmacists were highly valued and were effective team members to promote coordination of medication-related care; (2) Direct access to pharmacists facilitates efficient communication and effective patient care; (3) Trust is the foundation of an effective collaboration between pharmacists and providers; (4) Pharmacists demonstrating responsibility for patients enables collaboration with providers who view themselves as stewards of patient care; and (5) Providers believe that community pharmacists' dispensing requirements may limit their ability to participate in patient care. CONCLUSIONS: The following strategies to establish relationships with primary care practices are suggested: pharmacists should initiate face-to-face relationships with providers in practices; communication and patient interventions should be conveyed directly to providers and be conducted by the same person; and pharmacists need to demonstrate their commitment to patient care by following up promptly on patient interventions.

Shigellosis Among Gay and Bisexual Men: A Qualitative Assessment to Examine Knowledge, Attitudes, and Practices.

BACKGROUND: Shigellosis is a highly contagious enteric bacterial disease transmitted through the fecal-oral route. It is primarily transmitted through person-to-person contact and via contaminated food and water. Outbreaks of shigellosis among men who have sex with men (MSM) attributed to sexual person-to-person contact have been reported. These outbreaks are of concern because they are often caused by multidrug-resistant strains of Shigella. Little is known about shigellosis-related knowledge, attitudes, and practices among gay, bisexual, and other MSM. METHODS: Six focus groups were conducted among self-identified gay or bisexual men in Atlanta, GA, in Fall 2017. Participants were asked about shigellosis-related knowledge, attitudes, and practices. Focus groups were audio recorded, and the transcribed audio was analyzed using inductive and deductive thematic coding. RESULTS: Among the 24 focus group participants, most perceived that diarrheal illness was caused by contaminated food. Knowledge of shigellosis and Shigella was low, with most never having heard of the disease or bacteria. Participants did not perceive shigellosis to be a serious health concern, especially when compared with HIV; however, they did perceive gay and bisexual men to be at risk of Shigella infection. Participants reported mixed intentions to change sexual behaviors to prevent shigellosis or talk with sexual partners about diarrhea. CONCLUSIONS: Health communication and education efforts could be used to increase knowledge about shigellosis and shift perceptions about the severity of shigellosis among gay, bisexual, and other MSM. Additional work is needed to identify effective ways to promote shigellosis-related prevention behaviors among gay, bisexual, and other MSM.

Synthesis and Biological Evaluation of 4'-Substituted Kaempfer-3-ols.

The synthesis of two series of five kaempfer-3-ols was described. The first set all have a C-3 hydroxyl group and the second has a carboxymethoxy ether at the C-3 position. Both series have variable substitution at the C-4' position (i.e., OH, Cl, F, H, OMe). Both kaempferols and carboxymethoxy ethers were evaluated for their ability to inhibit ribosomal s6 kinase (RSK) activity and cancer cell proliferation.

The impact of community pharmacist involvement on transitions of care: A systematic review and meta-analysis.

OBJECTIVES: To evaluate the impact of community pharmacist involvement on transitions of care, specifically on 30-day hospital readmissions. DATA SOURCES: We searched the following databases from inception to August 2018: MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, International Pharmaceutical Abstracts, ProQuest Health and Medical Collection, ProQuest Nursing and Allied Health Database, and Web of Science. We also searched clinical trials registries and personal files to identify additional studies. STUDY SELECTION: Studies were eligible if the intervention included community pharmacists and patients were being discharged from the hospital to home. We included reports of randomized controlled trials, nonrandomized controlled trials, controlled before-and-after studies, and interrupted time series published in English. DATA EXTRACTION: We extracted intervention characteristics from each study and 30-day readmissions when present. RESULTS: From 744 abstracts that met our inclusion criteria, we included 39 articles describing 36 unique studies, 10 which contributed to the primary outcome of 30-day readmissions. Overall, community pharmacist involvement in transitions of care was associated with a non-statistically significant 28% reduction in 30-day readmissions (relative risk [RR], 0.72; 95% CI 0.50-1.02; I2 = 82%). When using per protocol data, community pharmacist involvement in transitions of care was associated with a statistically significant 40% reduction in 30-day readmissions (RR, 0.60; 95% CI 0.41-0.88; I2 = 77%). Studies with more active involvement of community pharmacists had a greater effect on 30-day readmissions (RR, 0.55; 95% CI 0.32-0.95; I2 = 88%) than those with less active involvement did (RR, 1.02; 95% CI 0.80-1.31; I2 = 0%). CONCLUSION: Our review shows that community pharmacists can have a beneficial effect on patients' transitions of care; however, the body of evidence is limited by the heterogeneity and imprecision. Future studies should test interventions in which community pharmacists play an integral part and ensure that interventions are completed with fidelity.

