Direct hospital cost of outcome pathways in implant-based reconstruction with acellular dermal matrices

BACKGROUND: Current cost data on tissue expansion followed by exchange for permanent implant (TE/I) reconstruction lack a necessary assessment of the experience of a heterogenous breast cancer patient population and their multiple outcome pathways. We extend our previous analysis to that of direct hospital cost as bundling of payments is likely to follow the changing centralization of cancer care at the hospital level. METHODS: We performed a retrospective analysis (2003–2009) of TE/I reconstructions with or without an acellular dermal matrix (ADM), namely Alloderm RTM. Postreconstructive events were analyzed and organized into outcome pathways as previously described. Aggregated and normalized inpatient and outpatient hospital direct costs and physician reimbursement were generated for each outcome pathway with or without ADM. RESULTS: Three hundred sixty-seven patients were analyzed. The average 2-year hospital direct cost per TE/I breast reconstruction patient was $11,862 in the +ADM and$12,319 in the −ADM groups (P > 0.05). Initial reconstructions were costlier in the +ADM ($6,868) than in the −ADM ($5,615) group, but the average cost of subsequent postreconstructive events within 2 years was significantly lower in +ADM ($5,176) than −ADM ($6,704) patients (P < 0.05). When a complication occurred, but reconstruction was still completed within 2 years, greater costs were incurred in the −ADM than in the +ADM group for most scenarios, leading to a net equalization of cost between study groups. CONCLUSION: Although direct hospital cost is an important factor for resource and fund allocation, it should not remain the sole factor when deciding to use ADM in TE/I reconstruction

Transcriptional regulation of S100B and identification of novel melanoma biomarkers

Summary Introduction Cutaneous melanoma is an aggressive disease, which is recognised as the most common fatal skin cancer worldwide. Approximately 450 cases are diagnosed in Ireland per year. Between 1994 and 2004, melanoma demonstrated a higher rate of increase in mortality than any other cancer in this country. Although the prognosis for early melanoma is favorable, less than 20 percent of patients with metastatic melanoma survive for five years. S100B is a calcium sensor protein that modulates biological activity via calcium binding, which is routinely used in histological diagnosis of malignant melanoma and which is also a well-recognized serum marker of the disease. HOX proteins are members of the homeodomain family of transcription factors, which are involved in a host of cellular functions including organogenesis, cellular differentiation, cell cycle and apoptosis. As transcription factors, HOX proteins require co-activator proteins to achieve their full function. SRC-1 is one such coactivator and our group has extensively explored its function. In particular, functional interactions between SRC-1 and HOXCI 1 in breast cancer cell lines and tissue have been described. HOXCI 1 is known to enhance expression of the secreted serum marker S100B. Given the strong association between S100B and malignant melanoma, we believe that this pathway may also have a role in melanoma tumour genesis. S100B is a well-described biomarker in melanoma and serum levels have been shown to correlate with disease stage and response to treatment. In spite of this and the availability other prognostic indicators, many patients go on to develop an unpredictable disease course. For this reason, identification of novel biomarkers is an active area of melanoma research. In the second part of this work, an autoantibody microarray screen was undertaken to identify differentially expressed biomarkers in sera from patients with melanoma. Hypothesis Production of S100B in malignant melanoma is regulated by the transcription factor HOXCI 1, in cooperation with coactivator SRC-1. Protein microarray technology may provide a useful means of identification of autoantibody biomarkers in serum from patients with melanoma. Aims To define the molecular role of HOXC11 and SRC-1 in the transcriptional control of S100B in malignant melanoma. To characterise the effect of manipulation of HOXC11 and SRC-1 on S100B expression. To identify new biomarkers in sera from patients with malignant melanoma. Results Expression of SIOOB, HOXC11 and SRC-1 protein in primary (SKMe128) and metastatic (MeWo) melanoma cell lines was confirmed by Western blotting and quantitative Real Time PCR (qRT-PCR) analysis. Colocalisation of HOXCI 1 and SRC-1 in melanoma cells was confirmed by immunofluorescence. Co-immunoprecipitation was carried out and demonstrated interaction of HOXC11 and SRC-1 in cell lysates. Paraffinembedded melanoma and nevi samples were examined by immunofluorescence and a significantly higher nuclear expression of HOXCI 1 and SRC-1 was observed in the melanoma cohort. Colocalisation of the two proteins was also demonstrated in a series of melanoma primary culture specimens. Chromatin-immunoprecipitation was employed to confirm recruitment of HOXCI 1 to the promoter region of the S100B gene. To determine the ability of HOXCI 1 to regulate expression of S1 OOB, HOXCI 1 was transfected into the SKMe128 cell line and it was found to significantly increase the expression of the target gene S100B. When concomitant HOXCI 1 and SRC- 1 knockdowns were performed, a significant reduction in the presence of S100B was noted. Treatment of cell lines with the phospho-Src inhibitor, dasatinib, resulted in decreased coassociation between HOXCI 1 and SRC-1 in both primary and metastatic cell lines as well as decreased expression of S100B in SKMe128 cells. Protein microarray analysis of sera from patients with melanoma and control patients was carried out. A series of differentially expressed autoantibodies was identified and the non-receptor tyrosine kinase, BMX was chosen for further study. Elevated expression of anti-BMX autoantibody in sera from a larger cohort of melanoma patients was confirmed. Furthermore, expression of BMX protein in melanoma cell lines and frozen tissue samples was confirmed by Western blotting. Conclusion In the absence of effective treatment for advanced melanoma, elucidation of novel signalling pathways and therapeutic targets remains at the forefront of molecular research. In this work, translational techniques have provided an insight in to the transcriptional regulation of S100B in melanoma. Furthermore, protein microarray analysis has been utilised to identify potentially useful autoantibody biomarkers. These findings constitute a small fragment of all the potential genetic aberrations that may be implicated in melanoma turnourgenesis. Advanced melanoma is likely to present a significant therapeutic challenge to clinicians and academics for many years to come. What is certain is that translational research methods, as have been employed here, are essential in pushing forward the boundaries of our molecular understanding of this fascinating disease

