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Breast Implants: Common Questions and Answers
Breast implants are used for a wide range of cosmetic and reconstructive purposes. In addition to breast augmentation, implants can be used for postmastectomy breast reconstruction, correction of congenital breast anomalies, breast or chest wall deformities, and male-to-female top surgery. Breast implants may confer significant benefits to patients, but several factors are important to consider preoperatively, including the impact on mammography, future lactation, and potential long-term implant complications (e.g., infection, capsular contracture, rupture, and the need for revision, replacement, or removal). A fundamental understanding of implant monitoring is also paramount to implant use. Patients with silicone breast implants should undergo routine screening for implant rupture with magnetic resonance imaging or ultrasonography completed five to six years postoperatively and then every two to three years thereafter. With the exception of complications, there are no formal recommendations regarding the timing of breast implant removal or exchange. Women with unilateral breast swelling should be evaluated with ultrasonography for an effusion that might indicate breast implant–associated anaplastic large cell lymphoma. There are no specific breast cancer screening recommendations for patients with breast implants, but special mammographic views are indicated to enhance accuracy. Although these discussions are a routine component of consultation and postoperative follow-up for plastic surgeons performing these procedures, family physicians should have a working knowledge of implant indications, characteristics, and complications to better counsel their patients, to ensure appropriate screening, and to coordinate care after surgery.
Journal Article
Healthcare Reform: An Update
The ACA expanded access to health insurance via state-based insurance markets for individuals and small business-with refundable premium tax credits for those with incomes between 100% and 400% of the federal poverty level and provided federal funding for states to expand Medicaid income eligibility to 138% federal poverty level ($16,394 for an individual, $33,534 for a family of four) (1). All told, an estimated 19 million Americans gained health insurance through these mechanisms, reducing the uninsured rate from approximately 18% in 2010 to an historic low of 10% in 2016 (2). Since its inception in 2010, repeal of the ACA became a cornerstone of the Republican platform and was a key feature of President Trump's 2016 campaign. Major organizations, including the American Thoracic Society, American Medical Association, American Heart Association, and American Lung Association, opposed the Congressional and Senate bills, citing decreased access to insurance coverage, potential loss of coverage for those with (Received in original form August 24, 2017; accepted in final form January 30, 2018) pre-existing conditions, limitations on health benefits, and annual and lifetime caps, as critically impacting patients, particularly those with chronic medical conditions. The Alexander-Murray Legislation would protect subsidies for low-income Americans buying insurance on the individual market and, although the bill increases state flexibility in some areas, would not cause the number of Americans without health insurance to increase per Congressional Budget Office estimates (17).
Journal Article
The Effect of Insurance Status on Mortality and Procedural Use in Critically Ill Patients
Lack of health insurance maybe an independent risk factor for mortality and differential treatment in critical illness.
To determine whether uninsured critically ill patients had differences in 30-day mortality and critical care service use compared with those with private insurance and to determine if outcome variability could be attributed to patient-level or hospital-level effects.
Retrospective cohort study using Pennsylvania hospital discharge data with detailed clinical risk adjustment, from fiscal years 2005 and 2006, consisting of 167 general acute care hospitals, with 138,720 critically ill adult patients 64 years of age or younger.
Measurements were 30-day mortality and receipt of five critical care procedures. Uninsured patients had an absolute 30-day mortality of 5.7%, compared with 4.6% for those with private insurance and 6.4% for those with Medicaid. Increased 30-day mortality among uninsured patients persisted after adjustment for patient characteristics (odds ratio [OR], 1.25 for uninsured vs. insured; 95% confidence interval [CI], 1.04–1.50) and hospital-level effects (OR, 1.26; 95% CI, 1.05–1.51). Compared with insured patients, uninsured patients had decreased risk-adjusted odds of receiving a central venous catheter (OR, 0.84; 95% CI,0.72–0.97), acute hemodialysis (OR, 0.59; 95% CI, 0.39–0.91), and tracheostomy (OR, 0.43; 95% CI, 0.29–0.64).
Lack of health insurance is associated with increased 30-day mortality and decreased use of common procedures for the critically ill in Pennsylvania. Differences were not attributable to hospital-level effects, suggesting that the uninsured have a higher mortality and receive fewer procedures when compared with privately insured patients treated at the same hospitals.