Migraine Surgery: An All or Nothing Phenomenon? Prospective Evaluation of Surgical Outcomes.

OBJECTIVE: A detailed analysis of outcomes after migraine surgery suggests an anatomic etiology of pain, such as peripheral nerve compression, in select patients. BACKGROUND: Historically, surgeons have not played a role in the treatment of migraine. However, a subgroup of patients with extracranial anatomic triggers appear to benefit from surgical intervention. Traditionally, the determination of success or failure of migraine surgery is based on whether there is greater or less than 50% improvement of the migraine headache index (MHI) after surgery. However, in this study, patients either did not respond to treatment (≤5%) or improved completely (≥80%). Detailed analysis is provided of this surprising finding. METHODS: Subjects completed a prospective migraine questionnaire preoperatively as well as at 3 and 12 months postoperatively. RESULTS: All variables improved significantly from baseline. Interestingly, in 83% of patients, the MHI improved either ≥80% or ≤5%, suggesting a more binary distribution. Only 17% of indices fell in the intermediate (5% to 80%) range. Moreover, 69% of patients had ≥80% improvement resulting in a mean improvement of 96% in this group. The remaining 14% had ≤5% improvement, with an average improvement of 0%. CONCLUSION: Migraine surgery remains controversial. Traditional conservative therapy targets the central theory of migraine propagation. This study again prospectively demonstrates the efficacy of surgical trigger site deactivation in migraine patients. Patients either failed to improve or improved after surgery, with few intermediate outcomes. The binary distribution of data lends further support to an anatomic etiology of pain, that is, peripheral nerve compression, in select patients.

Reductions in 30-day readmission, mortality, and costs with inpatient-to-community pharmacist follow-up.

OBJECTIVES: To determine the impact of pharmacist-provided continuous care and electronic communication on readmissions among a group of high-risk patients. DESIGN: Pragmatic interventional study with 5:1 matched control. SETTING AND PARTICIPANTS: Patients discharged from any of 4 hospitals with chronic obstructive pulmonary disease, pneumonia, heart failure, acute myocardial infarction, or diabetes within Pennsylvania. Patients in the intervention group received consultative services from inpatient pharmacists before discharge and inpatient-to-community pharmacist communication of hospitalization information facilitated with the use of a secure messaging system. After discharge, patients received up to 5 in-person or telephonic medication management consultations with their community pharmacists. MAIN OUTCOME MEASURES: The principal end point was 30-day readmission. Secondary end points included time to event (readmission, emergency department [ED] visit, death, or composite of hospitalization, ED, or death) over 90 days after discharge. Financial feasibility and sustainability were also assessed with the use of a return-on-investment (ROI) model based on information within the subset of patients with health plan coverage. RESULTS: Among patients who received inpatient intervention plus consultation with community pharmacists compared with matched control patients, we observed a lower 30-day readmission rate (9% vs. 15%, respectively; P = 0.02), 30-day all-cause mortality (2% vs. 5%; P = 0.04), and composite 30-day end point of readmission, ED visit, or death (22% vs. 28%; P = 0.09). Differences between the groups diminished and no longer maintained statistical significance at 90 days. An estimated average ROI of 8.1 was also observed among the subset with health plan information (worst base case range 1.9-16.3). CONCLUSION: Connecting community pharmacists to inpatient pharmacists during the transitional hospital-to-home time frame is feasible and resulted in lower 30-day readmissions and significant ROI, that is, significant impact on health care utilization and total health care costs. Results of this study have broad implications for improving the care of high-risk patients moving from hospital to home, most notably in the engagement of community pharmacists after discharge to assure medication use and follow-up to reduce readmissions and total costs of care.

