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1.
BMC Health Serv Res ; 24(1): 772, 2024 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-38951799

RESUMO

BACKGROUND: Alcohol-related mortality and morbidity increased during the COVID-19 pandemic in England, with people from lower-socioeconomic groups disproportionately affected. The North East and North Cumbria (NENC) region has high levels of deprivation and the highest rates of alcohol-related harm in England. Consequently, there is an urgent need for the implementation of evidence-based preventative approaches such as identifying people at risk of alcohol harm and providing them with appropriate support. Non-alcohol specialist secondary care clinicians could play a key role in delivering these interventions, but current implementation remains limited. In this study we aimed to explore current practices and challenges around identifying, supporting, and signposting patients with Alcohol Use Disorder (AUD) in secondary care hospitals in the NENC through the accounts of staff in the post COVID-19 context. METHODS: Semi-structured qualitative interviews were conducted with 30 non-alcohol specialist staff (10 doctors, 20 nurses) in eight secondary care hospitals across the NENC between June and October 2021. Data were analysed inductively and deductively to identify key codes and themes, with Normalisation Process Theory (NPT) then used to structure the findings. RESULTS: Findings were grouped using the NPT domains 'implementation contexts' and 'implementation mechanisms'. The following implementation contexts were identified as key factors limiting the implementation of alcohol prevention work: poverty which has been exacerbated by COVID-19 and the prioritisation of acute presentations (negotiating capacity); structural stigma (strategic intentions); and relational stigma (reframing organisational logics). Implementation mechanisms identified as barriers were: workforce knowledge and skills (cognitive participation); the perception that other departments and roles were better placed to deliver this preventative work than their own (collective action); and the perceived futility and negative feedback cycle (reflexive monitoring). CONCLUSIONS: COVID-19, has generated additional challenges to identifying, supporting, and signposting patients with AUD in secondary care hospitals in the NENC. Our interpretation suggests that implementation contexts, in particular structural stigma and growing economic disparity, are the greatest barriers to implementation of evidence-based care in this area. Thus, while some implementation mechanisms can be addressed at a local policy and practice level via improved training and support, system-wide action is needed to enable sustained delivery of preventative alcohol work in these settings.


Assuntos
Alcoolismo , COVID-19 , Pesquisa Qualitativa , Atenção Secundária à Saúde , Humanos , COVID-19/epidemiologia , COVID-19/prevenção & controle , COVID-19/psicologia , Inglaterra/epidemiologia , SARS-CoV-2 , Feminino , Masculino , Pandemias/prevenção & controle , Adulto , Entrevistas como Assunto
2.
Immunol Cell Biol ; 2024 Jul 07.
Artigo em Inglês | MEDLINE | ID: mdl-38973226

RESUMO

In this article, we discuss new insights into the distinct mechanisms for V(D)J recombination for different immunoglobulin loci. This follows the recent revelation that recombination signal sequences (RSS) within the IGKV locus have evolved to be more efficient mediators of recombination activating gene (RAG) recombination compared to the same elements in the IGH locus. This difference in RSS strength is proposed to be driven by different molecular mechanisms for RAG-mediated recombination between the two loci.

