Published Practice Guidelines Research Articles

Transection of the arterial ligament for extended mediastinal lymph node dissection by video-assisted thoracoscopic surgery: invaluable technique for the right patient

Lung cancer remains the leading cause of cancer-related deaths worldwide, with non-small cell lung cancer (NSCLC) accounting for 85% of cases (1). Five-year survival is heavily dependent upon cancer stage and follows the tumor, node, and metastasis staging model (TNM), with lymph node (LN) metastasis being an important determinant of prognosis (2). Stage I NSCLC includes tumors less than 4 cm in diameter without metastasis to LNs. Published practice guidelines recommend preoperative staging with positron emission tomography (PET) or PET-computed tomography (CT), with subsequent preoperative pathologic tissue diagnosis for mediastinal staging in centrally located tumors, tumors >3 cm, and for enlarged or PET-positive LNs (2,3). Endobronchial ultrasonography (EBUS) with fine needle aspirate is the recommended first choice where available; if unavailable or if aspirate is negative in the setting of high suspicion for involved LNs, recommendations are to proceed with cervical mediastinoscopy.

Nationwide salpingectomy rates for an indication of permanent contraception before and after published practice guidelines

ObjectiveTo identify the nationwide rate of salpingectomy for permanent contraception before and after the January 2015 American College of Obstetricians and Gynecologists (ACOG) Committee Opinion, Salpingectomy for Ovarian Cancer Prevention. Study DesignUsing ICD-9/10 diagnosis and procedure codes within the Vizient database, we identify permanent contraception procedures with and without salpingectomy, among females 18–50 years old between January 2013 and January 2017. Subject, hospital characteristics and costs information were recorded. To determine the changes in salpingectomy rates over time analysis was conducted using the Cochran-Armitage trend test and logistic regression models. ResultsA total of 211,312 women across 303 Vizient-member hospitals underwent a permanent contraception procedure over the study period. Of these, 174,930 subjects were selected from 160 hospitals that contributed data over the full 49-month period. Overall, 25,882 (14.8%) subjects underwent a salpingectomy for an indication of permanent contraception. Higher salpingectomy rates were identified among larger (p<.0001), teaching (p<.0001) hospitals versus smaller, non-teaching hospitals and in subjects with commercial/private payers (p<.0001). A lower salpingectomy rate was observed in Northeast hospitals (p<.0001). Median total hospital costs differed by $25 between permanent contraceptions performed with and without salpingectomy. The proportion of salpingectomies was <1% in January 2013 slowly rising to 20.6% in October 2015 and then 61.5% by January 2017 (p<.0001). During the pre-opinion period (Jan 2013–Dec 2014) the monthly increase in the odds of salpingectomy was 6% (OR 1.06, 95% CI 1.05, 1.06) compared to a monthly increase of 18% (OR 1.18, 95% CI 1.18, 1.18) during the post-opinion period (Jan 2015–Jan 2017). ConclusionsThe nationwide rate of salpingectomies for permanent contraception has steadily increased among Vizient-member hospitals since the ACOG committee opinion. ImplicationsSalpingectomy as an approach to permanent contraception in the United States is increasing since the ACOG Committee Opinion with differing utilization rates by hospital type, region, size, and patient payer types. Physician behavior may be influenced by practice guidelines but other factors mitigate the effect.

Reexamining the data used in the 2012 guidelines of the American Association for the Study of Liver Diseases for the management of adult patients with ascites due to cirrhosis.

Background:In 2012, the American Association for the Study of Liver Diseases published practice guidelines for the management of patients with ascites caused by cirrhosis, using data from randomized controlled trials (RCTs) and observational studies. We reexamined the strength of these RCTs by calculating the fragility index (FI), a novel metric proposed for evaluating the robustness of RCTs.Methods:We screened all RCTs referenced in the guidelines for specific criteria. We calculated the FI and fragility quotient (FQ), and analyzed the correlation between FI and several variables.Results:Twenty-one RCTs were included. The median (25th, 75th) FI and FQ were 1 (interquartile range [IQR] 0.5-6) and 0.070 (IQR 0.008-0.166), respectively. For studies that reported the number of patients lost to follow up (12 RCTs), the median of patients lost was 2 (IQR 0-6.5). There was no significant correlation between FI and sample size (rs=0.357), P-value (rs=-0.299), number lost to follow up (rs=0.355), Science Citation Index (rs=0.347), year of publication (rs=-0.085), blinding (rpb=-0.18) or number of centers (rpb=0.10). However, a significant correlation was seen between FI and number needed to treat (rs=-0.549; P=0.015).Conclusions:RCTs in the field of cirrhosis-related ascites are fragile. Of the 21 trials analyzed, 13 had an FI of 3 or below and these trials influenced 13 of the 49 recommendations in the guidelines. We recommend the incorporation of FI and FQ in addition to P-value to better understand the meaning of the results in gastroenterological studies.

