Traditional electrosurgery and a low thermal injury dissection device yield different outcomes following bilateral skin-sparing mastectomy: a case report

<p>Abstract</p> <p>Introduction</p> <p>Although a skin- and nipple-sparing mastectomy technique offers distinct cosmetic and reconstructive advantages over traditional methods, partial skin flap and nipple necrosis remain a significant source of post-operative morbidity. Prior work has suggested that collateral thermal damage resulting from electrocautery use during skin flap development is a potential source of this complication. This report describes the case of a smoker with recurrent ductal carcinoma <it>in situ </it>(DCIS) who experienced significant unilateral skin necrosis following bilateral skin-sparing mastectomy while participating in a clinical trial examining mastectomy outcomes with two different surgical devices. This unexpected complication has implications for the choice of dissection devices in procedures requiring skin flap preservation.</p> <p>Case presentation</p> <p>The patient was a 61-year-old Caucasian woman who was a smoker with recurrent DCIS of her right breast. As part of the clinical trial, each breast was randomized to either the standard of care treatment group (a scalpel and a traditional electrosurgical device) or treatment with a novel, low thermal injury dissection device, allowing for a direct, internally controlled comparison of surgical outcomes. Post-operative follow-up at six days was unremarkable for both operative sites. At 16 days post-surgery, the patient presented with a significant wound necrosis in the mastectomy site randomized to the control study group. Following debridement and closure, this site progressively healed over 10 weeks. The contralateral mastectomy, randomized to the alternative device, healed normally.</p> <p>Conclusion</p> <p>We hypothesize that thermal damage to the subcutaneous microvasculature during flap dissection may have contributed to this complication and that the use of a low thermal injury dissection device may be advantageous in select patients undergoing skin- and nipple-sparing mastectomy.</p

Dealing with femtorisks in international relations

The contemporary global community is increasingly interdependent and confronted with systemic risks posed by the actions and interactions of actors existing beneath the level of formal institutions, often operating outside effective governance structures. Frequently, these actors are human agents, such as rogue traders or aggressive financial innovators, terrorists, groups of dissidents, or unauthorized sources of sensitive or secret information about government or private sector activities. In other instances, influential .actors. take the form of climate change, communications technologies, or socioeconomic globalization. Although these individual forces may be small relative to state governments or international institutions, or may operate on long time scales, the changes they catalyze can pose significant challenges to the analysis and practice of international relations through the operation of complex feedbacks and interactions of individual agents and interconnected systems. We call these challenges "femtorisks," and emphasize their importance for two reasons. First, in isolation, they may be inconsequential and semiautonomous; but when embedded in complex adaptive systems, characterized by individual agents able to change, learn from experience, and pursue their own agendas, the strategic interaction between actors can propel systems down paths of increasing, even global, instability. Second, because their influence stems from complex interactions at interfaces of multiple systems (e.g., social, financial, political, technological, ecological, etc.), femtorisks challenge standard approaches to risk assessment, as higher-order consequences cascade across the boundaries of socially constructed complex systems. We argue that new approaches to assessing and managing systemic risk in international relations are required, inspired by principles of evolutionary theory and development of resilient ecological systems

The Payer and Patient Cost Burden of Open Breast Conserving Procedures Following Percutaneous Breast Biopsy

Objectives: Percutaneous core-needle biopsy (PCNB) is the standard of care to biopsy and diagnose suspicious breast lesions. Dependent on histology, many patients require additional open procedures for definitive diagnosis and excision. This study estimated the payer and patient out-of-pocket (OOP) costs, and complication risk, among those requiring at least 1 open procedure following PCNB. Methods: This retrospective study used the Truven Commercial database (2009-2014). Women who underwent PCNB, with continuous insurance, and no history of cancer, chemotherapy, radiation, or breast surgery in the prior year were included. Open procedures were defined as open biopsy or lumpectomy. Study follow-up ended at chemotherapy, radiation, mastectomy, or 90 days—whichever occurred first. Results: In total, 143 771 patients (mean age 48) met selection criteria; 85.1% underwent isolated PCNB, 12.4% one open procedure, and 2.5% re-excision. Incidence of complications was significantly lower among those with PCNB alone (9.2%) vs 1 open procedure (15.6%) or re-excision (25.3%, P  < .001). Mean incremental commercial payments were US $13 190 greater among patients with 1 open procedure vs PCNB alone (US$17 125 vs US $3935, P  < .001), and US$4767 greater with re-excision (US $21 892) relative to 1 procedure. Mean patient OOP cost was US$858 greater for 1 open procedure vs PCNB alone (US $1527 vs US$669), and US $247 greater for re-excision vs 1 procedure. Conclusions: A meaningful proportion of patients underwent open procedure(s) following PCNB which was associated with increased complication risk and costs to both the payer and the patient. These results suggest a need for technologies to reduce the proportion of cases requiring open surgery and, in some cases, re-excision