4.
Ann Surg Oncol ; 2024 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-38987370

RESUMO

INTRODUCTION: Extreme oncoplastic breast-conserving surgery (eOBCS) describes the application of OBCS to patients who would otherwise need a mastectomy, and its safety has been previously described. OBJECTIVE: We aimed to compare the costs of eOBCS and mastectomy. METHODS: We reviewed our institutional database to identify breast cancer patients treated surgically from 2018 to 2023. We included patients with a large disease span (≥5 cm) and multifocal/multicentric disease. Patients were grouped by their surgical approach, i.e. eOBCS or mastectomy. The direct costs of care were determined and compared; however, indirect costs were not included. RESULTS: Eighty-six patients met the inclusion criteria, 10 (11.6%) of whom underwent mastectomy and 76 (88.4%) who underwent eOBCS. Six mastectomy patients (60%) had reconstruction and 6 (60%) underwent external beam radiation therapy (EBRT). Reconstructions were completed in a staged fashion, and the mean cost of the index operation (mastectomy and tissue expander) was $17,816. These patients had one to three subsequent surgeries to complete their reconstruction, at a mean cost of $45,904. The mean cost of EBRT was $5542. Thirty-four eOBCS patients (44.7%) underwent 44 margin re-excisions, including 6 (7.9%) who underwent mastectomy. Sixty (78.9%) of the eOBCS patients had EBRT. The mean cost of their index operation was $6345; the mean cost of a re-excision was $3615; the mean cost of their mastectomies with reconstruction was $49,400; and the mean cost of EBRT was $6807. The cost of care for eOBCS patients remained lower than that for mastectomy patients, i.e. $17,318 versus $57,416. CONCLUSION: eOBCS is associated with a lower cost than mastectomy and had a low conversion rate to mastectomy.

5.
Immunity ; 57(5): 1037-1055.e6, 2024 May 14.
Artigo em Inglês | MEDLINE | ID: mdl-38593796

RESUMO

Memory B cells (MBCs) are key providers of long-lived immunity against infectious disease, yet in chronic viral infection, they do not produce effective protection. How chronic viral infection disrupts MBC development and whether such changes are reversible remain unknown. Through single-cell (sc)ATAC-seq and scRNA-seq during acute versus chronic lymphocytic choriomeningitis viral infection, we identified a memory subset enriched for interferon (IFN)-stimulated genes (ISGs) during chronic infection that was distinct from the T-bet+ subset normally associated with chronic infection. Blockade of IFNAR-1 early in infection transformed the chromatin landscape of chronic MBCs, decreasing accessibility at ISG-inducing transcription factor binding motifs and inducing phenotypic changes in the dominating MBC subset, with a decrease in the ISG subset and an increase in CD11c+CD80+ cells. However, timing was critical, with MBCs resistant to intervention at 4 weeks post-infection. Together, our research identifies a key mechanism to instruct MBC identity during viral infection.


Assuntos
Epigênese Genética , Interferon Tipo I , Coriomeningite Linfocítica , Vírus da Coriomeningite Linfocítica , Células B de Memória , Animais , Interferon Tipo I/metabolismo , Interferon Tipo I/imunologia , Coriomeningite Linfocítica/imunologia , Coriomeningite Linfocítica/virologia , Camundongos , Vírus da Coriomeningite Linfocítica/imunologia , Células B de Memória/imunologia , Camundongos Endogâmicos C57BL , Receptor de Interferon alfa e beta/genética , Memória Imunológica/imunologia , Doença Crônica , Subpopulações de Linfócitos B/imunologia , Análise de Célula Única
6.
Nat Commun ; 15(1): 3315, 2024 Apr 17.
Artigo em Inglês | MEDLINE | ID: mdl-38632311

RESUMO

This study investigates the humoral and cellular immune responses and health-related quality of life measures in individuals with mild to moderate long COVID (LC) compared to age and gender matched recovered COVID-19 controls (MC) over 24 months. LC participants show elevated nucleocapsid IgG levels at 3 months, and higher neutralizing capacity up to 8 months post-infection. Increased spike-specific and nucleocapsid-specific CD4+ T cells, PD-1, and TIM-3 expression on CD4+ and CD8+ T cells were observed at 3 and 8 months, but these differences do not persist at 24 months. Some LC participants had detectable IFN-γ and IFN-ß, that was attributed to reinfection and antigen re-exposure. Single-cell RNA sequencing at the 24 month timepoint shows similar immune cell proportions and reconstitution of naïve T and B cell subsets in LC and MC. No significant differences in exhaustion scores or antigen-specific T cell clones are observed. These findings suggest resolution of immune activation in LC and return to comparable immune responses between LC and MC over time. Improvement in self-reported health-related quality of life at 24 months was also evident in the majority of LC (62%). PTX3, CRP levels and platelet count are associated with improvements in health-related quality of life.