The SNMMI and EANM practice guideline for renal scintigraphy in adults.

The Society of Nuclear Medicine and Molecular Imaging (SNMMI) is an international scientific and professional organization founded in 1954 to promote the science, technology, and practical application of nuclear medicine. The European Association of Nuclear Medicine (EANM) is a professional nonprofit medical association that facilitates communication worldwide between individuals pursuing clinical and research excellence in nuclear medicine. The EANM was founded in 1985. SNMMI and EANM members are physicians, technologists, and scientists specializing in the research and practice of nuclear medicine. The SNMMI and EANM will periodically define new guidelines for nuclear medicine practice to help advance the science of nuclear medicine and to improve the quality of service to patients throughout the world. Existing practice guidelines will be reviewed for revision or renewal, as appropriate, on their fifth anniversary, or sooner, if indicated. Each practice guideline, representing a policy statement by the SNMMI/EANM, has undergone a thorough consensus process in which it has been subjected to extensive review. The SNMMI and EANM recognize that the safe and effective use of diagnostic nuclear medicine imaging requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guideline by entities not providing these services is not authorized.

Current treatment concepts for iatrogenic ventriculitis: a nationwide survey in Germany.

Iatrogenic ventriculitis is a common complication of the external ventricular drainage. While the procedure and indications for external ventricular drains (EVD) are highly standardized, the treatment of ventriculitis is not clearly defined. To depict the treatment of iatrogenic ventriculitis currently performed in German hospitals. A standardized questionnaire consisting of 18 multiple choice questions, each with the ability to provide additional individual answers, covering the diagnosis and treatment of iatrogenic ventriculitis as well as general handling of EVDs, was sent to 121 neurosurgical hospitals registered in the German Society for Neurosurgery (DGNC). Thirty-three out of 121 hospitals returned the questionnaire. While diagnostics are performed similarly in most hospitals, the treatment varies remarkably. Ten of the 33 (30%) units never applied antibiotics intrathecally and 12 (36%) only in selected (1-20%) cases, while 7 (21%) do this routinely, and the remaining 4 centers vary their treatment. While the targeted systemic therapy after pathogen identification and resistance testing is similar, the choice of empiric antibiotics varies as does the type of drug used for intrathecal therapy. Among the applied systemic antibiotics, vancomycin [n=23 (70%)] and meropenem [n=22 (67%)] were the most common, but many others, including ceftriaxone, metronidazol, linezolid, piperacillin/tazobactam, fosfomycin and ceftazidim, are used. There is no standard practice regarding EVD handling. Twelve (36%) hospitals do not replace the EVD after a new diagnosis of ventriculitis, 13 (39%) do so once after the diagnosis, and 8 (24%) regularly switch EVDs after a defined time span (7-20days), even without signs of infection. Treatment concepts for iatrogenic ventriculitis are very heterogeneous. Thus, there is an urgent need for generating outcome data and defining a standard treatment algorithm with the recently published practice guideline being an important first step.

Receipt of Medication and Behavioral Therapy Among a National Sample of School-Age Children Diagnosed With Attention-Deficit/Hyperactivity Disorder

