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The gender advantage reversal between 10 and 11-year-olds in Russian schoolchildren may be associated with a transition from primary to secondary school. However, further investigations are needed to understand the mechanism of such a rapid change. In general, differences between Russian and Chinese schoolchildren may be attributed to extremely high academic pressure on Chinese schoolchildren . Gender stereotypes also may play a role .
|
PMC11697699_p28
|
PMC11697699
|
Discussion
| 1.096971 |
other
|
Other
|
[
0.008260613307356834,
0.0004133405163884163,
0.9913260340690613
] |
[
0.027585836127400398,
0.9699938893318176,
0.001569826272316277,
0.0008504965808242559
] |
en
| 0.999997 |
Some limitations have to be acknowledged. First, a study was cross-sectional in design, whereas a longitudinal sample is more applicable for tracing trajectories of math anxiety development with age. Second, despite similar oldest and youngest ages of schoolchildren, Russian and Chinese samples differ in terms of age structure. In particular, 10–11-year-old children are underrepresented in the Russian sample, whereas 14–15-year-old children are underrepresented in the Chinese sample.
|
PMC11697699_p29
|
PMC11697699
|
Discussion
| 1.816276 |
other
|
Study
|
[
0.11843620985746384,
0.0005182718741707504,
0.8810455203056335
] |
[
0.9346873760223389,
0.06363554298877716,
0.001257711905054748,
0.0004193048516754061
] |
en
| 0.999998 |
In future studies, it is important to replicate the analysis in age-balanced samples and enhance the age range to cover all years of schooling.
|
PMC11697699_p30
|
PMC11697699
|
Discussion
| 1.698565 |
biomedical
|
Other
|
[
0.706532895565033,
0.0011266876244917512,
0.29234039783477783
] |
[
0.21716251969337463,
0.7777860760688782,
0.004275484476238489,
0.0007759176078252494
] |
en
| 0.999996 |
What is known on this topic: Rapid Access Chest Pain Clinics streamline care and improve clinical outcomes for patients presenting with new onset chest pain. Many do not have active cardiovascular disease, but there is a high prevalence of potentially modifiable risk factors.
|
39748242_p0
|
39748242
|
Callout box
| 2.175345 |
biomedical
|
Other
|
[
0.9388691186904907,
0.05672219768166542,
0.004408720415085554
] |
[
0.00798698328435421,
0.973622739315033,
0.011821960099041462,
0.006568362936377525
] |
en
| 0.999996 |
What this study adds: Using the SF-6D, we found that absolute cardiac risk counselling in a RACPC improves quality of life.
|
39748242_p1
|
39748242
|
Callout box
| 2.560152 |
biomedical
|
Study
|
[
0.9962487816810608,
0.0018944190815091133,
0.0018568345112726092
] |
[
0.9886621832847595,
0.00999346561729908,
0.0008165616309270263,
0.0005277711898088455
] |
en
| 0.999995 |
Cardiovascular disease is the leading cause of death worldwide and imposes a significant health economic burden, including health-related quality of life (HRQoL) burden, on individuals, health payers and society more broadly [ 1 – 5 ]. In Australia in 2017–18, an estimated 1.2 million (6%) adults aged 18 years and over had one or more conditions related to heart or vascular disease based on self-reported data from the Australian Bureau of Statistics (ABS) National Health Survey . The associated direct and indirect health economic costs worldwide are substantial and increasing and patients with concommitant cardiac risk factors generally have poor HRQoL . This has led to an increasing focus on affordable effective preventative strategies to shift the population risk, including the use of prognostic tools and risk scores . Moreover, a health consumer’s understanding of health risks is a key determinant of effective risk communication about health problems; individual’s make decisions about their health under uncertainty, and the influence of risk perception, risk preferences and information processing are crucial in these decision-making processes .