Assuntos
COVID-19 , Síndrome de COVID-19 Pós-Aguda , Humanos , Linfócitos T CD8-Positivos , Qualidade de Vida , SARS-CoV-2 , Anticorpos Antivirais
7.
J Exp Med ; 221(5)2024 May 06.
Artigo em Inglês | MEDLINE | ID: mdl-38557723

RESUMO

CD4+ T cells are vital for host defense and immune regulation. However, the fundamental role of CD4 itself remains enigmatic. We report seven patients aged 5-61 years from five families of four ancestries with autosomal recessive CD4 deficiency and a range of infections, including recalcitrant warts and Whipple's disease. All patients are homozygous for rare deleterious CD4 variants impacting expression of the canonical CD4 isoform. A shorter expressed isoform that interacts with LCK, but not HLA class II, is affected by only one variant. All patients lack CD4+ T cells and have increased numbers of TCRαß+CD4-CD8- T cells, which phenotypically and transcriptionally resemble conventional Th cells. Finally, patient CD4-CD8- αß T cells exhibit intact responses to HLA class II-restricted antigens and promote B cell differentiation in vitro. Thus, compensatory development of Th cells enables patients with inherited CD4 deficiency to acquire effective cellular and humoral immunity against an unexpectedly large range of pathogens. Nevertheless, CD4 is indispensable for protective immunity against at least human papillomaviruses and Trophyrema whipplei.


Assuntos
Linfócitos T CD4-Positivos , Linfócitos T Auxiliares-Indutores , Humanos , Linfócitos T CD8-Positivos , Ativação Linfocitária , Antígenos HLA , Isoformas de Proteínas/metabolismo
8.
Dis Model Mech ; 17(6)2024 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-38415925

RESUMO

Cholangiocarcinoma (CCA) is a deadly and heterogeneous type of cancer characterized by a spectrum of epidemiologic associations as well as genetic and epigenetic alterations. We seek to understand how these features inter-relate in the earliest phase of cancer development and through the course of disease progression. For this, we studied murine models of liver injury integrating the most commonly occurring gene mutations of CCA - including Kras, Tp53, Arid1a and Smad4 - as well as murine hepatobiliary cancer models and derived primary cell lines based on these mutations. Among commonly mutated genes in CCA, we found that Smad4 functions uniquely to restrict reactive cholangiocyte expansion to liver injury through restraint of the proliferative response. Inactivation of Smad4 accelerates carcinogenesis, provoking pre-neoplastic biliary lesions and CCA development in an injury setting. Expression analyses of Smad4-perturbed reactive cholangiocytes and CCA lines demonstrated shared enriched pathways, including cell-cycle regulation, MYC signaling and oxidative phosphorylation, suggesting that Smad4 may act via these mechanisms to regulate cholangiocyte proliferation and progression to CCA. Overall, we showed that TGFß/SMAD4 signaling serves as a critical barrier restraining cholangiocyte expansion and malignant transformation in states of biliary injury.


Assuntos
Neoplasias dos Ductos Biliares , Proteínas Proto-Oncogênicas c-myc , Animais , Camundongos , Transdução de Sinais , Carcinogênese/genética , Proliferação de Células , Ductos Biliares Intra-Hepáticos
9.
J Clin Immunol ; 44(3): 66, 2024 02 16.
Artigo em Inglês | MEDLINE | ID: mdl-38363477

