Introduction Health outcomes research has gained considerable traction over the past decade as the medical community attempts to move beyond traditional outcome measures such as morbidity and mortality. Since its inception in 2009, the BREAST-Q has provided meaningful and reliable information regarding health related – quality of life (HR-QOL) and patient satisfaction for use in both clinical practice and research. Now five years from its initial publication, we review how researchers have utilized the BREAST-Q and how it has enhanced our understanding and practice of plastic and reconstructive breast surgery. Methods An electronic literature review was performed to identify publications that used the BREAST-Q to assess patient outcomes. Studies developing and/or validating the BREAST-Q or an alternate patient reported outcome measure (PROM), review papers, conference abstracts, discussions, comments and/or responses to previously published papers, studies that modified a version of BREAST-Q, and studies not published in English were excluded. Results Our literature review yielded 214 unique articles, 49 of which met our inclusion criteria. Important trends and highlights were further examined. Discussion The BREAST-Q has provided important insights in breast surgery highlighted by literature concerning autologous reconstruction, implant type, fat grafting, and patient education. The BREAST-Q has increased the use of PROMs in breast surgery and provided numerous important insights in its brief existence. The increased interest in PROMs as well as the under utilized potential of the BREAST-Q should permit its continued use and ability to foster new innovations and improve quality of care.

Lysozyme is an abundant, cationic antimicrobial protein that plays an important role in pulmonary host defense. Increased concentration of lysozyme in the airspaces of transgenic mice enhanced bacterial killing whereas lysozyme deficiency resulted in increased bacterial burden and morbidity. Lysozyme degrades peptidoglycan in the bacterial cell wall leading to rapid killing of Gram-positive organisms; however, this mechanism cannot account for the protective effect of lysozyme against Gram-negative bacteria. The current study was therefore designed to test the hypothesis that the catalytic activity (muramidase activity) of lysozyme is not required for bacterial killing in vivo. Substitution of serine for aspartic acid at position 53 (D53S) in mouse lysozyme M completely ablated muramidase activity. Muramidase-deficient recombinant lysozyme (LysMD53S) killed both Gram-positive and Gram-negative bacteria in vitro. Targeted expression of LysMD53S in the respiratory epithelium of wild-type (LysM+/+/LysMD53S) or lysozyme Mnull mice (LysM−/−/LysMD53S) resulted in significantly elevated lysozyme protein in the airspaces without any increase in muramidase activity. Intratracheal challenge of transgenic mice with Gram-positive or Gram-negative bacteria resulted in a significant increase in bacterial burden in LysM−/− mice that was completely reversed by targeted expression of LysMD53S. These results indicate that the muramidase activity of lysozyme is not required for bacterial killing in vitro or in vivo.

Background: Clinical reasoning is at the core of health professionals' practice. A mapping of what constitutes clinical reasoning could support the teaching, development, and assessment of clinical reasoning across the health professions. Methods: We conducted a scoping study to map the literature on clinical reasoning across health professions literature in the context of a larger Best Evidence Medical Education (BEME) review on clinical reasoning assessment. Seven databases were searched using subheadings and terms relating to clinical reasoning, assessment, and Health Professions. Data analysis focused on a comprehensive analysis of bibliometric characteristics and the use of varied terminology to refer to clinical reasoning. Results: Literature identified: 625 papers spanning 47 years (1968-2014), in 155 journals, from 544 first authors, across eighteen Health Professions. Thirty-seven percent of papers used the term clinical reasoning; and 110 other terms referring to the concept of clinical reasoning were identified. Consensus on the categorization of terms was reached for 65 terms across six different categories: reasoning skills, reasoning performance, reasoning process, outcome of reasoning, context of reasoning, and purpose/goal of reasoning. Categories of terminology used differed across Health Professions and publication types. Discussion: Many diverse terms were present and were used differently across literature contexts. These terms likely reflect different operationalisations, or conceptualizations, of clinical reasoning as well as the complex, multi-dimensional nature of this concept. We advise authors to make the intended meaning of 'clinical reasoning' and associated terms in their work explicit in order to facilitate teaching, assessment, and research communication.

Note: The term "resident" in this document refers to both specialty residents and subspecialty fellows. Once the Common Program Requirements are inserted into each set of specialty and subspecialty requirements, the terms "resident" and "fellow" will be used respectively. Where applicable, text in italics describes the underlying philosophy of the requirements in that section. These philosophic statements are not program requirements and are therefore not citable.

