Incidence of Nonkeratinocyte Skin Cancer After Breast Cancer Radiation Therapy.

Importance: Previous studies have suggested that radiation therapy may contribute to an increased risk of subsequent nonkeratinocyte (ie, not squamous and basal cell) skin cancers. Objective: To test the hypothesis that radiation therapy for breast cancer increases the risk of subsequent nonkeratinocyte skin cancers, particularly when these cancers are localized to the skin of the breast or trunk. Design, Setting, and Participants: This population-based cohort study used longitudinal data from the Surveillance, Epidemiology, and End Results (SEER) Program for January 1, 2000, to December 31, 2019. The SEER database includes population-based cohort data from 17 registries. Patients with newly diagnosed breast cancer were identified and were evaluated for subsequent nonkeratinocyte skin cancer development. Data analysis was performed from January to August 2023. Exposures: Radiation therapy, chemotherapy, or surgery for breast cancer. Main Outcomes and Measures: The primary outcomes were standardized incidence ratios (SIRs) for subsequent nonkeratinocyte skin cancer development from 2000 to 2019 based on treatment type (radiation therapy, chemotherapy, or surgery), skin cancer site on the body, and skin cancer subtype. Results: Among the 875 880 patients with newly diagnosed breast cancer included in this study, 99.3% were women, 51.6% were aged older than 60 years, and 50.3% received radiation therapy. A total of 11.2% patients identified as Hispanic, 10.1% identified as non-Hispanic Black, and 69.5% identified as non-Hispanic White. From 2000 to 2019, there were 3839 patients with nonkeratinocyte skin cancer, including melanoma (3419 [89.1%]), Merkel cell carcinoma (121 [3.2%]), hemangiosarcoma (104 [2.7%]), and 32 other nonkeratinocyte skin cancers (195 [5.1%]), documented to occur after breast cancer treatment. The risk of nonkeratinocyte skin cancer diagnosis after breast cancer treatment with radiation was 57% higher (SIR, 1.57 [95% CI, 1.45-1.7]) than that of the general population when considering the most relevant site: the skin of the breast or trunk. When risk at this site was stratified by skin cancer subtype, the SIRs for melanoma and hemangiosarcoma were both statistically significant at 1.37 (95% CI, 1.25-1.49) and 27.11 (95% CI, 21.6-33.61), respectively. Receipt of radiation therapy was associated with a greater risk of nonkeratinocyte skin cancer compared with chemotherapy and surgical interventions. Conclusions and Relevance: In this study of patients with breast cancer, an increased risk of melanoma and hemangiosarcoma after breast cancer treatment with radiation therapy was observed. Although occurrences of nonkeratinocyte skin cancers are rare, physicians should be aware of this elevated risk to help inform follow-up care.

Large Language Models in Medicine: The Potentials and Pitfalls : A Narrative Review.

Large language models (LLMs) are artificial intelligence models trained on vast text data to generate humanlike outputs. They have been applied to various tasks in health care, ranging from answering medical examination questions to generating clinical reports. With increasing institutional partnerships between companies producing LLMs and health systems, the real-world clinical application of these models is nearing realization. As these models gain traction, health care practitioners must understand what LLMs are, their development, their current and potential applications, and the associated pitfalls in a medical setting. This review, coupled with a tutorial, provides a comprehensive yet accessible overview of these areas with the aim of familiarizing health care professionals with the rapidly changing landscape of LLMs in medicine. Furthermore, the authors highlight active research areas in the field that promise to improve LLMs' usability in health care contexts.

E = mc2 : Education (E), medication (m), and conditional cash (c2 ) to improve uptake of antiseizure medications in a low-resource population: Protocol for randomized trial.