RESUMO

B cells and their secreted antibodies are fundamental for host-defense against pathogens. The generation of high-affinity class switched antibodies results from both somatic hypermutation (SHM) of the immunoglobulin (Ig) variable region genes of the B-cell receptor and class switch recombination (CSR) which alters the Ig heavy chain constant region. Both of these processes are initiated by the enzyme activation-induced cytidine deaminase (AID), encoded by AICDA. Deleterious variants in AICDA are causal of hyper-IgM syndrome type 2 (HIGM2), a B-cell intrinsic primary immunodeficiency characterised by recurrent infections and low serum IgG and IgA levels. Biallelic variants affecting exons 2, 3 or 4 of AICDA have been identified that impair both CSR and SHM in patients with autosomal recessive HIGM2. Interestingly, B cells from patients with autosomal dominant HIGM2, caused by heterozygous variants (V186X, R190X) located in AICDA exon 5 encoding the nuclear export signal (NES) domain, show abolished CSR but variable SHM. We herein report the immunological and functional phenotype of two related patients presenting with common variable immunodeficiency who were found to have a novel heterozygous variant in AICDA (L189X). This variant led to a truncated AID protein lacking the last 10 amino acids of the NES at the C-terminal domain. Interestingly, patients' B cells carrying the L189X variant exhibited not only greatly impaired CSR but also SHM in vivo, as well as CSR and production of IgG and IgA in vitro. Our findings demonstrate that the NES domain of AID can be essential for SHM, as well as for CSR, thereby refining the correlation between AICDA genotype and SHM phenotype as well as broadening our understanding of the pathophysiology of HIGM disorders.


Assuntos
Citidina Desaminase , Síndrome de Imunodeficiência com Hiper-IgM , Switching de Imunoglobulina , Humanos , Citidina Desaminase/genética , Citidina Desaminase/metabolismo , Síndrome de Imunodeficiência com Hiper-IgM/genética , Imunoglobulina A/genética , Switching de Imunoglobulina/genética , Imunoglobulina G/genética , Fenótipo , Hipermutação Somática de Imunoglobulina
10.
JAMA Netw Open ; 7(2): e2354751, 2024 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-38319662

RESUMO

Importance: While smoking is associated with a decreased incidence of cutaneous melanoma, the association of smoking with melanoma progression and death is not well defined. Objective: To determine the association of smoking with survival in patients with early-stage primary cutaneous melanoma. Design, Setting, and Participants: This cohort study performed a post hoc analysis of data derived from the randomized, multinational first and second Multicenter Selective Lymphadenectomy Trials (MSLT-I and MSLT-II). Participants were accrued for MSLT-I from January 20, 1994, to March 29, 2002; MSLT-II, from December 21, 2004, to March 31, 2014. Median follow-up was 110.0 (IQR, 53.4-120.0) months for MSLT-I and 67.6 (IQR, 25.8-110.2) months for MSLT-II. Patients aged 18 to 75 years with clinical stages I or II melanoma with a Breslow thickness of 1.00 mm or greater or Clark level IV to V and available standard prognostic and smoking data were included. Analyses were performed from October 4, 2022, to March 31, 2023. Exposure: Current, former, and never smoking. Main Outcomes and Measures: Melanoma-specific survival of patients with current, former, and never smoking status was assessed for the entire cohort and for nodal observation and among subgroups with sentinel lymph node biopsy (SLNB)-negative and SLNB-positive findings. Results: Of 6279 included patients, 3635 (57.9%) were men, and mean (SD) age was 52.7 (13.4) years. The most common tumor location was an extremity (2743 [43.7%]), and mean (SD) Breslow thickness was 2.44 (2.06) mm. Smoking status included 1077 (17.2%) current, 1694 (27.0%) former, and 3508 (55.9%) never. Median follow-up was 78.4 (IQR, 30.5-119.6) months. Current smoking was associated with male sex, younger age, trunk site, thicker tumors, tumor ulceration, and SLNB positivity. Current smoking was associated with a greater risk of melanoma-associated death by multivariable analysis for the entire study (hazard ratio [HR], 1.48 [95% CI, 1.26-1.75]; P < .001). Former smoking was not. The increased risk of melanoma-specific mortality associated with current smoking was greatest for patients with SLNB-negative melanoma (HR, 1.85 [95% CI, 1.35-2.52]; P < .001), but also present for patients with SLNB-positive melanoma (HR, 1.29 [95% CI, 1.04-1.59]; P = .02) and nodal observation (HR, 1.68 [95% CI, 1.09-2.61]; P = .02). Smoking at least 20 cigarettes/d doubled the risk of death due to melanoma for patients with SLNB-negative disease (HR, 2.06 [95% CI, 1.36-3.13]; P < .001). Conclusions and Relevance: The findings of this cohort study suggest that patients with clinical stage I and II melanoma who smoked had a significantly increased risk of death due to melanoma. Smoking status should be assessed at time of melanoma diagnosis and may be considered a risk factor for disease progression.