Journal Article
Coffee and Community
We are told that simply by sipping our morning cup of organic, fair-trade coffee we are encouraging environmentally friendly agricultural methods, community development, fair prices, and shortened commodity chains. But what is the reality for producers, intermediaries, and consumers? This ethnographic analysis of fair-trade coffee analyzes the collective action and combined efforts of fair-trade network participants to construct a new economic reality. Focusing on La Voz Que Clama en el Desierto-a cooperative in San Juan la Laguna, Guatemala-and its relationships with coffee roasters, importers, and certifiers in the United States, Coffee and Community argues that while fair trade does benefit small coffee-farming communities, it is more flawed than advocates and scholars have acknowledged. However, through detailed ethnographic fieldwork with the farmers and by following the product, fair trade can be understood and modified to be more equitable. This book will be of interest to students and academics in anthropology, ethnology, Latin American studies, and labor studies, as well as economists, social scientists, policy makers, fair-trade advocates, and anyone interested in globalization and the realities of fair trade. Winner of the Society for Economic Anthropology Book Award
eBook
Medicaid Expansion under the Affordable Care Act. Implications for Insurance-related Disparities in Pulmonary, Critical Care, and Sleep
Abstract
The Affordable Care Act was intended to address systematic health inequalities for millions of Americans who lacked health insurance. Expansion of Medicaid was a key component of the legislation, as it was expected to provide coverage to low-income individuals, a population at greater risk for disparities in access to the health care system and in health outcomes. Several studies suggest that expansion of Medicaid can reduce insurance-related disparities, creating optimism surrounding the potential impact of the Affordable Care Act on the health of the poor. However, several impediments to the implementation of Medicaid’s expansion and inadequacies within the Medicaid program itself will lessen its initial impact. In particular, the Supreme Court’s decision to void the Affordable Care Act’s mandate requiring all states to accept the Medicaid expansion allowed half of the states to forego coverage expansion, leaving millions of low-income individuals without insurance. Moreover, relative to many private plans, Medicaid is an imperfect program suffering from lower reimbursement rates, fewer covered services, and incomplete acceptance by preventive and specialty care providers. These constraints will reduce the potential impact of the expansion for patients with respiratory and sleep conditions or critical illness. Despite its imperfections, the more than 10 million low-income individuals who gain insurance as a result of Medicaid expansion will likely have increased access to health care, reduced out-of-pocket health care spending, and ultimately improvements in their overall health.
Journal Article
Medicaid Expansion and Mechanical Ventilation in Asthma, Chronic Obstructive Pulmonary Disease, and Heart Failure
Abstract
Rationale
The Affordable Care Act’s Medicaid expansion has led to increased access to chronic disease care among newly insured adults. Despite this, its effects on clinical outcomes, particularly for patients with asthma, chronic obstructive pulmonary disease, and heart failure, are uncertain.
Objectives
To assess whether Medicaid expansion was associated with changes in mechanical ventilation rates among hospitalized patients with heart failure, asthma, and chronic obstructive pulmonary disease.
Methods
Difference-in-differences analysis comparing discharge data from four states that expanded Medicaid in 2014 (Arizona, Iowa, New Jersey, and Washington) and three comparison states that did not (North Carolina, Nebraska, and Wisconsin) was performed. Models were adjusted for patient and hospital factors.
Results
Mechanical ventilation rates at baseline were 7.2% in nonexpansion states and 8.8% in expansion states. Medicaid expansion was associated with a decline in mechanical ventilation rates at −0.2% per quarter (95% confidence interval [CI], −0.3% to 0.0%; P = 0.010). We did not observe a change in the rate of ICU admission (−0.4% per quarter; 95% CI, −0.8% to 0.1%; P = 0.10) or in-hospital mortality (0.1% per quarter; 95% CI, 0.0% to 0.1%; P = 0.30). In a negative control among adults aged 65 years or older, changes in mechanical ventilation rates were similar, though the CIs crossed zero (−0.1%; 95% CI, −0.2% to 0.0%; P = 0.08).
Conclusions
Medicaid expansion may have been associated with a decline in mechanical ventilation rates among uninsured and Medicaid-covered patients admitted with heart failure, chronic obstructive pulmonary disease, and asthma.
Journal Article
Coffee and community
We are told that simply by sipping our morning cup of organic, fair-trade coffee we are encouraging environmentally friendly agricultural methods, community development, fair prices, and shortened commodity chains. But what is the reality for producers, intermediaries, and consumers? This ethnographic analysis of fair-trade coffee analyzes the collective action and combined efforts of fair-trade network participants to construct a new economic reality. Focusing on La Voz Que Clama en el Desierto-a cooperative in San Juan la Laguna, Guatemala-and its relationships with coffee roasters, importers, and certifiers in the United States, Coffee and Community argues that while fair trade does benefit small coffee-farming communities, it is more flawed than advocates and scholars have acknowledged. However, through detailed ethnographic fieldwork with the farmers and by following the product, fair trade can be understood and modified to be more equitable. This book will be of interest to students and academics in anthropology, ethnology, Latin American studies, and labor studies, as well as economists, social scientists, policy makers, fair-trade advocates, and anyone interested in globalization and the realities of fair trade. Winner of the Society for Economic Anthropology Book Award
eBook
Fair Trade and Social Justice
By 2008, total Fair Trade purchases in the developed world reached nearly $3 billion, a five-fold increase in four years. Consumers pay a “fair price” for Fair Trade items, which are meant to generate greater earnings for family farmers, cover the costs of production, and support socially just and environmentally sound practices. Yet constrained by existing markets and the entities that dominate them, Fair Trade often delivers material improvements for producers that are much more modest than the profound social transformations the movement claims to support. There has been scant real-world assessment of Fair Trade’s effectiveness. Drawing upon fine-grained anthropological studies of a variety of regions and commodity systems including Darjeeling tea, coffee, crafts, and cut flowers, the chapters in Fair Trade and Social Justice represent the first works to use ethnographic case studies to assess whether the Fair Trade Movement is actually achieving its goals. Contributors: Julia Smith, Mark Moberg, Catherine Ziegler , Sarah Besky, Sarah M. Lyon, Catherine S. Dolan, Patrick C. Wilson, Faidra Papavasiliou, Molly Doane, Kathy M’Closkey, Jane Henrici
eBook