Postburn breast reconstruction: a scoping review.

Introduction: Postburn breast deformities pose functional and aesthetic concerns for burn patients, particularly when injury occurs before puberty, as normal breast development may be hindered. Postburn breast reconstruction aims at restoration of native anatomic features, as well as re-establishment of symmetry. The objectives of this scoping review are to map the literature on scar management and breast reconstruction, highlighting strategies that are particular to postburn deformities, as well as to establish optimal timing principles. Methods: A comprehensive search of the English literature across MEDLINE and EMBASE databases, including the grey literature, was conducted. Literature of all study designs were eligible, provided it discussed the treatment of postburn breast deformities. Results: A total of 64 studies were included. The most common study design was case series (58%) followed by retrospective cohorts (28%). Scar contracture release with split thickness skin grafts (26%) and various techniques for nipple-areola reconstruction (22%) were the most common reconstructive procedures. Discussion: Scar contracture releases predominate when there is normal breast development under a contracted skin envelope, and should be performed as soon as breast mound development is restricted. Surgical techniques widely used for postmastectomy reconstruction are required for patients with amastia or hypoplastic breasts. Conclusion: Given the heterogeneity of defects, availability of donor sites, and patient preference, no standardized guideline is available. Surgeons should combine basic scar management principles with postmastectomy techniques, adapting the surgical approach to features that are particular to thermally injured patients, as well as taking into account ideal timing considerations. Lay Summary: Breast deformities secondary to burn scars pose functional and aesthetic concerns for burn patients, particularly when injury occurs before puberty, as normal breast development may be hindered. Postburn breast reconstruction aims at restoration of native anatomic features, as well as re-establishment of symmetry. This literature review aimed at summarizing the available techniques to treat postburn breast deformities, as well as establishing optimal timing guidelines, given these issues may occur at any phase of breast development. When there is breast development under a scarred skin envelope, treatment entails scar contracture release and should be recommended as soon as the diagnosis is established, in order to allow the breast to further develop in an unrestricted manner. When there is absence of breast tissue, surgical techniques widely utilized for breast cancer reconstruction are warranted, and should be delayed until no further breast development is expected. Given the heterogeneity of deformities, availability of donor sites, and patience preference, no standardized guideline is available. Treatment options include several surgical techniques, in addition to non-surgical scar management, and timing considerations must take into account the patient's developmental phase and psychosocial wellness.

Futility considerations in surgical ethics.

The topic of futility has been intensely debated in bioethical discourse. Surgical futility encompasses considerations across a continuum of care, from decision-making during initial triage, to the choice to operate or refrain from operating on the critically ill, to withdrawal of life-supporting care. Determinations over futility may result in discord between providers and patients or their families, who might insist that treatment be provided at all costs to sustain life. In this manuscript, we will explore some of the possible sources for and manifestations of these disputes, and describe approaches by which to resolve them. Part I will briefly address some of the reasons that families ask for life-sustaining measures against medical advice in the surgical setting. These include variable determinations of both the quality of life and the inherent value of life (stemming from religious, cultural, and personal beliefs). Part II will detail some general instances in which physicians and surgeons can override requests to provide futile treatment, namely: instances of resource scarcity, interventions which carry a high probability of harm, and those that carry significant moral distress. To conclude, Part III will provide concrete guidelines for navigating futility, making an argument for individual case-based communication models in surgical decision-making.

The Spillover Effect of the Medicare Mandatory Bundled Payment Program on Joint Replacement Outcomes: Analysis of Patients with Commercial Insurance and Medicare Advantage.

BACKGROUND: To improve the value and efficiency of care among traditional Medicare enrollees, the Centers for Medicare & Medicaid Services has implemented alternative payment models designed to control health-care spending and improve quality. These models may affect care beyond traditional Medicare enrollees, "spilling over" into other populations. Established in April 2016, the Medicare mandatory bundled payment program, called the Comprehensive Care for Joint Replacement (CJR) model, holds hospitals accountable for spending and quality of care for traditional Medicare joint-replacement patients during care episodes that span from the index hospitalization to 90 days post-discharge. We assessed the extent to which the CJR model was associated with outcomes for patients enrolled in commercial insurance and Medicare Advantage plans. METHODS: With use of Health Care Cost Institute claims data from 2012 through 2017, we assessed the association of the CJR model with total expenditures, discharges to institutional post-acute care, and readmissions among commercial insurance and Medicare Advantage joint-replacement patients. The exposure variable was the implementation of the CJR model in 67 randomly selected metropolitan statistical areas compared with 103 similar areas without CJR implementation. We utilized difference-in-differences models to estimate the spillover effects of the CJR model by comparing outcomes between these areas before and after CJR implementation. RESULTS: The study included 174,893 joint-replacement episodes of care in commercial insurance enrollees and 202,070 episodes in Medicare Advantage enrollees. Among both commercial insurance and Medicare Advantage enrollees, CJR implementation was associated with no meaningful changes in total episode expenditures, discharges to institutional post-acute care, or readmissions. CONCLUSIONS: We found no evidence for spillover effects of the CJR model on commercial insurance and Medicare Advantage patients, suggesting that alternative payment models targeting traditional Medicare patients may have limited effects on the cost and quality of care for patients outside of the traditional Medicare system.