Assessment of risk behaviors in patients with opioid prescriptions: A study of indiana's inspect data.

BACKGROUND AND OBJECTIVES: Prescription Drug Monitoring Programs (PDMPs) can serve as screening tools and support the clinical decision-making process in patients receiving opioids. The objective of the study was to utilize 2014 INSPECT (Indiana's PDMP) data to identify factors that increase patients' likelihood to engage in opioid-related risk behaviors. METHODS: Based on a literature review, four risk behaviors were identified: Receiving >90 morphine milligram equivalents (MME), having >4 opioid prescribers, obtaining opioids from >4 pharmacies, and concurrent use of opioids and benzodiazepines. Two binary logistic regression analyses (engaging in at least one risk behaviors; engaging in all four risk behaviors) and an ordinal regression analysis (engaging in 0-4 risk behaviors) were conducted to identify factors associated with these opioid-related risk behaviors. RESULTS: Of the 1,538,120 unique opioid patients included in the study, 18.4% engaged in one, 5.3% in two, 1.6% in three, and .4% in all four risk behaviors. Depending on the model, prescribing a second monthly opioid increased patients' odds to engage in risk behaviors by a factor of 10 or more and prescribing two or more benzodiazepines annually increased the odds at least 13-fold. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: About one-fourth of all patients consuming opioids engaged in one or more risk behaviors; higher number of opioid prescriptions and addition of even a small number of benzodiazepine prescriptions dramatically increased these odds. PDMPs can be helpful in identifying opioid users at high-risk for misuse. This information could be used to target efforts to reduce the prescription drug epidemic. (Am J Addict 2017;26:822-829).

Cleft Lip Standardized Patient Examinations: The Role in Plastic Surgery Resident Education.

BACKGROUND: Our institution has incorporated the use of objective structured clinical examinations (OSCE) in our residency curriculum. The OSCE provides trainee education and evaluation while addressing the six Accreditation Council for Graduate Medical Education (ACGME) core competencies required within training programs. We report our program's experience with the first cleft OSCE ever conducted. METHODS: A validated method for administration of OSCEs currently used at our medical school was utilized for residents in postgraduate years (PGYs) 3 through 6. The video-recorded patient encounter involved a 1-month-old newborn with a unilateral cleft lip and palate and used standardized patient actors as parents. A post-encounter written exam assessed medical knowledge. A questionnaire regarding the utility of the exercise was administered to residents after the OSCE. Results were evaluated using analysis of variance (P < .05). RESULTS: There was a positive correlation with increasing level of training in terms of medical knowledge (P < .04). Residents in PGY-3 and PGY-4 demonstrated lower understanding of the surgical markings and details of the lip repair compared with those in PGY-5 and PGY-6 (P < .03). All residents performed similarly on evaluation of the remaining ACGME core competencies. All residents agreed that this was a realistic and useful encounter. CONCLUSION: Results of our cleft OSCE demonstrate that medical knowledge regarding the evaluation, management, and surgical repair of patients is less in midlevel residents. All residents expressed an interest in earlier exposure to pediatric patients in the training period. Although a cleft OSCE does not replace clinical rotations, it is a valuable adjunct to training and evaluation of trainees, particularly for junior residents.

State-level marriage equality and the health of same-sex couples.

