Citations

Abstract Background Medical tourism (MT) is an increasingly utilized modality for acquiring medical treatment for patients globally. This review assimilates the current literature regarding MT, with particular focus on the applications, ethics and economics. Methods A systematic review of MEDLINE and PubMed Central databases for publications relating to MT from 2005 to 2018 yielded 43 articles for this review. Results Patients seeking elective bariatric, cosmetic and orthopedic surgery abroad are motivated by significantly lower costs, all-inclusive vacation packages and reduced wait times. Complication rates as high as 56% include infection, poor aesthetic and functional outcome and adverse cardiovascular events. Cross-border reproductive care has steadily increased due to less restrictive policies in select countries; however, the depth of research on outcomes and quality of care is abysmal. Stem cell therapy promise treatments that are often not well researched and offer minimal evidence of efficacy, yet patients are drawn to treatment through anecdotal advertisements and a last sense of hope. Transplant surgery sought to decrease wait times carries many of the similar aforementioned risks and may contribute to the practice of organ trafficking in countries with high rates of poverty. Patients and countries alike are motivated by a plethora of factors to engage in the MT industry but may be doing so without accurate knowledge of the quality, safety or potential for economic gain. Safety is of utmost importance to prevent surgical complications and the spread of treatment-resistant bacteria. Conclusions MT is growing in popularity and complexity. The lack of standardization in its definition and regulation leads to difficulty in epidemiologic and economic analysis and ethical issues of informed consent and health equity. The findings of this review may be used by the stakeholders of MT, including patients and providers, to enhance informed decision-making and quality of care.

ABSTRACT Natural killer (NK) cells eliminate abnormal cells through the release of cytolytic granule contents. In this process, NK cells must adhere to target cells through integrin-mediated adhesion, which is highly dependent on the generation of F-actin. Ena/VASP-like (EVL) is an actin regulatory protein previously shown to regulate integrin-mediated adhesion in other cell types, but its role in NK cell biology is not known. Herein, we show that EVL is recruited to the NK cell cytotoxic synapse and is required for NK cell cytotoxicity. Significantly, EVL is involved in the generation of F-actin at the cytotoxic synapse, antibody-stimulated spreading, and NK cell-target cell adhesion. EVL interacts with WASP (also known as WAS) and VASP and is required for localization of both proteins to the synapse. Recruitment of EVL to points of cellular activation occurs through the receptor NKG2D–DAP10 (also known as KLRK1 and HCST, respectively) via a binding site previously implicated in VAV1 and Grb2 recruitment. Taken together, this study implicates DAP10-mediated Grb2 and VAV1 signaling in the recruitment of an EVL-containing actin regulatory complex to the cytotoxic synapse where it can promote F-actin nucleation leading to NK cell-mediated killing.

PURPOSE: To describe the frequency, content, dynamics, and patterns of cost conversations in academic medical oncology across tumor types. PATIENTS AND METHODS: We reviewed 529 audio recordings between May 3, 2012, to September 23, 2014, from a prospective three-site communication study in which patients at any stage of management for any solid tumor malignancy were seen in routine oncology appointments. Recordings were deidentified, transcribed, and flagged for any mention of cost. We coded encounters and used qualitative thematic analysis. RESULTS: Financial issues were discussed in 151 (28%) of 529 recordings. Conversations lasted shorter than 2 minutes on average. Patients/caregivers raised a majority of discussions (106 of 151), and 40% of cost concerns raised by patients/caregivers were not verbally acknowledged by clinicians. Social service referrals were made only six times. Themes from content analysis were related to insurance eligibility/process, work insecurity, cost of drugs, cost used as tool to influence medical decision making, health care–specific costs, and basic needs. Financial concerns influenced oncology work processes via test or medication coverage denials, creating paperwork for clinicians, potentially influencing patient involvement in trials, and leading to medication self-rationing or similar behaviors. Typically, financial concerns were associated with negative emotions. CONCLUSION: Financial issues were raised in approximately one in four academic oncology visits. These brief conversations were usually initiated by patients/caregivers, went frequently unaddressed by clinicians, and seemed to influence medical decision making and work processes and contribute to distress. Themes identified shed light on the kinds of gaps that must be addressed to help patients with cancer cope with the rising cost of care.