Can medical students accurately predict their learning? A study comparing perceived and actual performance in neuroanatomy

It is important that clinicians are able to adequately assess their level of knowledge and competence in order to be safe practitioners of medicine. The medical literature contains numerous examples of poor self-assessment accuracy amongst medical students over a range of subjects however this ability in neuroanatomy has yet to be observed. Second year medical students attending neuroanatomy revision sessions at the University of Southampton and the competitors of the National Undergraduate Neuroanatomy Competition were asked to rate their level of knowledge in neuroanatomy. The responses from the former group were compared to performance on a ten item multiple choice question examination and the latter group were compared to their performance within the competition. In both cohorts, self-assessments of perceived level of knowledge correlated weakly to their performance in their respective objective knowledge assessments (r = 0.30 and r = 0.44). Within the NUNC, this correlation improved when students were instead asked to rate their performance on a specific examination within the competition (spotter, rS = 0.68; MCQ, rS = 0.58). Despite its inherent difficulty, medical student self-assessment accuracy in neuroanatomy is comparable to other subjects within the medical curriculum. Anat Sci Educ. (c) 2016 American Association of Anatomists

Attitudes, Influences and Perceptions towards Plastic Surgery amongst Medical Students

Introduction: Plastic surgery is a dynamic and evolving field but remains poorly understood due to lack of knowledge, media misconceptions and recent changes to medical undergraduate curricula. To address issues around student interest and recruitment into the speciality, it is imperative to understand the factors influencing medical students and future clinicians. Aims: To examine influences, interest and perceptions of plastic surgery amongst Scottish medical students and explore methods to increase undergraduate engagement. Method: Cross-sectional survey distributed online via Scottish undergraduate medical school offices comprising 6 domains: demographics; career interest; perceptions, interests and influences in plastic surgery; curriculum and trainer views; understanding the role of a plastic surgeon; and undergraduate engagement. Results: A total of 193 students responded with no statistically significant relationship between year group, gender, and interest in plastic surgery. Phrases most strongly identified with plastic surgery included private practice, reconstruction and cosmetics. Placements, teaching staff and workshops/courses were found to influence perception of plastic surgery. Fortunately, only 6% of students encountered antagonism towards plastic surgery encompassing themes of negative stereotypes of surgeons and connotations surrounding cosmetic surgery. Importantly, many students were largely unaware of the range of common procedures undertaken by plastic surgeons. To overcome this lack of awareness and generate greater interest, students suggested greater plastics exposure, consultant-led teaching and workshops showcasing the specialty. Conclusion: Medical students want varied, stimulating and flexible careers – something which plastic surgery can provide. However it seems the understanding of the scope of plastic surgery is poorly understood amongs future trainees. To increase uptake and interest, negative perceptions need to be addressed and greater engagement is required from medical school upwards