Assuntos
Melanoma , Neoplasias Cutâneas , Humanos , Masculino , Feminino , Melanoma/epidemiologia , Melanoma/cirurgia , Neoplasias Cutâneas/epidemiologia , Neoplasias Cutâneas/cirurgia , Estudos de Coortes , Fumar/epidemiologia , Fumar Tabaco
11.
J Autoimmun ; 142: 103129, 2024 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-37952292

RESUMO

BACKGROUND: PR3 autoantibodies are essential to the diagnosis and monitoring of granulomatosus with polyangiitis, but to date no PR3 autoantibody sequences have been published. OBJECTIVES: To identify and characterise PR3-specific B cells from the peripheral blood of patients with PR3 autoantibodies. METHODS: Peripheral blood mononuclear cells from seven patients with PR3 autoantibodies were stained with PR3. B cells that bound PR3 underwent single cell sorting, transcriptome sequencing, and their immunoglobulin sequences expressed as antibodies and tested for PR3-specificity by ELISA. RESULTS: We identified 19 PR3-specific B cells from only one PR3-seropositive patient at a low frequency (0.0075 % of B cells) in the peripheral blood. These were polyclonal, IgG+ and enriched for IgG4, lambda pairing, IGHJ6 gene usage, CDRH3 length, IGHE and CD71 expression. They demonstrated relatively low levels of somatic hypermutation and variably reduced PR3 binding when reverted to germline. CONCLUSIONS: Identifying PR3-specific B cells in the peripheral blood is possible but challenging and those we did identify exhibited features suggesting that PR3-self reactivity may occur early in B-cell development.


Assuntos
Granulomatose com Poliangiite , Humanos , Mieloblastina , Anticorpos Anticitoplasma de Neutrófilos , Leucócitos Mononucleares/metabolismo , Autoanticorpos
13.
Addiction ; 119(2): 268-280, 2024 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-37778755

RESUMO

BACKGROUND AND AIMS: Heavy alcohol use and depression commonly co-occur. However, health and social care services rarely provide coordinated support for these conditions. Using relational autonomy, which recognizes how social and economic contexts and relational support alter people's capacity for agency, this study aimed to (1) explore how people experience formal care provision for co-occurring alcohol use and depression, (2) consider how this context could lead to adverse outcomes for individuals and (3) understand the implications of these experiences for future policy and practice. DESIGN: Semi-structured qualitative interviews underpinned by the methodology of interpretive description. SETTING: North East and North Cumbria, UK. PARTICIPANTS: Thirty-nine people (21 men and 18 women) with current or recent experience of co-occurring heavy alcohol use ([Alcohol Use Disorders Identification Test [AUDIT] score ≥ 8]) and depression ([Patient Health Questionnaire test ≥ 5] screening tools to give an indication of their current levels of alcohol use and mental score). MEASUREMENTS: Semi-structured interview guide supported in-depth exploration of the treatment and care people had sought and received for heavy alcohol use and depression. FINDINGS: Most participants perceived depression as a key factor contributing to their heavy alcohol use. Three key themes were identified: (1) 'lack of recognition' of a relationship between alcohol use and depression and/or contexts that limit people's capacity to access help, (2) having 'nowhere to go' to access relevant treatment and care and (3) 'supporting relational autonomy' as opposed to assuming that individuals can organize their own care and recovery. Lack of access to appropriate treatment and provision that disregards individuals' differential capacity for agency may contribute to delays in help-seeking, increased distress and suicidal ideation. CONCLUSIONS: Among people with co-occurring heavy alcohol use and depression, lack of recognition of a relationship between alcohol use and depression and formal care provision that does not acknowledge people's social and economic context, including their intrinsic need for relational support, may contribute to distress and limit their capacity to get well.