Background The ideal timing of post-mastectomy radiation therapy (PMRT) in the setting of two-staged implant-based breast reconstruction remains unclear. In this cohort study, we sought to determine whether complication rates differed between patients who received PMRT following tissue expander placement (TE-XRT) and those who received PMRT after exchange for permanent implant (Implant-XRT) utilizing prospective, multicenter data. Methods Eligible patients in the Mastectomy Reconstruction Outcomes Consortium (MROC) study from 11 institutions across North America were included in the analysis. All patients had at least six-month follow-up after their last intervention (i.e. implant exchange for TE-XRT patients and radiation for Implant-XRT patients). Complications including seroma, hematoma, infection, wound dehiscence, capsular contracture, and implant loss were recorded. Results We identified a total of 150 patients who underwent immediate, two-staged implant-based breast reconstruction and received PMRT. Of these, there were 104 (69.3%) TE-XRT and 46 (30.7%) Implant-XRT patients. There were no differences in the incidence of any complications or complications leading to reconstructive failure between the two cohorts. After adjusting for patient characteristics and site effect, the timing of PMRT (i.e. TE-XRT versus Implant-XRT) was not a significant predictor in the development of any complication, a major complication, or reconstructive failure. Conclusions In the setting of PMRT and two-staged implant-based reconstruction, patients who received PMRT after expander placement (TE-XRT) did not have a higher incidence or increased odds of developing complications than those who received PMRT after exchange for a permanent implant (Implant-XRT).

Introduction: Clinical reasoning is considered to be at the core of health practice. Here, we report on the diversity and inferred meanings of the terms used to refer to clinical reasoning, and consider implications for teaching and assessment. Methods: In the context of a Best Evidence Medical Education (BEME) review of 625 papers drawn from 18 health professions, we identified 110 terms for clinical reasoning. We focus on iterative categorization of these terms across three phases of coding and considerations for how terminology influences educational practices. Results: Following iterative coding with 5 team members, consensus was possible for 74, majority coding was possible for 16, and full team disagreement existed for 20 terms. Categories of terms included: purpose/goal of reasoning, outcome of reasoning, reasoning performance, reasoning processes, reasoning skills, and context of reasoning. Discussion: Findings suggest that terms used in reference to clinical reasoning are nonsynonymous, not uniformly understood, and the level of agreement differed across terms. If the language we use to describe, to teach, or to assess clinical reasoning is not similarly understood across clinical teachers, program directors, and learners, this could lead to confusion regarding what the educational or assessment targets are for 'clinical reasoning'.

Clinical reasoning is an essential component of a health professional's practice. Yet clinical reasoning research has produced a notably fragmented body of literature. In this article, the authors describe the pause-and-reflect exercise they undertook during the execution of a synthesis of the literature on clinical reasoning in the health professions. Confronted with the challenge of establishing a shared understanding of the nature and relevant components of clinical reasoning, members of the review team paused to independently generate their own personal definitions and conceptualizations of the construct. Here, the authors describe the variability of definitions and conceptualizations of clinical reasoning present within their own team. Drawing on an analogy from mathematics, they hypothesize that the presence of differing "boundary conditions" could help explain individuals' differing conceptualizations of clinical reasoning and the fragmentation at play in the wider sphere of research on clinical reasoning. Specifically, boundary conditions refer to the practice of describing the conditions under which a given theory is expected to hold, or expected to have explanatory power. Given multiple theoretical frameworks, research methodologies, and assessment approaches contained within the clinical reasoning literature, different boundary conditions are likely at play. Open acknowledgment of different boundary conditions and explicit description of the conceptualization of clinical reasoning being adopted within a given study would improve research communication, support comprehensive approaches to teaching and assessing clinical reasoning, and perhaps encourage new collaborative partnerships among researchers who adopt different boundary conditions.

Background Optimizing the patient experience is a central pillar in healthcare quality. While this may be recognized as important in breast reconstruction, surgeons are often unaware of how well they and members of their team achieve this goal. The objective of our study was to evaluate patient satisfaction with the experience of care in a multicenter, prospective cohort of patients undergoing breast reconstruction. Specifically, we sought to determine which aspects of the care experience might be most amenable to quality improvement. Methods As part of the Mastectomy Reconstruction Outcomes Consortium Study (MROC), 2,093 patients were recruited from 11 centers in North America. Of these, 1,534 (73.3%) completed the BREAST-Q Satisfaction with Care scales (Satisfaction with Information, Surgeon, Medical team, and Office staff) at three months post-reconstruction and were included in the analysis. Results Patients scored lowest on ‘Satisfaction with Information’ (mean = 72.8) compared to all other Satisfaction with Care scales (means: 89.5 - 95.5). Patients with immediate reconstruction were less satisfied with their plastic surgeon compared to those with delayed reconstruction. The racial category, “Other” (Asians, Pacific Islanders, Hawaiians, American Indians), was the least satisfied group across all Satisfaction with Care scales. Conclusion Patients undergoing breast reconstruction perceive significant gaps in their knowledge and understanding of expected outcomes. Immediate reconstruction patients and minority racial groups may require additional resources and attention. As a means to improve quality of care, these findings highlight an important unmet need and suggest that improving patient education may be central to providing patient-centered care.