Chronic lymphocytic leukemia skin infiltrates presenting as eyebrow alopecia and erythematous pruritic papules refractory to treatment with topical steroids.

We describe a patient who presented with erythematous papules and hair loss solely limited to the eyebrows. Clinicians should be aware of this presentation of leukemia cutis and consider this diagnosis in a patient with a history of CLL.

Access to Primary, Mental Health, and Specialty Care: a Comparison of Medicaid and Commercially Insured Populations in Oregon.

OBJECTIVE: To describe how access to primary and specialty care differs for Medicaid patients relative to commercially insured patients, and how these differences vary across rural and urban counties, using comprehensive claims data from Oregon. DESIGN: Cross-sectional study of risk-adjusted access rates for two types of primary care providers (physicians; nurse practitioners (NPs) and physician assistants (PAs)); four types of mental health providers (psychiatrists, psychologists, advanced practice NPs or PAs specializing in mental health care, behavioral specialists); and four physician specialties (obstetrics and gynecology, general surgery, gastroenterology, dermatology). PARTICIPANTS: 420,947 Medicaid and 638,980 commercially insured adults in Oregon, October 2014-September 2015. OUTCOME: Presence of any visit with each provider type, risk-adjusted for sex, age, and health conditions. RESULTS: Relative to commercially insured individuals, Medicaid enrollees had lower rates of access to primary care physicians (- 11.82%; CI - 12.01 to - 11.63%) and to some specialists (e.g., obstetrics and gynecology, dermatology), but had equivalent or higher rates of access to NPs and PAs providing primary care (4.33%; CI 4.15 to 4.52%) and a variety of mental health providers (including psychiatrists, NPs and PAs, and other behavioral specialists). Across all providers, the largest gaps in Medicaid-commercial access rates were observed in rural counties. The Medicaid-commercial patient mix was evenly distributed across primary care physicians, suggesting that access for Medicaid patients was not limited to a small subset of primary care providers. CONCLUSIONS: This cross-sectional study found lower rates of access to primary care physicians for Medicaid enrollees, but Medicaid-commercial differences in access rates were not present across all provider types and displayed substantial variability across counties. Policies that address rural-urban differences as well as Medicaid-commercial differences-such as expansions of telemedicine or changes in the workforce mix-may have the largest impact on improving access to care across a wide range of populations.

Medicare's bundled payment model did not change skilled nursing facility discharge patterns.

OBJECTIVES: To evaluate whether participation in Medicare's voluntary Bundled Payments for Care Improvement (BPCI) model was associated with changes in discharge referral patterns to skilled nursing facilities (SNFs), specifically number of SNF partners and discharge concentration. STUDY DESIGN: Retrospective observational study using difference-in-differences analysis. METHODS: We used Medicare claims data from 2010 to 2015 to identify admissions for lower joint replacement surgery and the following medical conditions: congestive heart failure, renal failure, sepsis, pneumonia, urinary tract and kidney infections, chronic obstructive pulmonary disease, and stroke. We used difference-in-differences analyses to assess changes in discharge patterns among BPCI-participating hospitals compared with matched control hospitals. RESULTS: Our analytic sample included 3078 acute care hospitals and 14,866 Medicare-certified SNFs in the United States, encompassing more than 47 million hospital discharges. Of these hospitals, 416 participated in BPCI, with the majority selecting into joint replacement episodes (n = 295). BPCI participation was not associated with any change in number of SNF partners (increase by 0.8 SNFs among BPCI hospitals relative to non-BPCI hospitals; 95% CI, -0.2 to 1.9; P = .11) or in discharge concentration (increase in Herfindahl-Hirschman Index of 0.2 among BPCI hospitals relative to non-BPCI hospitals; 95% CI, -68.7 to 69.1; P = .36). Results did not vary across clinical conditions and were robust across duration of BPCI participation and with different comparison groups. CONCLUSIONS: Hospital participation in BPCI was not associated with changes in the number of SNF partners or in discharge concentration relative to non-BPCI hospitals. More research is needed to understand how hospitals are responding to bundled payment incentives and specific practices that contribute to improvements in cost and quality.

A multidisciplinary investigation of a polycythemia vera cancer cluster of unknown origin.

Cancer cluster investigations rarely receive significant public health resource allocations due to numerous inherent challenges and the limited success of past efforts. In 2008, a cluster of polycythemia vera, a rare blood cancer with unknown etiology, was identified in northeast Pennsylvania. A multidisciplinary group of federal and state agencies, academic institutions, and local healthcare providers subsequently developed a multifaceted research portfolio designed to better understand the cause of the cluster. This research agenda represents a unique and important opportunity to demonstrate that cancer cluster investigations can produce desirable public health and scientific outcomes when necessary resources are available.