ObjectiveIn 2011, the American Academy of Pediatrics published practice guidelines for attention-deficit/hyperactivity disorder (ADHD), recommending both medication and behavioral therapy for school-age children. The current study examines associations between child/family characteristics and ADHD medication, behavioral, and combined therapy. MethodsThis study used data from the 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette syndrome, a nationally representative follow-up survey to the 2011–2012 National Survey of Children's Health. Descriptive statistics were used to estimate frequencies of ADHD treatments and multivariable logistic regression to examine child/family characteristics associated with parent-reported medication use, classroom management, and parent training for children aged 8 to 17 diagnosed with ADHD (n = 2401). ResultsBlack and Hispanic children were less likely than white children to have ever received ADHD medication. Hispanic children were less likely than white children to be currently receiving medications (adjusted odds ratio, 0.49; 95% confidence interval, 0.30–0.80). No differences were found in current medication use for black children compared to white children. Thirty-percent of parents reported that their child was currently receiving classroom management, and 31% reported having ever received parent training for ADHD. Children whose ADHD medication was managed by a primary care physician were less likely to receive combined medication and behavioral therapy compared to children managed by specialty physicians (adjusted odds ratio, 2.58; 95% confidence interval, 1.75–3.79). ConclusionsMost school-age children reported receiving medication for ADHD; however, medication disparities persist. Parent-reported use of behavioral therapies are low. Future research should examine reasons for observed variation in treatment and interventions to optimize ADHD care.

A Novel Approach to Improving Utilization of Laboratory Testing.

- The incorporation of best practice guidelines into one's institution is a challenging goal of utilization management, and the successful adoption of such guidelines depends on institutional context. Laboratorians who have access to key clinical data are well positioned to understand existing local practices and promote more appropriate laboratory testing. - To apply a novel approach to utilization management by reviewing international clinical guidelines and current institutional practices to create a reliable mechanism to improve detection and reduce unnecessary tests in our patient population. - We targeted a frequently ordered genetic test for HFE-related hereditary hemochromatosis, a disorder of low penetrance. After reviewing international practice guidelines, we evaluated 918 HFE tests and found that all patients with new diagnoses had transferrin saturation levels that were significantly higher than those of patients with nonrisk genotypes (72% versus 42%; P < .001). - Our "one-button" order that restricts HFE genetic tests to patients with transferrin saturation greater than 45% is consistent with published practice guidelines and detected 100% of new patients with HFE-related hereditary hemochromatosis. - Our proposed algorithm differs from previously published approaches in that it incorporates both clinical practice guidelines and local physician practices, yet requires no additional hands-on effort from pathologists or clinicians. This novel approach to utilization management embraces the role of pathologists as leaders in promoting high-quality patient care in local health care systems.

Management of pediatric acute gastroenteritis in the outpatient setting—Introduction of " Clinical Practice Guideline for the Treatment of Pediatric Acute Gastroenteritis in the Outpatient Setting" of Children′s National Medical Center, Washington, District of Columbia

Acute gastroenteritis is a common illness in childhood that usually can be treated in the outpatient setting.Despite suggestion that acute gastroenteritis children with mild to moderate dehydration receive oral rehydration therapy as the main treatment, but there are still many children were given unnecessary tests and intravenous fluids.Children′s National Medical Center, Washington, District of Columbia published practice guideline to clarify the basic principles of the evaluation and management of illness.The guideline for pediatric acute gastroenteritis management has not yet been released in China.As the reference for clinicians in domestic, the content of this practice guideline will be reorganized and introduced. Key words: Pediatric; Acute gastroenteritis; Clinical management; Outpatient setting

AAPM-RSS Medical Physics Practice Guideline 9.a. for SRS-SBRT.

The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education, and professional practice of medical physics. The AAPM has more than 8,000 members and is the principal organization of medical physicists in the United States.The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner.Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized.The following terms are used in the AAPM practice guidelines: Must and Must Not: Used to indicate that adherence to the recommendation is considered necessary to conform to this practice guideline.Should and Should Not: Used to indicate a prudent practice to which exceptions may occasionally be made in appropriate circumstances. Approved by AAPM Professional Council 3‐31‐2017 and Executive Committee 4‐4‐2017.

AAPM medical physics practice guideline 6.a.: Performance characteristics of radiation dose index monitoring systems.

The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education and professional practice of medical physics. The AAPM has more than 8,000 members and is the principal organization of medical physicists in the United States.The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner.Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized.The following terms are used in the AAPM practice guidelines: •Must and Must Not: Used to indicate that adherence to the recommendation is considered necessary to conform to this practice guideline. •Should and Should Not: Used to indicate a prudent practice to which exceptions may occasionally be made in appropriate circumstances.