OBJECTIVES: We assessed the association between the health of people in same-sex relationships and the degree and nature of the legal recognition of same-sex relationships offered in the states in which they resided. METHODS: We conducted secondary data analyses on the 2010 to 2013 Current Population Survey and publicly available data from Freedom to Marry, Inc. We estimated ordered logistic regression models in a 4-level framework to assess the impact of states' legal stances toward same-sex marriage on self-assessed health. RESULTS: Our findings indicated, relative to states with antigay constitutional amendments, that same-sex couples living in states with legally sanctioned marriage reported higher levels of self-assessed health. CONCLUSIONS: Our findings suggested that full legal recognition of same-sex relationships through marriage might be an important legal and policy strategy for improving the health of same-sex couples.

Responses to ionizing radiation mediated by inflammatory mechanisms.

Since the early years of the twentieth century, the biological consequences of exposure to ionizing radiation have been attributed solely to mutational DNA damage or cell death induced in irradiated cells at the time of exposure. However, numerous observations have been at variance with this dogma. In the 1950s, attention was drawn to abscopal effects in areas of the body not directly irradiated. In the 1960s reports began appearing that plasma factors induced by irradiation could affect unirradiated cells, and since 1990 a growing literature has documented an increased rate of DNA damage in the progeny of irradiated cells many cell generations after the initial exposure (radiation-induced genomic instability) and responses in non-irradiated cells neighbouring irradiated cells (radiation-induced bystander effects). All these studies have in common the induction of effects not in directly irradiated cells but in unirradiated cells as a consequence of intercellular signalling. Recently, it has become clear that all the various effects demonstrated in vivo may reflect an ongoing inflammatory response to the initial radiation-induced injury that, in a genotype-dependent manner, has the potential to contribute primary and/or ongoing damage displaced in time and/or space from the initial insult. Importantly, there is direct evidence that non-steroidal anti-inflammatory drug treatment reduces such damage in vivo. These new findings highlight the importance of tissue responses and indicate additional mechanisms of radiation action, including the likelihood that radiation effects are not restricted to the initiation stage of neoplastic diseases, but may also contribute to tumour promotion and progression. The various developments in understanding the responses to radiation exposures have implications not only for radiation pathology but also for therapeutic interventions.

Sharing Physician Notes Through an Electronic Portal is Associated With Improved Medication Adherence: Quasi-Experimental Study.

BACKGROUND: In surveys, interviews, and focus groups, patients taking medications and offered Web portal access to their primary care physicians' (PCPs) notes report improved adherence to their regimens. However, objective confirmation has yet to be reported. OBJECTIVE: To evaluate the association between patient Internet portal access to primary care physician visit notes and medication adherence. METHODS: This study is a retrospective comparative analysis at one site of the OpenNotes quasi-experimental trial. The setting includes primary care practices at the Geisinger Health System (GHS) in Danville, Pennsylvania. Participants include patients 18 years of age or older with electronic portal access, GHS primary care physicians, and Geisinger health plan insurance, and taking at least one antihypertensive or antihyperlipidemic agent from March 2009 to June 2011. Starting in March 2010, intervention patients were invited and reminded to read their PCPs' notes. Control patients also had Web portal access throughout, but their PCPs' notes were not available. From prescription claims, adherence was assessed by using the proportion of days covered (PDC). Patients with a PDC ≥.80 were considered adherent and were compared across groups using generalized linear models. RESULTS: A total of 2147 patients (756 intervention participants, 35.21%; 1391 controls, 64.79%) were included in the analysis. Compared to those without access, patients invited to review notes were more adherent to antihypertensive medications-adherence rate 79.7% for intervention versus 75.3% for control group; adjusted risk ratio, 1.06 (95% CI 1.00-1.12). Adherence was similar among patient groups taking antihyperlipidemic agents-adherence rate 77.6% for intervention versus 77.3% for control group; adjusted risk ratio, 1.01 (95% CI 0.95-1.07). CONCLUSIONS: Availability of notes following PCP visits was associated with improved adherence by patients prescribed antihypertensive, but not antihyperlipidemic, medications. As the use of fully transparent records spreads, patients invited to read their clinicians' notes may modify their behaviors in clinically valuable ways.

