Are We Cutting Enough? A Five-Year Audit of Melanoma Excision Margins in the South East of Ireland.

AIM: Malignant melanoma is the fifth commonest invasive cancer in Ireland. The British Association of Dermatology (BAD) guidelines are currently the recognized standard for melanoma related surgery. The aim was to examine adherence to BAD guidelines and establish contributing factors resulting in non-adherence to guidelines in a group of melanoma patients in the South East Region of Ireland. METHODS: A retrospective review of a prospectively maintained melanoma registry of all patients undergoing surgery in the South East Region of Ireland from January 2011 to 2016 was performed. Data were analyzed using SPSS statistical software. Univariate analysis using logistic regression was performed to examine factors associated with not meeting the BAD margin excision guidelines Data with a p < 0.05 was analyzed using a multivariate logistic regression model. RESULTS: 459 patients underwent surgery for invasive cutaneous melanoma. 314 (68.4%) surgeries had excision margins adequately recorded and of these 234(74.5%) fulfilled the BAD guidelines. 267(58.2%) patients (2011-2016 inclusive) qualified for sentinel lymph node biopsy (SNLB) with a cancer staging of pT1b or higher. Of these patients 100(37%) agreed to proceed to a SNLB following informed discussion. 33 had a positive sentinel node. On multivariate analysis inadequate margins were independently associated with tumor thickness 2.01-4.00 mm (p = 0.0001) and >4.00 mm (p = 0.0001) and head and neck location (p < 0.0001). CONCLUSIONS: Adherence to BAD guidelines in the South East is good but requires optimization since centralization of melanoma treatment in 2013 to a single specialized center. It is important that Clinicians are fully aware of the implications of not achieving adequate excision margins in surgery. Improvements in melanoma data management is needed to fully evaluate current practices in Ireland.

An analytical framework for assessing drug and therapeutics committee structure and work processes in tertiary Brazilian hospitals.

University teaching hospitals usually provide tertiary care and are subject to early adoption of new technologies, which may compromise healthcare systems when uncritically adopted. Knowledge on the decision-making process - drug selection by drug selection committees or DTCs - is crucial to improve the quality of care. There are no models for studying the selection of drugs in Brazilian healthcare services. This study aims to discuss DTC structure and the processes regarding adoption of medicines in tertiary university hospitals in Brazil and to propose an analytical structure for providing direction for the future. State of the art content regarding drug selection processes and DTC procedures was reviewed in three databases. Information on the medicine selection process in a Brazilian gold standard teaching hospital was collected through observations and a review of existing procedures. A structured discussion on medicine selection and DTC procedures in tertiary hospitals ensued. This discussion resulted in findings that were organized in three dimensions, composing an analytical framework for the application in tertiary Brazilian hospitals (i) motivations for the adoption of drugs; (ii) necessary structural and organizational aspects for decision-making; and (iii) criteria and methods employed by the decision-making process. We believe that the suggested framework is compatible with tertiary Brazilian hospitals, because a gold standard in the country was able to conduct all its procedures in the light of WHO and international recommendations. We hope to contribute in producing knowledge which may hopefully be adopted in tertiary hospitals across Brazil.

Optimal placement of syringe-exchange programs.

Syringe-exchange programs (SEPs) will likely play a major role in slowing the spread of acquired immunodeficiency syndrome (AIDS) among injecting drug users (IDUs), but the success of any single SEP will depend to a large extent on where it is located. We show how the optimal position for a new SEP can be chosen given accurate knowledge of where IDUs live and how far they are willing to travel to an SEP. This information is not normally available, and one of our major points is that SEPs will necessarily be placed in suboptimal locations and will serve fewer IDUs than they otherwise might until it becomes available. Our method for choosing the best SEP placement is illustrated with Manhattan as an idealized example.