Asian American, Native Hawaiian, and Pacific Islander (AANHPI) patient populations are often defined as one monolithic group in medical research despite cultural, socioeconomic, and clinical ...heterogeneity. Although the general AANHPI population is underrepresented in reception of postmastectomy breast reconstruction, existing literature has not characterized the disaggregation of such rates for AANHPI ethnic subgroups.
Patients who underwent mastectomy were identified in the 2007 to 2020 registries within the Surveillance, Epidemiology and End Results database. Patients were stratified by race and ethnicity, and additional demographic and oncologic variables were collected. Multivariate binary logistic regression was conducted to assess for reception of postmastectomy immediate breast reconstruction (p < 0.05).
Among 33,422 AANHPI patients who underwent mastectomy, South Asian patients were associated with the highest breast reconstruction rates (33%) and Melanesians with the lowest (15%). Overall, AANHPI patients were associated with a lower breast reconstruction rate than non-Hispanic Whites (27% vs. 35%; p < 0.001). This difference increased from 6.4% in 2007 to 10% in 2020. After controlling for demographic and oncologic covariates, all AANHPI ethnic subgroups predicted a lower likelihood of breast reconstruction than non-Hispanic Whites (p < 0.001). Odds ratios for reconstruction ranged from 0.17 95% confidence interval (95% CI), 0.11–0.27 for Melanesian patients to 0.45 (95% CI, 0.42–0.48) for South Asian patients.
Disparities in the receipt of immediate breast reconstruction exist within the AANHPI patient population in the United States. This analysis supported the need for disaggregation in plastic surgery research for improved knowledge and targeted interventions.
Asian patient populations continue to be underrepresented in both plastic surgery research and rates of breast reconstruction. Better elucidation of reconstruction in Asian women may help guide ...patient-directed counseling. This study investigates the differential effect of body mass index (BMI), a well-known risk factor, for Asian patients in outcomes after breast reconstruction.
Asian and White breast reconstruction patients were identified by CPT code in the National Surgical Quality Improvement Program. Within each cohort, BMI was converted into percentile ranks for standardized comparisons between cohorts. The effects of BMI on occurrence of complications for Asian and White patients were then quantified with multivariate logistic regression models.
The final cohort included 86,514 White patients and 4813 Asian patients, of which 9876 (11%) and 424 (8.8%) experienced at least one postoperative complication. The average BMI of White patients who experienced complications was 29.2 ± 6.3 kg/m2, a higher average than that of Asian patients, 25.6 ± 4.8 kg/m2. Higher BMI percentile was a significant predictor of increased risk of complications in White patients (OR: 1.005, 95% CI: 1.004–1.006, p < 0.001). In Asian patients, however, BMI percentile was not a significant predictor of postoperative complications (OR: 1.001, 95% CI: 0.997–1.005, p = 0.62). BMI percentile significantly predicted risk of unplanned reoperation in both cohorts (p < 0.001 and p = 0.029, respectively).
Whereas BMI is a direct predictor of complications in White populations, this effect is held more inconsistently for Asian patients. Such trends can guide more informed interpretations of BMI in current risk algorithms.
Under the Affordable Care Act, states were given the option to expand Medicaid in 2014. By the end of 2014, 32 states had opted to expand Medicaid and 19 did not. Previous quasi-experimental studies ...took advantage of this state-specific policy implementation and found increased insurance coverage in expansion compared with nonexpansion states. With longer-term data now available, we studied the effect of Medicaid expansion on changes in insurance coverage and mammography rates in expansion and nonexpansion states.
Seven states that expanded Medicaid eligibility in 2014 and 6 nonexpansion states were selected based on available data. The US Census American Community Survey was queried for insurance coverage from 2011 to 2016 and the CDC Behavioral Risk Factor Surveillance System from 2010 to 2018. Difference-in-difference linear mixed models were used to estimate and compare insurance coverage and screening mammogram rates between expansion and nonexpansion states before and after 2014.
