Zachary Predmore

Breast implant-associated anaplastic large cell lymphoma: a systematic review.

Background: There is substantial evidence that a type of anaplastic large cell lymphoma (ALCL) is associated with breast implants. However, the course in patients with breast implants seems to be unusually benign compared with other systemic ALCL. The purpose of this study was to identify and analyze recently published cases of breast implant–associated ALCL, with an emphasis on diagnosis, staging, treatment, and outcomes. Methods: The authors conducted a systematic literature review of reported cases of ALCL in patients with breast implants. Publications were identified with a search algorithm and forward searches. Case-based data were abstracted independently and reconciled by multiple investigators. Results: Of 248 identified articles, only 102 were relevant to breast implant–associated ALCL, and 27 were included in this study. Fifty-four cases of ALCL in patients with breast implants were identified. Detailed clinical information was lacking in many cases. Most presented with a seroma (76 percent), and approximately half were associated with the capsule (48 percent). Most presented as stage IE (61 percent). All but one case were ALK-negative. Most received chemotherapy (57 percent) and radiation therapy (48 percent), and 11 percent received stem cell transplants. Approximately one-quarter recurred, and 9 percent died. Conclusions: Since the publication of guidance related to breast implant–associated ALCL in 2010, a number of cases have been reported. Despite the typically benign course, many of the cases have been treated with radiation therapy and/or chemotherapy. Increasing awareness of this disease entity among clinicians would be helpful, along with standardizing an approach to diagnosis, staging, and treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, V.

Breast Implant-associated Anaplastic Large Cell Lymphoma: Updated Results from a Structured Expert Consultation Process.

Background: Despite increased cases published on breast implant–associated anaplastic large cell lymphoma (BIA-ALCL), important clinical issues remain unanswered. We conducted a second structured expert consultation process to rate statements related to the diagnosis, management, and surveillance of this disease, based on their interpretation of published evidence. Methods: A multidisciplinary panel of 12 experts was selected based on nominations from national specialty societies, academic department heads, and recognized researchers in the United States. Results: Panelists agreed that (1) this disease should be called “BIA-ALCL”; (2) late seromas occurring >1 year after breast implantation should be evaluated via ultrasound, and if a seroma is present, the fluid should be aspirated and sent for culture, cytology, flow cytometry, and cell block to an experienced hematopathologist; (3) surgical removal of the affected implant and capsule (as completely as possible) should occur, which is sufficient to eradicate capsule-confined BIA-ALCL; (4) surveillance should consist of clinical follow-up at least every 6 months for at least 5 years and breast ultrasound yearly for at least 2 years; and (5) BIA-ALCL is generally a biologically indolent disease with a good prognosis, unless it extends beyond the capsule and/or presents as a mass. They firmly disagreed with statements that chemotherapy and radiation therapy should be given to all patients with BIA-ALCL. Conclusions: Our assessment yielded consistent results on a number of key, incompletely addressed issues regarding BIA-ALCL, but additional research is needed to support these statement ratings and enhance our understanding of the biology, treatment, and outcomes associated with this disease.

Anesthesia Service Use During Outpatient Gastroenterology Procedures Continued to Increase From 2010 to 2013 and Potentially Discretionary Spending Remained High

OBJECTIVES:Previous studies have identified an increasing number of gastroenterology (GI) procedures using anesthesia services to provide sedation, with a majority of these services delivered to low-risk patients. The aim of this study was to update these trends with the most recent years of data.METHODS:We used Medicare and commercial claims data from 2010 to 2013 to identify GI procedures and anesthesia services based on CPT codes, which were linked together using patient identifiers and dates of service. We defined low-risk patients as those who were classified as ASA (American Society of Anesthesiologists) physical status class I or II. For those patients without an ASA class listed on the claim, we used a prediction algorithm to impute an ASA physical status.RESULTS:Over 6.6 million patients in our sample had a GI procedure between 2010 and 2013. GI procedures involving anesthesia service accounted for 33.7% in 2010 and 47.6% in 2013 in Medicare patients, and 38.3% in 2010 and 53.0% in 2013 in commercially insured patients. Overall, as more patients used anesthesia services, total anesthesia service use in low-risk patients increased 14%, from 27,191 to 33,181 per million Medicare enrollees. Similarly, we observed a nearly identical uptick in commercially insured patients from 15,871 to 22,247 per million, an increase of almost 15%. During 2010–2013, spending associated with anesthesia services in low-risk patients increased from US