Quality of life and patient satisfaction after microsurgical abdominal flap versus staged expander/implant breast reconstruction: a critical study of unilateral immediate breast reconstruction using patient-reported outcomes instrument BREAST-Q.

Staged expander-implant breast reconstruction (EIBR) and microsurgical abdominal flap breast reconstruction (MAFBR) are the most common modes of breast reconstruction (BR) in the United States. Whether the mode of breast reconstruction has an impact on patient quality of life (QoL) and satisfaction remains a question. A retrospective study was conducted identifying a population of 119 patients who underwent unilateral immediate BR. Only patients who were eligible for either EIBR or MAFBR based on preoperative characteristics were included in the study. The following parameters were retrieved: demographics, mode of reconstruction, cancer, recovery, QoL, and patient satisfaction. The latter two parameters were determined using the BREAST-Q BR module questionnaire. Two-way analysis of variance with mode of reconstruction and occurrence of complication as independent variables was used to determine the effect on patient satisfaction and QoL. The association between mode of reconstruction and patient response with each item of the QoL and satisfaction survey domains was analyzed. The overall response rate was 62.2 %. Non-respondents and respondents did not significantly differ in demographics, surgery type, cancer staging, adjuvant therapy, and complication rate. Age and BMI were significantly higher in MAFBR, while level of education was higher in EIBR. MAFBR had higher scores in psychosocial and sexual wellbeing, satisfaction with outcome, breast, information, and plastic surgeon when compared with patients who underwent EIBR. For patients eligible for both MAFBR and EIBR, MAFBR is associated with higher levels of satisfaction and QoL. Comprehensive pre-operative information of pros and cons of both modes of BR is crucial for patients to make a well-informed decision, thus, resulting in higher levels of satisfaction.

Outcome analysis of expander/implant versus microsurgical abdominal flap breast reconstruction: a critical study of 254 cases.

BACKGROUND: Expander-implant breast reconstruction (EIBR) and microsurgical abdominal flap breast reconstruction (MAFBR) are currently the two most frequent breast reconstruction techniques performed in the United States. The aim of this study was to compare outcomes between EIBR and MAFBR in order to help future breast cancer patients to be more knowledgeable and better informed in choosing their optimal reconstruction option. METHODS: Medical records of 795 patients who underwent breast reconstruction at Stanford Hospital from 2007 to 2011 were reviewed. We found 254 patients to be candidates for both MAFBR and EIBR preoperatively and included them in the study. Patients demographics, postoperative clinic visits, length of hospital stay, postoperative complications, and follow-up time were compared. Logistic regression analysis was used to determine risk factors for major complications. RESULTS: MAFBR patients had 8.7 clinic visits postoperatively, while 14.6 visits were needed for EIBR patients. Length of hospital stay was 4.8 ± 1.32 days for MAFBR and 2.1 ± 0.9 days for EIBR. Complication occurred in 21.3 % of MAFBR versus 37.4 % for EIBR patients. Follow-up duration was 24.7 ± 17.2 months for EIBR and 30.1 ± 18.5 months for MAFBR. On multivariate analysis, EIBR and a body mass index of ≥30 kg/m(2) were the only significant predictors of major complication. CONCLUSIONS: For patients eligible for both options, MAFBR has a lower incidence of major complications and fewer postoperative visits, but it has a longer initial hospital stay compared to EIBR. Patients should be informed of not only short-term but also long-term possible risks and benefits in order to make an informed decision.

Radiation and the microenvironment - tumorigenesis and therapy.

Radiation rapidly and persistently alters the soluble and insoluble components of the tissue microenvironment. This affects the cell phenotype, tissue composition and the physical interactions and signalling between cells. These alterations in the microenvironment can contribute to carcinogenesis and alter the tissue response to anticancer therapy. Examples of these responses and their implications are discussed with a view to therapeutic intervention.