OBJECTIVE: Most people with epilepsy (PWE) could live seizure-free if treated with one or more antiseizure medications (ASMs). The World Health Organization (WHO) estimates that 75% of PWE in low-resource settings lack adequate antiseizure treatment. Limited education surrounding epilepsy and the out-of-pocket costs of ASMs in particular pose barriers to managing epilepsy in resource-poor, low-income settings. The aim of this study is to implement and test a novel strategy to improve outcomes across the epilepsy care cascade marked by (1) retention in epilepsy care, (2) adherence to ASMs, and (3) seizure reduction, with the measured goal of seizure freedom. METHODS: A randomized, double-blinded clinical trial will be performed, centered at the Ignace Deen Hospital in Conakry, Republic of Guinea, in Western Sub-Saharan Africa. Two hundred people with clinically diagnosed epilepsy, ages 18 years and above, will receive education on epilepsy and then be randomized to (i) free ASMs versus (ii) conditional cash, conditioned upon return to the epilepsy clinic. Participants will be followed for 360 days with study visits every 90 days following enrollment. SIGNIFICANCE: We design a randomized trial for PWE in Guinea, a low-resource setting with a high proportion of untreated PWE and a nearly completely privatized healthcare system. The trial includes a conditional cash transfer intervention, which has yet to be tested as a targeted means to improve outcomes for people with a chronic neurological disorder. The trial aims to provide an evidence base for the treatment of epilepsy in such settings. PLAIN LANGUAGE SUMMARY: We present a clinical trial protocol for a randomized, blinded study of 200 people with epilepsy in the low-resource African Republic of Guinea, providing an educational intervention (E), and then randomizing in a 1:1 allocation to either free antiseizure medication (m) or conditional cash (c2 ) for 360 days. Measured outcomes include (1) returning to outpatient epilepsy care, (2) adherence to antiseizure medications (ASMs), and (3) reducing the number of seizures. This study is an initial look at giving small amounts of cash for desired results (or "nudges") for improving epilepsy outcomes in the sub-Saharan African and brain disorder contexts.

The Current State of Transgender Health Curricula in Graduate Surgical Education: A Systematic Review of Survey Data.

OBJECTIVES: Transgender and gender diverse (TGD) individuals in the U.S. face significant healthcare disparities, which can be further exacerbated by providers' unfamiliarity with this population's specific needs. ACGME currently does not have requirements for gender-affirming surgery (GAS) in the residency programs of surgical specialties that are responsible for providing this care. This systematic review evaluates gender-affirming care (GAC) and GAS training in surgical residency programs in the U.S. through the analysis of survey respondent data. METHODS: Six databases (PubMed, Embase, Web of Science and Scopus, Cochrane Library and Google Scholar) were searched in December 2022 and May 2023. The search process ultimately yielded 22 survey-based studies, published between 2015 and 2023, with responses from 3020 respondents (2582 trainees and/or attending physicians, 438 program directors). RESULTS: Six different surgical specialties were the focus of included studies, and common questions revolved around GAS training availability, comfort in treating TGD patients, and the importance of GAS in graduate surgical education (GSE). Less than half of trainees indicated that they received some form of previous GAC or GAS training, and less than half of program directors indicated that their residency or fellowship program offered such training. CONCLUSIONS: While comfort levels around treating TGD patients ranged, the studies indicated an overall perceived importance of GAS training. These findings highlight the need to incorporate GAS training into graduate surgical education to improve access to and quality of care for TGD patients.

The effect of activity and face masks on exhaled particles in children.

Importance: Despite the high burden of respiratory infections among children, the production of exhaled particles during common activities and the efficacy of face masks in children have not been sufficiently studied. Objective: To determine the effect of type of activity and mask usage on exhaled particle production in children. Methods: Healthy children were asked to perform activities that ranged in intensity (breathing quietly, speaking, singing, coughing, and sneezing) while wearing no mask, a cloth mask, or a surgical mask. The concentration and size of exhaled particles were assessed during each activity. Results: Twenty-three children were enrolled in the study. Average exhaled particle concentration increased by intensity of activity, with the lowest particle concentration during tidal breathing (1.285 particles/cm3 [95% CI 0.943, 1.627]) and highest particle concentration during sneezing (5.183 particles/cm3 [95% CI 1.911, 8.455]). High-intensity activities were associated with an increase primarily in the respirable size (≤ 5 µm) particle fraction. Surgical and cloth masks were associated with lower average particle concentration compared to no mask (P = 0.026 for sneezing). Surgical masks outperformed cloth masks across all activities, especially within the respirable size fraction. In a multivariable linear regression model, we observed significant effect modification of activity by age and by mask type. Interpretation: Similar to adults, children produce exhaled particles that vary in size and concentration across a range of activities. Production of respirable size fraction particles (≤ 5 µm), the dominant mode of transmission of many respiratory viruses, increases significantly with coughing and sneezing and is most effectively reduced by wearing surgical face masks.

Body mass index and benign breast surgeries: A survey of plastic surgeons' knowledge and attitudes.