Upcoding and Anesthesia Risk in Outpatient Gastrointestinal Endoscopy Procedures

3.14 million to US

Medicare Coverage of Anesthesia Services During Screening Colonoscopies for Patients at Low Risk of Sedation-Related Complications.

3.45 million per million Medicare enrollees and from US

Suicide Risk among Women Veterans in Distress: Perspectives of Responders on the Veterans Crisis Line

7.69 million to US

Improving Antipsychotic Adherence Among Patients With Schizophrenia: Savings for States

10.66 million per million commercially insured patients.CONCLUSIONS:During 2010 to 2013, anesthesia service use in GI procedures continued to increase and the proportion of these services rendered for low-risk patients remained high.

Potential Benefits to Patients and Payers From Increased Measurement of Antipsychotic Plasma Levels in the Management of Schizophrenia

have been safely provided in primary care settings, but it is unknown if these individuals had timely access to primary care services. Nevertheless, the findings by Hsia and colleagues3 suggest that there is some uncertainty during ED triage assessment of visit urgency and policies that are based on this assessment must take this uncertainty into account or risk unfairly, and inappropriately, imposing cost-sharing penalties.

Mental Health Service Preferences and Utilization Among Women Veterans in Crisis: Perspectives of Veterans Crisis Line Responders

Medicare Coverage of Anesthesia Services During Screening Colonoscopies for Patients at Low Risk of Sedation-Related Complications In 2014, the Centers for Medicare & Medicaid Services waived patient cost sharing for anesthesia services during screening colonoscopies.1 The current professional guidelines recommend that sedation be provided by the gastroenterologist-nurse team; a separate anesthesiologist or nurseanesthetist should be involved and paid separately only for patients with an increased risk of sedationrelated complications.2 The stated rationale is that the provision of anesthesia has become standard practice for colonoscopies and that eliminating cost sharing may increase the rates of these examinations. We examined the costs and potential benefit of the Medicare rule change.

Factors Associated With the Overuse of Colorectal Cancer Screening: A Systematic Review

BACKGROUND Women veterans are at increasingly high risk of suicide, but little is known about the concerns and needs of this population. This is, in part, owing to the low base rate of suicide and the inability to conduct retrospective interviews with individuals who died. In this study, we used a qualitative approach to gain insight about the concerns and nature of comments regarding suicidal ideation and intent among women veterans calling the Veterans Crisis Line (VCL). METHODS Fifty-four VCL call responders were interviewed in the spring of 2015. They were asked about the concerns and level of suicide risk of women veteran callers with whom they have spoken and about the ways in which women callers are similar to or different from men callers. Interviews were transcribed and thematic analyses were conducted to examine patterns or themes emerging from the data. FINDINGS Military sexual trauma and non-suicidal self-harm were two commonly reported concerns of women veteran callers according to responders. VCL responders also noted differences between men and women veteran callers, including differences in clinical presentation, suicidal means, and protective factors. CONCLUSIONS Our findings shed light on potential avenues to prevent suicide among women veterans, although we spoke to VCL responders about their impressions, rather than to women veterans themselves. Efforts to 1) prevent and treat the consequences of military sexual trauma, 2) recognize, prevent, and treat non-suicidal self-harm, and 3) restrict access to lethal means most commonly reported among women veteran callers may be helpful to mitigate suicide risk in this vulnerable group of veterans.