Introduction: The ability to treat more advanced laryngeal cancers by transoral approaches has expanded significantly in the past several decades. Transoral management of laryngeal cancers that require removal of the laryngeal framework is controversial. Resecting cartilage through endoscopic means carries inherent technical challenges and the question of oncologic safety. Methods: We describe a retrospective review of patients undergoing resection of the thyroid cartilage during transoral laser microsurgery (TLM) for laryngeal cancer over a 10-year period. Only patients with 5-year follow-up were included. Results: Fourteen patients were identified that underwent attempted endoscopic resection of the thyroid cartilage. Preoperative staging ranged from T1 to T4 laryngeal cancers. Most patients underwent resection of the thyroid cartilage either for close proximity of the tumor to cartilage or microscopic involvement of the inner perichondrium, although 6 patients had gross invasion of the cartilage. Twelve patients underwent successful endoscopic clearance. Two patients were converted to total laryngectomy either at the time of surgery or shortly after due to extent of disease that was deemed not amenable to endoscopic resection. Overall 5-year survival was 71%. Disease-free survival was 62% at 5 years. The majority of patients avoided gastrostomy and tracheostomy tube dependence. One patient underwent total laryngectomy following initial TLM for chronic aspiration. Conclusion: We conclude that TLM for laryngeal cancer performed with removal of thyroid cartilage is feasible. Both oncologic and functional outcomes are reasonable in a select group of patients. This paper describes that cartilage can be resected endoscopically in the appropriate setting and not necessarily that cartilage invasion should routinely be treated with TLM.

Objective: To remove barriers and improve access for patients seeking cochlear implantation. Study Design: Prospective quality improvement study at a large tertiary academic care center. Methods: A Kaizen quality improvement model was applied over the course of a year. Four weeklong meetings were used to identify areas for improvement and remediation. Data were collected at baseline, 90-days, and 1-year postcompletion of the project. Outcome measures included lead times, defined as the wait time between first contact with the clinic and the first appointment, and the wait time between surgery and activation, and cycle times defined as the total test time needed to determine cochlear implant candidacy, and total time needed to complete initial activation. The total inventory kept as clinic stock was also calculated Results: Kaizen team members collected data for each outcome measure. After the Kaizen principles were applied, the following outcomes were observed: median lead times between first contact with the clinic to candidacy testing, candidacy testing to surgery, and surgery to activation of the implant remained stable from baseline to 1-year follow-up. Median cycle time for candidacy testing decreased from 7.3 hours at baseline to 3.0 hours at 1-year follow-up. Cycle times for initial activation of the device did not change over time. The total inventory of clinic stock was reduced by 31%. Conclusions: Though outcomes for lead and cycle times varied, implementation of Kaizen principles was found to be an effective method for completing this quality improvement project at a large cochlear implant program overall. Level of Evidence: 3a

Abstract Background Little is known about how complementary and alternative medicine (CAM) is discussed in cancer care across varied settings in the U.S. Methods In two practices affiliated with one academic medical center in southern California (SoCal), and one in the upper Midwest (UM), we audio-recorded patient-clinician interactions in medical oncology outpatient practices. We counted the frequency and duration of CAM-related conversations. We coded recordings using the Roter Interaction Analysis System. We used chi-square tests for bivariate analysis of categorical variables and generalized linear models for continuous variables to examine associations between dialogue characteristics, practice setting, and population characteristics with the occurrence of CAM discussion in each setting followed by multivariate models adjusting for clinician clustering. Results Sixty-one clinicians and 529 patients participated. Sixty-two of 529 (12%) interactions included CAM discussions, with significantly more observed in the SoCal university practice than in the other settings. Visits that included CAM were on average 6 minutes longer, with CAM content lasting an average of 78 seconds. In bivariate tests of association, conversations containing CAM included more psychosocial statements from both clinicians and patients, higher patient-centeredness, more positive patient and clinician affect, and greater patient engagement. In a multivariable model including significant bivariate terms, conversations containing CAM were independently associated with higher patient-centeredness, slightly longer visits, and being at the SoCal university site. Conclusion The frequency of CAM-related discussion in oncology varied substantially across sites. Visits that included CAM discussion were longer and more patient centered. Implications for Practice The Institute of Medicine and the American Society of Clinical Oncology have called for more open discussions of complementary and alternative medicine (CAM). But little is known about the role population characteristics and care contexts may play in the frequency and nature of those discussions. The present data characterizing actual conversations in practice complements a much larger literature based on patient and clinician self-report about CAM disclosure and use. It was found that CAM discussions in academic oncology visits varied significantly by practice context, that the majority were initiated by the patient, and that they may occur more when visit time exists for lifestyle, self-care, and psychosocial concerns.