The increase in insurance rates for all persons covered by some type of health insurance after Medicaid expansion was significantly different in expansion than nonexpansion states (p = 0.001). The increase in Medicaid coverage was significant in expansion compared with nonexpansion states (p < 0.001). A similar trend was seen in screening mammogram rates in women from low-income households in expansion vs nonexpansion states (p = 0.049).
Medicaid expansion states saw greater improvement in total insurance and Medicaid coverage, and in mammogram rates in lower-income women compared with nonexpansion states after Medicaid legislation was passed. Our study demonstrates that people do take advantage of expanded eligibility by acquiring insurance and this can improve access to preventive measures, such as screening mammography.
Axillary lymph node dissection (ALND) remains the leading cause of lymphedema nationally, and there is still no cure for the disease. The lymphatic microsurgical preventive healing approach (LYMPHA) ...is a promising option for lymphedema prophylaxis in patients undergoing ALND, but long-term outcomes of the LYMPHA are not well established.
The authors conducted a retrospective review of patients undergoing ALND at their center from November of 2012 to November of 2016 and assembled two cohorts, those who received the LYMPHA and those who did not (non-LYMPHA). Patient data were collected to evaluate lymphedema risk and long-term lymphedema incidence of each group.
Forty-five women were included in both our LYMPHA and non-LYMPHA cohorts. Mean body mass index (27.7 kg/m2 versus 29.9 kg/m2; P = 0.15) and radiation therapy rates (60.0% versus 68.9%; P = 0.51) did not differ between groups. Non-LYMPHA patients underwent complete mastectomy more frequently than LYMPHA patients (97.8% versus 77.8%; P = 0.007), but had a similar number of nodes removed during ALND (14.4 versus 15.8; P = 0.32). Median follow-up time was greater than 4 years for both LYMPHA and non-LYMPHA groups (57.0 months versus 63.0 months; P = 0.07). Overall, lymphedema incidence was 31.1% in the LYMPHA group and 33.3% in the non-LYMPHA group (P > 0.99). No significant differences in lymphedema incidences were observed between the LYMPHA and non-LYMPHA groups for patients with obesity, patients who received radiation therapy, or patients with obesity who also received radiation therapy (P > 0.05 for all subgroups).
The LYMPHA may not prevent lymphedema long-term in patients who undergo ALND. More long-term studies are needed to determine the true potential of the procedure.
Therapeutic, III.
New York State passed the Breast Cancer Provider Discussion Law in 2010, mandating discussion of insurance coverage for reconstruction and expedient plastic surgical referral, two significant factors ...found to affect reconstruction rates. This study examines the impact of this law.
A retrospective cohort study of the New York State Planning and Research Cooperative System database to examine breast reconstruction rates 3 years before and 3 years after law enactment was performed. Difference-interrupted time series models were used to compare trends in the reconstruction rates by sociodemographic factors and provider types.
The study included 32,452 patients. The number of mastectomies decreased from 6479 in 2008 to 5235 in 2013; the rate of reconstruction increased from 49 percent in 2008 to 62 percent in 2013. This rise was seen across all median income brackets, races, and age groups. When comparing before to after law enactment, the increase in risk-adjusted reconstruction rates was significantly higher for African Americans and elderly patients, but the disparity in reconstruction rates did not change for other races, different income levels, or insurance types. Reconstruction rates were also not significantly different between those treated in various hospital settings.
The aim of the Breast Cancer Provider Discussion Law is to improve reconstruction rates through provider-driven patient education. The authors' data show significant change following law passage in African American and elderly populations, suggesting effectiveness of the law. The New York State Provider Discussion Law may provide a template for other states to model legislation geared toward patient-centered improvement of health outcomes.