Background: The academic literature has not arrived at a consensus on the importance of body mass index (BMI) as an indicator of surgical feasibility and risk. This study evaluates board-certified plastic surgeons' and trainees' knowledge, experiences, and concerns around performing benign breast surgeries in high-BMI patients. Methods: An online survey instrument was developed and shared with plastic surgeons and plastic surgery trainees from December 2021 to January 2022. Results: There were 30 respondents (18 from Israel, 11 from the United States, and 1 from Turkey). For respondents who had BMI guidelines for performing benign breast surgeries, the median maximum BMI was 35 for all procedures. Most respondents supported or strongly supported their BMI guidelines.The majority of respondents indicated that they tended to have less training and experience in performing benign breast surgeries on high-BMI patients compared to those with BMI <30. Most respondents indicated that they were less satisfied with the results of these procedures on high-BMI patients compared to those with BMI <30. The median post-operation recovery time was indicated to be similar for high-BMI patients compared to those with BMI <30 across all procedures; however, the postoperative complication rate was indicated as higher. Conclusions: Respondents indicated that the risks of complication, more frequent need for surgical revisions, and unsatisfactory outcomes were their greatest concerns when conducting chest surgeries among high-BMI patients. Given that most surgeons practice in settings where high-BMI patients are excluded from procedure access, further research is needed to assess the extent to which these concerns reflect actual outcome differences.

Streamlining Interstate Access to Gender-Affirming Surgeries.

This Viewpoint explains the obstacles faced by individuals seeking gender-affirming care and summarizes needed changes to improve quality of care and access to care.

Conditional cash transfers to improve health-focused outcomes: a global scoping review.

This scoping review assesses the use of conditional cash transfer (CCT) interventions - direct distribution of money to individuals conditional on their compliance to certain requirements - in randomised controlled trials, quasi-experimental studies and large community-based randomised trials with health-focused outcomes. Five databases were searched to identify 68 records published 2004-2021 from 25 countries (8 low- (32%), 5 lower middle- (20%), 6 upper middle- (24%) and 6 high-income (24%), according to the World Bank Categorisation (2017). Forty-six studies were unique (after excluding multiple publications on a single study). The most common outcomes assessed were infectious diseases (30%); maternal health (24%); vaccination rates (17%); and childhood developmental measures (17%). The number of participants receiving CCT in each study ranged from 47 to 5,788, with a median of 487 individuals. The number of total participants ranged from 72 to 14,000, with a median of 1,289 individuals. Fifteen percent of studies involved mobile CCT disbursement. More than a quarter of payments were greater than 50 USD (29%), and most payments were 20 USD or less (58%). Seventy-eight percent of unique full-length studies reported statistically significant CCT effects. Although CCTs remain controversial, a growing evidence base is emerging for their potential impact in specific health conditions.

Encephalitis and meningitis in Western Africa: a scoping review of pathogens.

OBJECTIVE: To give an overview of the recently reported literature on the aetiologies of meningitis and encephalitis in western sub-Saharan Africa. METHODS: We conducted a scoping review following PRISMA guidance on published meningitis and encephalitis cases in the 16 countries of the United Nations-defined western sub-Saharan African region as identified in cohort studies, case series, and case reports, published 01/01/2000-08/01/2020, and available in four databases in August 2020 with an abstract in English, French or Italian. RESULTS: There were 38 distinct pathogens identified from 91 cohort studies' data and 48 case reports or case series' data. In cohort-level data, the majority of cases were caused by Neisseria meningitidis (71.5%), Streptococcus pneumoniae (17.6%) and Haemophilus influenzae (7.3%). In case report- and case series-level data, 40.5% of patients were <18 years old, 28.6% were female, and 28.6% were known to be immunocompromised. The case fatality rate was 39.3%. The most commonly reported pathogens among immunocompetent patients were Salmonella species (13 cases) and Ebola virus (9 cases), and the most commonly reported pathogen among immunocompromised patients was Cryptococcus neoformans (18 cases). Most cohort cases (52.3%) derived from Niger followed by Burkina Faso (28.6%). Most cases from single reports or series were reported from Nigeria (21.4%), Mali (20.2%) and Burkina Faso (19.0%). CONCLUSIONS: Given the small number of pathogens reported, our findings underscore the need to better screen, diagnose and monitor populations in western sub-Saharan Africa for additional CNS pathogens, including those posing significant outbreak risks.

Neuromyelitis optica practice and prescribing changes in the setting of Covid19: A survey of neurologists.

PURPOSE: This study reports and analyzes the findings from the responses of 192 neurologists in the United States and Canada to a new survey instrument distributed in April 2020 to assess NMO practice and prescribing changes during the Covid19 pandemic. PRINCIPAL RESULTS: 92% of responding neurologists considered their NMO patients to be at an elevated risk of acquiring Covid19. They also indicated sharp declines in visits, delays in treatment and related services, and several unmet needs deterring treatment. MAJOR CONCLUSIONS: There is a need for evidence-based, comprehensive guidelines for treating NMO patients amid healthcare crises moving forward.