Assuntos
Alcoolismo , Depressão , Masculino , Humanos , Feminino , Alcoolismo/terapia , Autonomia Relacional , Pesquisa Qualitativa , Apoio Social
14.
Ann Surg Oncol ; 31(1): 672-680, 2024 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-37938474

RESUMO

BACKGROUND: Breast cancer-related lymphedema (BCRL) remains a significant post-surgical complication of breast cancer treatment. Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) has shown promise in preventing BCRL. While the primary literature supporting ILR comes from academic institutions, the majority of breast cancer care in the USA occurs in the community setting. This study evaluated a preventative lymphedema program performing ILR at a community health system. PATIENTS AND METHODS: A prospective database including all patients who underwent ALND with concurrently attempted ILR from 2019 to 2021 was retrospectively reviewed. The historical benchmark lymphedema rate was calculated through retrospective review of electronic medical records for all patients who underwent ALND without ILR from 2011 to 2021. RESULTS: Ninety patients underwent ALND with ILR, of which ILR was successful in 69 (76.7%). ILR was more likely to be aborted in smokers (p < 0.05) and those with fewer lymphatic channels (p < 0.05) or a higher body mass index (BMI) (p = 0.08). Patients with successful versus aborted ILR had lower lymphedema rates (10.9% versus 66.7%, p < 0.01) and improved Disability of the Arm, Shoulder, and Hand (DASH) scores (8.7 versus 19.8, p = 0.25), and lower lymphedema rates than the historical benchmark (10.9% versus 50.2%, p < 0.01). Among patients with successful ILR, older patients were more likely to develop lymphedema (p < 0.05). CONCLUSIONS: Successful ILR after ALND significantly reduced the lymphedema rate when compared with patients with aborted ILR and our institution's historical benchmark. Our experience supports the efficacy of ILR and highlights the feasibility of ILR within a community health system.


Assuntos
Linfedema Relacionado a Câncer de Mama , Neoplasias da Mama , Linfedema , Humanos , Feminino , Estudos Retrospectivos , Axila/patologia , Planejamento em Saúde Comunitária , Estudos de Viabilidade , Excisão de Linfonodo/efeitos adversos , Neoplasias da Mama/patologia , Linfedema Relacionado a Câncer de Mama/etiologia , Linfedema/etiologia , Linfedema/prevenção & controle , Linfedema/patologia , Biópsia de Linfonodo Sentinela/efeitos adversos
15.
Future Healthc J ; 10(1): 63-68, 2023 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-37786489

RESUMO

Aim: To synthesise research on the view of the public and patients of the use of artificial intelligence (AI) in radiology investigations. Methods: A literature review of narrative synthesis of qualitative and quantitative studies that reported views of the public and patients toward the use of AI in radiology. Results: Only seven studies related to patient and public views were retrieved, suggesting that this is an underexplored area of research. Two broad themes, of confidence in the capabilities of AI, and the accountability and transparency of AI, were identified. Conclusions: Both optimism and concerns were expressed by participants. Transparency in the implementation of AI, scientific validation, clear regulation and accountability were expected. Combined human and AI interpretation of imaging was strongly favoured over AI acting autonomously. The review highlights the limited engagement of the public in the adoption of AI in a radiology setting. Successful implementation of AI in this field will require demonstrating not only adequate accuracy of the technology, but also its acceptance by patients.