Many patients with unilateral breast cancer opt for contralateral prophylactic mastectomy (CPM) at the time of therapeutic mastectomy (immediate CPM) or following completion of adjuvant therapy. ...Studies show that immediate CPM increases the risk of surgical complications related to unilateral mastectomy (UM) alone, which may lead to delays in adjuvant therapy initiation. However, it is unclear if these complications cause clinically significant delays in initiating adjuvant chemotherapy, radiotherapy, or hormonal therapy.
A retrospective chart review was conducted on patients with breast cancer who underwent immediate CPM versus UM alone at Columbia University Medical Center from January 2000 to December 2020. Patient demographic and oncologic characteristics; complications; and timing of adjuvant chemotherapy, radiotherapy, and/or hormonal therapy relative to therapeutic mastectomy were collected.
In this study, 239 UM alone patients were propensity score matched to 239 immediate CPM patients. No significant difference in complication rates was found between the index and contralateral breasts in CPM patients. A similar percentage of CPM and UM patients experienced postoperative complications (19% vs. 17%, p = 0.64). No significant difference in time to adjuvant chemotherapy, radiotherapy, or hormonal therapy was found between CPM patients with complications and all CPM patients or all UM patients.
There is a lack of clear guidance for clinical decision-making regarding timing of CPM relative to adjuvant therapy. Our study suggests that immediate CPM does not significantly increase the risks of postoperative complications or complication-related delays in the initiation of adjuvant chemotherapy, radiotherapy, or hormonal therapy. This information may help patients and providers to plan, select, and schedule breast cancer treatment options.
Many factors influence a patient's decision to undergo autologous versus implant-based breast reconstruction, including medical, social, and financial considerations. This study aims to investigate ...differences in out-of-pocket and total spending for patients undergoing autologous and implant-based breast reconstruction.
The IBM MarketScan Commercial Databases were queried to extract all patients who underwent inpatient autologous or implant-based breast reconstruction from 2017 to 2021. Financial variables included gross payments to the provider (facility and/or physician) and out-of-pocket costs (total of coinsurance, deductible, and copayments). Univariate regressions assessed differences between autologous and implant-based reconstruction procedures. Mixed-effects linear regression was used to analyze parametric contributions to total gross and out-of-pocket costs.
The sample identified 2079 autologous breast reconstruction and 1475 implant-based breast reconstruction episodes. Median out-of-pocket costs were significantly higher for autologous reconstruction than implant-based reconstruction ($597 vs $250, P < 0.001) as were total payments ($63,667 vs $31,472, P < 0.001). Type of insurance plan and region contributed to variable out-of-pocket costs (P < 0.001). Regression analysis revealed that autologous reconstruction contributes significantly to increasing out-of-pocket costs (B = $597, P = 0.025) and increasing total costs (B = $74,507, P = 0.006).
The US national data demonstrate that autologous breast reconstruction has higher out-of-pocket costs and higher gross payments than implant-based reconstruction. More study is needed to determine the extent to which these financial differences affect patient decision-making.
As a step towards better understanding of diversity and biology of phages and their hosts in haloalkaline Lake Elmenteita, phages were isolated from sediment samples and overlying water using ...indigenous bacteria as hosts. 17 seemingly different phages of diverse morphotypes with different dimensions and partly exhibiting remarkably unusual ultrastructures were revealed by transmission electron microscopy. 12 clonal phage isolates were further characterized. Infection capability of the phages was optimum at 30-35°C and in alkali condition with optimum at pH 10-12. Structural protein profiles and restriction fragment length polymorphism analyses patterns were distinct for each of the phage type. Complete nucleotide sequences of phages vB-VmeM-32, vB_EauS-123 and vB_BhaS-171 genomes varied in size from 30,926-199,912 bp and G + C content of between 36.25-47.73%. A range of 56-260 potential open reading frames were identified and annotated. The results showed that the 12 phages were distinct from each other and confirmed the presence and diversity of phages in extreme environment of haloalkaline Lake Elmenteita. The phages were deposited at the German Collection of Microorganisms and Cell Cultures and three of their genomes uploaded to NCBI GenBank.
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