Surgical antibiotic prophylaxis use and infection prevalence in non-cosmetic breast surgery procedures at a tertiary hospital in Western Australia—a retrospective study

Copyright 2018 Lavers et al. Background. Surgical site infections (SSIs) are a common complication following breast surgery procedures, despite being considered a clean surgery. The prevalence of SSIs can be minimised with the appropriate use of antibiotic prophylaxis as outlined in the Australian Therapeutic Guidelines (eTG). The aims of this study were to evaluate adherence to the eTG for antibiotic prophylaxis in breast surgery procedures at a Western Australian teaching hospital following an update of the guidelines in 2014 and examine the impact of prophylactic antibiotics on SSI incidence and length of hospital stay. Method. A retrospective cross-sectional study which reviewed medical records from a random sample of 250 patients selected from 973 patients who underwent breast surgical procedures between February 2015 and March 2017. Results. Overall adherence to current eTG occurred in 49.2% (123/250) of operations. Pre-operative and post-operative antibiotics were prescribed in 98.4% (246/250) and 11.2% (28/250) operations respectively. Adherence rates to three specific elements of the eTG (drug prescribed, drug dosage and timing of administration) were 91.6% (229/250), 53.6% (134/250) and 86.4% (216/250) respectively. For the 14.4% (36/250) patients with relevant drug allergies, there was zero adherence to the eTG. Overall recorded SSI prevalence was low at 5.2% (13/250). The mean length of stay in patients (2.3 ± 1.7 days) was not influenced by level of eTG adherence (p = 0.131) or SSIs (p = 0.306). Conclusion.These data demonstrate a significant improvement in overall adherence to the eTG from 13.3% to 49.2% (p = &lt; 0.001). The level of detected SSIs in this study was low. Further improvement is necessary with respect to prescribing appropriate antibiotic dosages and for those with allergies

International expert panel consensus on fat grafting of the breast

Background: Autologous fat grafting has broad applications in reconstructive and aesthetic breast surgery as a natural filler and for its regenerative purposes. Despite the widespread use of fat grafting, there remains no shared consensus on what constitutes the optimal fat grafting technique and its oncological safety. For this reason, the authors of this study have organized a Survey and an International Consensus Conference that was held at the Aesthetic Breast Meeting in Milan (December 15, 2018). Methods: All studies on fat grafting, both for breast aesthetic and reconstructive purposes, were electronically screened. The literature review led to 17 "key questions" that were used for the Survey. The authors prepared a set of 10 "key statements" that have been discussed in a dedicated face-to-face session during the meeting. Results: The 10 key statements addressed all the most debated topics on fat grafting of the breast. Levels of evidence for the key statements ranged from III to IV with 2 statements (20%) supported by a level of evidence III and 6 statements (60%) by level of evidence IV. Overall consensus was reached for 2 statements (20%) with >75% agreement reached for 7 statements. Conclusions: The survey demonstrated a diversity of opinion and attitude among the panelists with regard to technique. Clear recommendations for evidence-based clinical practice for fat grafting use both in aesthetic and reconstructive breast surgery could not be defined due to the scarcity of level 1 or 2 studies

Defining the Elements of an Enhanced Recovery Pathway For Primary Cleft Palate Repair: A Scoping Review

Cleft palate is a relatively common congenital anomaly, with an incidence of approximately 8.2 per 10,000 live births in Ireland. A cleft is a major disruption of the face and upper aerodigestive tract and can affect the infant’s airway, feeding, speech, communication, dentofacial development, and facial appearance. There is a wide disparity among surgeons in terms of peri-operative management. This scoping review will map the existing sources of evidence on perioperative care and recovery strategies for paediatric primary cleft palate repair. The aim is to define a list of elements that should be included in an institutional enhanced recovery programme