P-132 Feasibility of Screening for Anemia Using the Crohn's and Colitis Foundation Anemia Care Pathway in IBD Qorus

Background:Anemia is a common but under-recognized complication of inflammatory bowel diseases (IBD). Anemia in IBD is associated with increased resource utilization and reduced quality of life. Despite published practice guidelines and quality measures for anemia in IBD, screening for and managemen

Major publications in the critical care pharmacotherapy literature in 2015.

Recently published practice guidelines and research reports on pharmacotherapy in critical care patient populations are summarized. The Critical Care Pharmacotherapy Literature Update (CCPLU) Group is composed of over 50 experienced critical care pharmacists who evaluate 31 peer-reviewed journals monthly to identify literature pertaining to pharmacotherapy in critical care populations. Articles are chosen for summarization in a monthly CCPLU Group publication on the basis of applicability and relevance to clinical practice and strength of study design. From January to December 2015, a total of 121 articles were summarized; of these, 3 articles presenting clinical practice guidelines and 12 articles presenting original research findings were objectively selected for inclusion in this review based on their potential to change or reinforce current evidence-based practice. The reviewed guidelines address the management of intracranial hemorrhage (ICH), adult advanced cardiac life support (ACLS) and post-cardiac arrest care, and the management of supraventricular tachycardia (SVT). The reviewed research reports address topics such as nutrition in critically ill adults, administration of β-lactams for severe sepsis, anticoagulant selection in the context of continuous renal replacement therapy, early goal-directed therapy in septic shock, magnesium use for neuroprotection in acute stroke, and progesterone use in patients with traumatic brain injury. Important recent additions to the critical care pharmacy literature include updated joint clinical practice guidelines on the management of spontaneous ICH, ACLS, and SVT.

Upper extremity sarcoma: impact of current practice guidelines and controversies on reconstructive approaches.

The goals of sarcoma management include both a cure and the functional preservation of involved tissues and adjacent critical structures with common opinions favoring immediate reconstruction. The question arises whether these goals are contradictory. This paper discusses the question based on the experience of 28 patients with different types of extremity sarcoma, with 24 surgically treated by the University of California San Diego (UCSD) orthopedic and plastic surgery team (2011–2016) and the collection of evidence from published practice guidelines, reviews, case studies, and clinical trials. Included are the impact of limb-sparing and functional reconstructive concepts, efforts regarding the adequacy of surgical margins, and the rationale of immediate versus delayed reconstructive approaches, and the disease-free status of sarcoma management.

Current Diagnostic and Treatment Strategies for Specific Dilated Cardiomyopathies: A Scientific Statement From the American Heart Association.

The intent of this American Heart Association (AHA) scientific statement is to summarize our current understanding of dilated cardiomyopathies. There is special emphasis on recent developments in diagnostic approaches and therapies for specific cardiomyopathies. Recommendations in this document are based on published studies, published practice guidelines from the American College of Cardiology (ACC)/AHA1 and other organizations,2,3 and the multidisciplinary expertise of the writing group. Existing evidence in epidemiology, classification, diagnosis, and management of specific cardiomyopathies is usually derived from nonrandomized observational studies, registries, case reports, or expert opinion based on clinical experience, not large-scale randomized clinical trials or systematic reviews. Therefore, in this document, rather than using the standard ACC/AHA classification schema of recommendations and level of evidence,4 we have included key management strategies at the end of each section and categorized our recommendations according to the level of consensus. Although the format of our recommendations might resemble the ACC/AHA classification of recommendations used in the ACC/AHA practice guidelines, because of the preponderance of expert opinion or level of evidence C evidence in our document, we elected to use different terminology to provide a distinction from the practice guidelines, in which stronger levels and quality of evidence with randomized clinical trials or meta-analyses are usually present.4 The levels of evidence follow the AHA and ACC methods of classifying the level of certainty of the treatment effect.4 The term dilated cardiomyopathy (DCM) refers to a spectrum of heterogeneous myocardial disorders that are characterized by ventricular dilation and depressed myocardial performance in the absence of hypertension, valvular, congenital, or ischemic heart disease.5 In clinical practice, the pathogenesis of heart failure (HF) has often been placed into 2 categories: ischemic and nonischemic cardiomyopathy. The term nonischemic cardiomyopathy has been interchangeably used with DCM. Although this …

Contributory Risk and Management of Comorbidities of Hypertension, Obesity, Diabetes Mellitus, Hyperlipidemia, and Metabolic Syndrome in Chronic Heart Failure: A Scientific Statement From the American Heart Association.

