After TSSM and immediate reconstruction, patient satisfaction with their breasts, as well as psychosocial and sexual well-being, returns to baseline by 1 year. Although overall nipple satisfaction is high, patients often report dissatisfaction with nipple position and sensation; appropriate preoperative counseling is important to set realistic expectations.
Background Over a third of middle-aged or older women suffer from urinary incontinence, but less than half undergo evaluation or treatment for this burdensome condition. With national organizations now including assessment of incontinence as a quality performance measure, providers and healthcare organizations have a growing incentive to identify and engage these women who are undiagnosed and untreated. Objective We sought to identify clinical and sociodemographic determinants of patient-provider discussion and treatment of incontinence among ethnically diverse, community-dwelling women. Study Design We conducted an observational cohort study from 2003-2012 of 969 women 40 years and older enrolled in a Northern California integrated healthcare delivery system, who reported at least weekly incontinence. Clinical severity, type, treatment, and discussion of incontinence were assessed by structured questionnaires. Multivariable regression evaluated predictors of discussion and treatment. Results Mean age of the 969 participants was 59.9 (±9.7) years, and 55% were racial/ethnic minorities (171 Black, 233 Latina, 133 Asian or Native American). Fifty-five percent reported discussing their incontinence with a healthcare provider, 36% within one year of symptom onset, and with only 3% indicating that their provider initiated the discussion. Over half (52%) reported being at least moderately bothered by their incontinence. Of these women, 324 (65%) discussed their incontinence with a clinician, with 200 (40%) doing so within 1 year of symptom onset. In multivariable analysis, women were less likely to have discussed their incontinence if they had a household income <$30,000/year versus ≥$120,000/year (AOR=0.49, CI=0.28-0.86), or were diabetic (AOR=0.71, CI=0.51-0.99). They were more likely to have discussed incontinence if they had clinically severe incontinence (AOR=3.09, CI=1.89-5.07), depression (AOR=1.71, CI=1.20-2.44), pelvic organ prolapse (AOR= 1.98, CI=1.13-3.46), or arthritis (AOR=1.44, CI=1.06-1.95). Among the subset of women reporting at least moderate subjective bother from incontinence, Black race (aOR=0.45, CI =0.25-0.81, versus white race), and income <$30,000/year (aOR=0.37, CI=0.17-0.81 versus ≥$120,000/year) were associated with reduced likelihood of discussing incontinence. Those with clinically severe incontinence (aOR=2.93, CI=1.53-5.61, versus low moderate incontinence by the Sandvik scale) were more likely to discuss it with a clinician. Conclusions Even in an integrated healthcare system, lower income was associated with decreased rates of patient-provider discussion of incontinence among women with at least weekly incontinence. Despite being at increased risk of incontinence, diabetic women were also less likely to have discussed incontinence or received care. Findings provide support for systematic screening of women to overcome barriers to evaluation and treatment.
There is a growing body of evidence that peripheral artery disease (PAD) may be impacted by depression. The objective of this study is to determine whether outcomes, primarily major amputation, differ between patients with depression and those without who presented to hospitals with critical limb ischemia (CLI), the end-stage of PAD. A retrospective cohort of patients hospitalized for CLI during 2012 and 2013 was identified from the National Inpatient Sample (NIS) using ICD-9 codes. The primary outcome was major amputation and secondary outcomes were length of stay and other complications. The sample included 116,008 patients hospitalized for CLI, of whom 10,512 (9.1%) had comorbid depression. Patients with depression were younger (64 ± 14 vs 67 ± 14 years, p < 0.001) and more likely to be female (55% vs 41%, p < 0.001), white (73% vs 66%, p < 0.001), and tobacco users (46% vs 41%, p < 0.001). They were also more likely to have prior amputations (9.8% vs 7.9%, p < 0.001). During the hospitalization, the rate of major amputation was higher in patients with comorbid depression (11.5% vs 9.1%, p < 0.001). In multivariable analysis, excluding patients who died prior to/without receiving an amputation ( n = 2621), comorbid depression was associated with a 39% increased odds of major amputation (adjusted OR 1.39, 95% CI 1.30, 1.49; p < 0.001). Across the entire sample, comorbid depression was also independently associated with a slightly longer length of stay (β = 0.199, 95% CI 0.155, 0.244; p < 0.001). These results provide further evidence that depression is a variable of interest in PAD and surgical quality databases should include mental health variables to enable further study.
Regulation is necessary to ensure the safety, efficacy and equitable impact of clinical artificial intelligence (AI). The number of applications of clinical AI is increasing, which, amplified by the need for adaptations to account for the heterogeneity of local health systems and inevitable data drift, creates a fundamental challenge for regulators. Our opinion is that, at scale, the incumbent model of centralized regulation of clinical AI will not ensure the safety, efficacy, and equity of implemented systems. We propose a hybrid model of regulation, where centralized regulation would only be required for applications of clinical AI where the inference is entirely automated without clinician review, have a high potential to negatively impact the health of patients and for algorithms that are to be applied at national scale by design. This amalgam of centralized and decentralized regulation we refer to as a distributed approach to the regulation of clinical AI and highlight the benefits as well as the pre-requisites and challenges involved.
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