Citations

Background: Surgical-site infection after implant-based breast reconstruction adversely affects surgical outcomes and increases health care costs. This 11-year case-control study examines risk factors specific for surgical-site infection after immediate tissue expander/implant-based breast reconstruction. Methods: The authors performed a retrospective review to identify all consecutive patients with breast implant infections between 2006 and 2016. Patients who developed surgical-site infection after immediate tissue expander/implant-based breast reconstruction were included. Surgical-site infection was defined using the Centers for Disease Control and Prevention criteria; specifically, infections requiring hospital admission, intravenous antibiotics, or surgical intervention were included. The authors matched a control patient to each infection case by patient age and date of surgery. Patient demographics, medical comorbidities, and perioperative surgical variables were examined. Univariate and multivariable conditional logistic regression models were constructed. Results: A total of 270 breasts in 252 patients were evaluated. On multivariate analysis, patients with a higher body mass index (OR, 1.1 per 1 body mass index point increase; 95 percent CI, 1.0 to 1.2; p = 0.02), hypertension (OR, 6.5; 95 percent CI, 1.9 to 22.3; p = 0.002), neoadjuvant chemotherapy (OR, 2.6; 95 percent CI, 1.0 to 6.3; p = 0.04), axillary lymph node dissection (OR, 7.1; 95 percent CI, 1.7 to 29.2; p = 0.006), seroma formation (OR, 15.34; 95 percent CI, 3.7 to 62.5; p = 0.0001), and wound healing complications (OR, 23.91; 95 percent CI, 6.1 to 93.4; p < 0.0001) were significantly associated with surgical-site infection. Conclusions: Women with obesity, women with hypertension, and those treated with neoadjuvant chemotherapy are at increased risk of surgical-site infection. Further risks are also associated with postoperative seroma and wound complications. This may help patient selection and counseling, adjusted based on risk factors regarding complications of immediate implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Abstract Context Myth busting engages scholars in the critical examination of commonly accepted but poorly evidenced claims with the goal of instilling quality and trust in knowledge making. The debunking of such knowledge “myths” and associated misguided practices purportedly serves to avert resources and attention from wasteful and dangerous scholarship. We address the myth that “all myths in medical education deserve to be busted”. Methods Using a critical narrative approach, we searched the medical education literature for orientations to myths and myth busting, and reviewed this literature analytically drawing from the sociology of science and Merton's concepts of manifest and latent functions. The results of this analysis are presented in the form of a narrative that deploys the articles reviewed to explore the utility of myth busting for medical education reform and begins with a brief exploration of the etymology of “myth” and how meaning making is related to symbols, practices and storytelling. Results Our analysis revealed the important function of myths in the social practice of medical education and practice. A deconstruction of five salient examples of the contemporary myth in medical education (the myth of the “ideal candidate”, the myth of “cut‐throats”, the myth of “cadaver stories”, the myth of “learning styles”, and the myth of “patient information leaflets”) demonstrates that myths continue to have material effects even after they have been busted. Conclusions Our analysis makes evident that myth busting disrupts, renegotiates and reconstitutes socio‐epistemic relationships rather than simply correcting falsehoods. We also argue that myths play important and inescapable roles in the social practice of medical education and the negotiation of values, and in constructing the conditions for group change and transformation. Imperatives related to humanism , compassion and patient engagement offer a healthy humanising counter‐mythologising that we suggest must survive any contemporary myth‐busting endeavour aimed at improving medical education practice.

Background and objectives: Differences in patient anatomy and physiology exist between young and older patients undergoing breast reconstruction after mastectomy. Breast cancer has been described as being more aggressive, more likely to receive radiation, contralateral mastectomy, as well as bilateral reconstruction in young patients. Our purpose is to report long-term experience on two-staged implant-based breast reconstruction (IBR) in young females, with complication sub-analysis based on obesity and adjuvant radiation. Materials and Methods: Retrospective chart review of all consecutive young patients who underwent two-staged IBR at our institution, between 2000 and 2016, was performed. Patients between 15 and 40 years old with least 1-year follow-up were included. Univariate logistic regression models and receiver operating characteristic (ROC) curves were created. Results: Overall 594 breasts met our inclusion criteria. The mean age was 34 years, and the median follow-up was 29.6 months. Final IBR was achieved in 98% of breasts. Overall, 12% of breasts had complications, leading to explantations of 5% of the devices. Adjuvant radiation was followed by higher rates of total device explantations (p = 0.003), while obese patients had higher rates of total complications (p < 0.001). For each point increase in BMI, the odds of developing complications increased 8.1% (p < 0.001); the cutoff BMI to predict higher complications was 24.81 kg/m2. Conclusions: This population demonstrates high successful IBR completion and low explantation rates. These data suggest that obese women and those with planned adjuvant radiation deserve special counseling about their higher risk of complications.