The comorbidities of hypertension, diabetes mellitus, obesity, hyperlipidemia, and metabolic syndrome are common in patients with heart failure (HF) and affect clinical outcomes.1–3 Interestingly, although these comorbidities are associated with the development of incident HF in the general population, in patients with established HF, their contributory roles to clinical outcomes are not predictable, and their management is quite challenging. Recent American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) guidelines have addressed the role of lifestyle modification,4 treatment of blood cholesterol,5 and management of overweight and obesity6 in the general population and in patients with increased cardiovascular risk, and a recent report from the Eighth Joint National Committee addressed the management of hypertension.7 However, these guidelines did not specifically address the management of such comorbidities in patients with HF. Similarly, the most recent ACCF/AHA HF practice guidelines8 in 2013 addressed the overall management of comorbidities in patients with HF in broad terms, but again, specific and detailed recommendations on how to manage hypertension, obesity, diabetes mellitus, hyperlipidemia, and metabolic syndrome are lacking. The intent of this AHA scientific statement is to summarize data relevant to contributory risk and to provide guidance on the management of hypertension, obesity, diabetes mellitus, hyperlipidemia, and metabolic syndrome in the development and prognosis of HF to provide recommendations (Table 1) and to foster communication between physicians and other healthcare professionals and patients on the management of these comorbidities. Recommendations in this document are based on published studies and the multidisciplinary expertise of the writing group and harmonized with published practice guidelines from the ACC/AHA4–6,8–12 and other organizations.7,13–15 View this table: Table 1. Applying Classification of Recommendations and Level of Evidence Hypertension is a worldwide epidemic; in many countries, 50% of …

Nutritional support practices in hematopoietic stem cell transplantation centers: A nationwide comparison

ObjectiveIn 2009, international nutritional societies published practice guidelines on screening and nutritional support for patients undergoing stem cell transplantation. Little is known about how these guidelines are implemented in clinical practice. We performed a nationwide survey with the aim of understanding current practice patterns, differences between clinical practice, and international recommendations as well as barriers to the use of nutritional therapy. MethodsWe performed a qualitative survey including all centers across Switzerland offering allogeneic (n = 3) or autologous (n = 7) stem cell transplantation. We focused on in-house protocols pertaining to malnutrition screening, indications for nutritional support, types of nutritional therapy available and provided, and recommendations regarding neutropenic diets. ResultsAll centers offering allogeneic, and most of the centers offering autologous transplantation, had a malnutrition screening tool, mainly the nutritional risk score (NRS 2002) method. Only one center does not provide nutritional support. There is wide variation regarding start and stop of nutritional therapy as well as route of delivery, with five centers recommending parenteral nutrition and five centers recommending enteral nutrition as a first step. Although all centers offering allogeneic transplantation, and approximately every other autologous transplant center, used a neutropenic diet, specific recommendations regarding the type of food and food handling showed significant variation. ConclusionThis Swiss survey found wide variation in the use of nutritional therapy in patients undergoing stem cell transplantation, with low adherence overall to current practice guidelines. Understanding and reducing barriers to guideline implementation in clinical practice may improve clinical outcomes. Close collaboration of centers will facilitate future research needed to improve current practice and ensure high quality of treatment.

Trends in patterns of antidepressant use in older general population between 2006 and 2012 following publication of practice guidelines.

The French regulatory agency published in 2006 practice guidelines related to the management of depressive and anxiety disorders. The main objective of the study was to assess their impact regarding use and monitoring of antidepressant drug treatment in older patients. The secondary objective was to identify factors associated with compliance with practice guidelines. A historical fixed cohort study with dynamic follow-up time was conducted in 16,144 subjects aged 65 years and over, initiating antidepressant treatment and registered in the National Health Insurance Database between 2006 and 2012. Compliance with guidelines was assessed from year to year using segmented regression analysis. Multiple logistic regressions were used to identify factors associated with compliance with guidelines. Duration of antidepressant treatment was compliant with guidelines in 13.0% of patients aged 65-74 years and 18.5% of patients aged 75 years and over. Biological monitoring was performed in 12.6% of patients aged 65-74 years and 18.5% of patients aged 75 years and over. No significant change of rate of compliance with guidelines was observed over the study period. Compliance of prescriptions with guidelines was associated with patient's age, specialty of the prescriber, presence of chronic disease, year of treatment initiation, and presence of a university hospital in the area of residence. While treatment duration and biological monitoring were often inadequate in older patients, the publication of guidelines by the French health regulatory authorities did not lead to any significant and sustained improvement in their patterns of antidepressant use. Copyright © 2016 John Wiley & Sons, Ltd.