16.
Disabil Rehabil ; : 1-18, 2023 Oct 31.
Artigo em Inglês | MEDLINE | ID: mdl-37905706

RESUMO

Objectives: 1. To identify validated quantitative Patient Reported Experience Measures (PREM's) being used in Community Rehabilitation and/or Support services for people with long term neurological conditions (PwLTNC). 2. To explore how data from quantitative PREM's adds to research on patient experiences of Community Rehabilitation and Support for PwLTNC.Method: Eight data bases were searched for peer reviewed studies (2005-2021) which met inclusion criteria. Data extraction and quality assessment for sixteen studies was performed by two reviewers. Narrative synthesis was conducted.Results: Eleven validated PREM's were identified which captured data for 15,831 PwLTNC. PREM scores indicated positive and negative experiences for people with Multiple Sclerosis (n = 13,123), Parkinson's Disease (n = 2215) and Acquired Brain Injury (n = 493). Negative experiences related to Picker Institute Principles: 1 (accessibility); 3 (coordination/continuity); 4 (involvement/support for family and carers); 5 (information provision), 6 (Involvement in decision making) and 7 (empathy and emotional support).Conclusion: Quantitative PREM's provide evidence of process quality and person-centred care within community rehabilitation and support services across large data sets of heterogeneous neurological conditions and geographical locations. Quality improvement initiatives for people with MS, PD and ABI should target processes relating to Picker Institute Principles 1,3,4,5,6, and 7.Implications for RehabilitationQuantitative validated Patient Reported Experience Measures can be used to evaluate process quality and person- centred care within community rehabilitation and support services for people with long term neurological conditions.Experiences of people with Multiple Sclerosis, Parkinson's Disease and Acquired Brain Injury indicate the need for quality improvement in community rehabilitation.Training in communication skills and person-centred care may enhance information provision and support for self-management for people with long term neurological conditions.

18.
Ann Surg Oncol ; 30(10): 6135-6139, 2023 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-37537484

RESUMO

INTRODUCTION: In the era of oncoplastic breast conserving-surgery (OBCS), cosmetic outcomes and the desire for symmetry have become essential elements of the surgical management of breast cancer (BC). The timing of contralateral symmetry procedures remains a controversial topic. Simultaneous symmetry procedures (SSP) in OBCS have not been routinely offered due to the perceived risk of delayed asymmetry, potentially increasing the need for delayed cosmetic revision. This study evaluates the rate of revision after SSP in patients undergoing OBCS. METHODS: We reviewed our institutional prospectively maintained database identifying all BC patients treated surgically since our introduction of oncoplastic surgery in 2018. We routinely offer SSP when appropriate. Descriptive statistics evaluated oncoplastic surgical techniques, SSP offerings and procedures, perioperative complications, and revision rates after treatment completion. RESULTS: Between 2018 and 2022, 485 breast cancer patients underwent partial mastectomy, and 396 (82%) underwent OBCS. Of the 313 patients offered SSP, 272 (87%) accepted. The margin reexcision rate of this cohort was 20%. Of the 272 patients with SSP, 152 (56%) underwent intraoperative radiation therapy (IORT), and 105 (39%) had adjuvant external beam radiation therapy. Three patients (1%) experienced complications involving the symmetry side. No patients with complications experienced a delay in adjuvant therapies or requested cosmetic revisions. Three patients (1%) desired surgical revisions due to asymmetry. CONCLUSIONS: Symmetry procedures at the time of OBCS are widely accepted by patients and rarely require delayed cosmetic revision. Simultaneous symmetry procedures should be routinely discussed with patients during the surgical planning of OBCS.


Assuntos
Neoplasias da Mama , Mamoplastia , Feminino , Humanos , Neoplasias da Mama/cirurgia , Terapia Combinada , Mamoplastia/métodos , Mastectomia/métodos , Mastectomia Segmentar/métodos , Estudos Retrospectivos
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