Abstract Background: Standard treatment for stage III melanoma is surgery followed by consideration of adjuvant therapy. This strategy is inadequate for high-risk stage III patients who have a substantial risk of subsequent relapse and distant metastasis. The goals of this trial are to improve oncologic outcomes, assess treatment response and spare patients with poorly responsive, rapidly metastatic disease from a futile operation. This protocol based on the hypothesis that treatment before surgery will immunize patients against his or her own unique tumor. While new drugs are now FDA-approved for adjuvant treatment of stage III melanoma, outcomes are still suboptimal in high-risk patients. The neoadjuvant approach is largely untested and preclinical data suggest neoadjuvant therapy is more effective than adjuvant immunotherapy. While targeted therapies can be rapidly effective, immunotherapy responses, when they occur, tend to be much more durable, prompting this study. Our specific strategy is based on the fact that BRAFm melanoma patients benefit both from BRAF/MEK inhibition (vemurafenib/cobimetinib) and PD-1 axis inhibition (atezolizumab) while patients with BRAFwt melanoma benefit from PD-1 axis inhibition (atezolizumab) and intermittent MEKi (cobimetinib) may increase effector function in tumor-infiltrating T cells. A second component of the study is robust evaluation of biomarkers of response, toxicity and outcome. Specific correlatives include assessment of the predictive value of Bim levels in tumor-related T cells, correlation of sPD-L1 with efficacy and toxicity, correlation of PD-L1 expression with efficacy, and determination of key relationships between tumor and immune cells via mIHC spatial analysis, gene expression profiles and microbiome associations with clinical response. Methods: The NeoACTIVATE trial enrolls melanoma patients with resectable clinically detectable nodal metastases (by physical examination or imaging), dual nodal basin disease or nodal recurrence of melanoma. Neoadjuvant systemic therapy is based on BRAF mutation status; participants receive either vemurafenib, cobimetinib and atezolizumab (vem/cobi/atezo), or cobimetinib and atezolizumab (cobi/atezo) before surgery. Following surgery, all patients receive atezo immunotherapy. The primary aim of the study is RFS estimates for each cohort. Secondary aims are safety/toxicity, pathologic complete response rate and prospective evaluation of biomarkers of treatment response and toxicity. This study is significant in that it is the first to test 1) combined of targeted and immunotherapy in the neoadjuvant setting for patients with resectable Stage III melanoma and 2) the novel combination of MEK-inhibition with immunotherapy in the neoadjuvant setting for resectable Stage III melanoma. As of January 1, 2019, 10% of planned patients have been enrolled and enrollment continues. Citation Format: Tina J. Hieken, Vera J. Suman, Shernan G. Holtan, Thomas J. Flotte, Lisa A. Kottschade, Matthew S. Block. Neoadjuvant combination targeted and immunotherapy for high-risk resectable stage III melanoma (NeoACTIVATE), NCT03554083 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT121.

The need for a guidance document on MR safe practices arose from a growing awareness of the MR environment's potential risks and adverse event reports involving patients, equipment, and personnel. Initially published in 2002, the American College of Radiology White Paper on MR Safety established de facto industry standards for safe and responsible practices in clinical and research MR environments. The most recent version addresses new sources of risk of adverse events, increases awareness of dynamic MR environments, and recommends that those responsible for MR medical director safety undergo annual MR safety training. With regular updates to these guidelines, the latest MR safety concerns can be accounted for to ensure a safer MR environment where dangers are minimized.Level of Evidence: 1Technical Efficacy Stage: 5J. Magn. Reson. Imaging 2020;51:331–338.