Real-life Perception and Practice Patterns of NAFLD/NASH in Romania: Results of a Survey Completed by 102 Board-certified Gastroenterologists.

Nonalcoholic fatty liver disease (NAFLD) has an increasing incidence worldwide, reflecting the epidemics of obesity and metabolic syndrome. Data on knowledge, attitude and management by the Romanian gastroenterologists with regard to NAFLD are lacking. We assessed current diagnostic and treatment patterns of the management of NAFLD among 102 Romanian board certified gastroenterologists using a survey developed to collect information regarding participants' clinical practice, diagnostic tools and usage of medication in patients with NAFLD. 71.6% of the surveyed gastroenterologists (SG) had more than 5 years of gastroenterology practice, were university affiliated and 37.3% had predominant activity in hepatology (>60%). In Romania, 60.8% of the SG would diagnose NAFLD only if all other causes of liver disease were absent. All practitioners use a noninvasive tool for staging NAFLD, 45.1% use both serum markers and transient elastography. Liver biopsy is performed by 61.8% of the SG in the presence of a discordant result in two noninvasive methods of fibrosis evaluation. The most frequently prescribed drugs are: silymarin (88.2%), vitamin E (78.4%) and ursodeoxycholic acid (77.4%). The results of this survey suggest that clinical practice patterns among Romanian gastroenterologists for the diagnosis (mainly liver biopsy) and management of NAFLD frequently diverge from published practice guidelines. Nonalcoholic steatohepatitis is probably underdiagnosed, especially in patients with normal transaminase levels and is also overtreated with drugs that are not recommended in the guidelines.

Evolving Trends in Breast Surgery: Oncoplastic to Onco-Aesthetic Surgery.

The term oncoplastic surgery was first coined by Gabka and Bohmert [1], reflecting a recognition that the cosmetic outcome of breast surgery is an important part of patient outcomes. With the publication of practice guidelines, the principles of oncoplastic surgery were embedded in the management of breast cancer [2,3,4,5,6]. The evidence that poor aesthetic outcomes after breast surgery adversely impacted the quality of life led surgeons to seek out and refine surgical techniques that would preserve the size, volume, shape, and cosmetic appearance of breasts treated for breast cancer [7]. This led to the evolution of surgical procedures that utilize fibroglandular flap advancement to fill the surgical defect left after the excision of the breast, and therapeutic mammoplasty to excise large tumours or tumours located at cosmetically unforgiving sites on the breast such as the lower and medial quadrants of the breast [8,9]. Various techniques have been described for reconstructing large-volume breast excisions [10,11,12]. Increased awareness regarding the availability of these techniques has led women of today to be well informed and to expect an aesthetically acceptable breast form after the conservative treatment of breast cancer. Advancements in reconstruction techniques after mastectomy using latissimus dorsi flaps, transverse rectus abdominus muscle flaps, and deep inferior epigastric perforator flaps, as well as improvements in implant-based reconstruction, contributed to an increase in the demand for and uptake of post-mastectomy reconstruction; moreover, the safety of nipple sparing mastectomy has been demonstrated in large-scale cohort studies [13,14]. The evidence that post-mastectomy radiotherapy can contribute to patient survival compelled breast surgeons to revise the reconstruction options offered to women after mastectomy. Delayed reconstruction with autologous flaps or two-staged reconstruction deploying a tissue expander during radiotherapy, followed by a fixed-volume implant or autologous flap reconstruction, became the reconstruction of choice for patients who were likely to need chest wall radiotherapy after mastectomy [14]. The literature regarding potential comorbidities associated with silicone-based breast implants led to declining patient acceptance of silicone-based implants. After safety statements by the Food and Drug Administration, the uptake of silicone-based resumed in North America, and silicone and saline-based implants are more commonly used implants [15]. The advent of acellular dermal matrix (ADM) dramatically increased the number of options and techniques available for breast reconstruction, and the increasing use of ADM diminished the surgical challenge of donor site morbidity, enhancing patient acceptance. Guidelines for the optimal use of ADM are still evolving and are the focus of intense research and training [16]. Advancements in liposuction techniques that yield a high success rate after autologous fat transplant have led to the development of lipo-modelling techniques as an adjunct in restoring cosmetic defects after breast-conserving surgery and enhancing the cosmetic appearance of a reconstructed breast [17,18,19]. Oncoplastic breast surgery has come of age: the technical skills of surgeons have advanced, the technology of reconstructive mechanical adjuncts has improved, and a better scientific understanding of restorative and reconstructive breast surgery has been achieved. The new frontiers of aesthetic enhancement after breast cancer surgery in terms of restoring normal anatomical appearance and symmetry have been reached by breast surgeons. Indeed, most modern oncoplastic-trained surgeons are able and willing to undertake surgery on the contralateral side to enhance the aesthetics and cosmetic appearance of the breast treated for cancer. One could perhaps argue that surgical treatment that involves the techniques of flap formation, reconstruction with pedicled grafts, liposuction, lipo-modelling, and the use of ADM now deserves to be called onco-aesthetic surgery, which is a significant and rewarding step forward from oncoplastic surgery!

Just Do It: Changing our Culture to Embrace Optimal Perioperative Venous Thromboembolism Chemoprophylaxis for Abdominal and Pelvic Cancer Patients

Early in the 21st century, postoperative venous thromboembolism (VTE), deep vein thrombosis (DVT), and pulmonary embolism (PE) continue to plague roughly 2.5– 10 % of abdominopelvic cancer patients. Cancer patients are an especially high-risk group, and VTE is the most common cause of early postoperative mortality, accounting for half of all deaths within 30 days after abdominopelvic cancer surgery. Given that half of all VTE events occur after hospital discharge, there has been long-standing interest in extended chemoprophylaxis (ECP), typically for 28 days postoperatively. The hypothesis that ECP is more efficacious in preventing VTE than traditional hospital-only based prophylaxis has proven true; ECP also has been proven safe. Both randomized and large observation studies have shown that ECP after abdominopelvic cancer surgery significantly decreases VTE events but does not significantly increasing the risk of bleeding. Moreover, major organizations, such as the American Society of Chest Physicians (ACCP), American Society of Clinical Oncology (ASCO), and the National Comprehensive Cancer Network (NCCN), have published practice guidelines that recommend ECP. Despite this unified expert consensus regarding the benefit of ECP nationally, these recommendations have not been embraced and adoption of ECP has been poor. For example, Merkow et al. examined the adherence to postdischarge VTE prophylaxis in Medicare beneficiaries undergoing colorectal cancer surgery and found a compliance rate of a paltry 1.5 % overall. In this issue of Annals of Surgical Oncology, we are presented with two studies examining issues integral to the implementation of ECP into clinical practice. The first, by Fagarasanu et al., is a meta-analysis reexamining the efficacy and potential risk of ECP and represents the highestquality level of evidence supporting ECP to date. The second, by Krell et al., examines the operationalization of ECP using a Michigan statewide registry, highlighting that ECP has not been widely adopted. Fagarasanu et al. reported the results of a well-performed systematic review and meta-analysis examining the efficacy of ECP. The authors, not surprisingly, found a significant reduction of proximal DVT, and all VTE, with ECP, with no increased rate of major bleeding. The three randomized control trials referenced in the Fagarasanu et al. meta-analysis are summarized below. The ENOXACAN-II study, by Bergqvist et al., randomized patients to ECP with low molecular weight heparin (LMWH), enoxaparin, or standard duration LMWH prophylaxis and found a lower rate of VTE in the ECP group of 4.8 versus 12.0 % in controls. Of note, there was persistence of the protective effect at 3 months. In the European multinational CANBESURE study by Kakkar et al., patients were randomized to ECP with bemiparin, an ultraLMWH associated with a lower risk of bleeding than LMWH, or standard duration bemiparin prophylaxis, and similarly found a lower rate of major VTE in the ECP group of 0.8 versus 4.6 % in controls; however, there was no difference in a composite outcome of DVT, nonfatal PE, and all-cause mortality. Finally, in Vedovati et al., patients Society of Surgical Oncology 2016