|
39748242_p2
|
39748242
|
Introduction
| 3.996512 |
biomedical
|
Review
|
[
0.9979289770126343,
0.0008732263231649995,
0.0011978590628132224
] |
[
0.3960983157157898,
0.005835846532136202,
0.5975354313850403,
0.000530409102793783
] |
en
| 0.999998 |
Rapid Access Chest Pain Clinics (RACPCs), first utilised in the United Kingdom, provide safe and efficient evaluation of patients with new onset chest pain [ 11 – 15 ]. Patients and referrers report a high degree of satisfaction with this streamlined model of care . Compared to a traditional general cardiology clinic model, RACPC assessment may result in lower rates of emergency department re-attendance .
|
39748242_p3
|
39748242
|
Introduction
| 3.33072 |
biomedical
|
Other
|
[
0.9086204171180725,
0.08558325469493866,
0.0057963221333920956
] |
[
0.023375308141112328,
0.836577296257019,
0.1341153383255005,
0.005932119209319353
] |
en
| 0.999996 |
Following assessment in RACPCs, fewer than 15% of patients presenting with chest pain are found to have a cardiac cause for their symptoms . However, patients presenting with chest pain have a high prevalence of risk factors for future cardiovascular events . Generally, the management of underlying risk factors is not a major focus of chest pain clinics and there is potentially a missed opportunity to embed a preventive health role in these clinics. Our group conducted a randomised clinical trial to investigate the effects of absolute risk-guided proactive cardiac risk counselling (intervention group) on subsequent cardiac risk within a RACPC. The details of the trial protocol as well as the clinical outcomes have previously been reported . The primary end point was change in 5-year absolute risk score. Secondary end-points included lipid profile, blood pressure, smoking status, body-mass index (BMI), major adverse cardiac events and global health state utility (HSU) assessed with the SF-6D multi-attribute utility instrument . This study describes in detail the changes in HRQoL amongst trial participants.
|
39748242_p4
|
39748242
|
Introduction
| 4.050321 |
biomedical
|
Other
|
[
0.7007130980491638,
0.29564210772514343,
0.003644773503765464
] |
[
0.44344326853752136,
0.5341130495071411,
0.004980437457561493,
0.017463242635130882
] |
en
| 0.999996 |
Preference-based HRQoL measures such as the SF-6D, EQ-5D, HUI 3 and AQoL-8D are not only patient-reported outcome measures but also relevant for health economic evaluations since they can be used to derive health state utilities (HSUs) . HSUs have also been shown to be independent predictors of patient outcomes, including all-cause mortality and development of complications and clinicians have found that measuring HSU is of benefit to patients regarding clinical assessment, relationships, communication and management . It has been suggested that clinicians could routinely adopt these instruments in their clinical care . For people with complex and chronic disease, capturing and assessing complex physical and psychosocial health needs through patient-reported outcome measures is crucial . Some multi-attribute utility instruments also capture and assess dimensional scores that drive the HSU. These dimensional scores include, for example: ‘social role’, ‘mental health’ and ‘vitality’ (SF-6D); or ‘happiness’, ‘coping’, ‘self-worth’ (AQoL-8D) .
|
39748242_p5
|
39748242
|
Introduction
| 4.025839 |
biomedical
|
Review
|
[
0.9952216744422913,
0.0020295947324484587,
0.0027488109190016985
] |
[
0.060004912316799164,
0.006155079696327448,
0.9334407448768616,
0.0003992253332398832
] |
en
| 0.999997 |
To our knowledge, no studies have presented a detailed evaluation of HRQoL using SF-6D HSUs (including stratified for cardiac risk scores) and dimensional scores to determine HRQoL impacts for people who receive absolute cardiovascular risk counselling versus usual care in an outpatient cardio-protective cohort without clinically overt cardiac disease. This study used the SF-6D multi-attribute utility instrument to provide a detailed assessment of HRQoL impacts at baseline and follow-up for people who presented with chest pain where cardiac pathology had been excluded yet had a high burden of cardiovascular risk factors (defined as five-year absolute risk ≥ 8%). Patients were: 1. counselled on their absolute cardiac risk (intervention), prior to discussing a proactive strategy aimed at reducing this risk; or 2. counselled on individual cardiac risk factors at the discretion of the treating clinician (best practice usual care). All participants were invited to complete the SF-36 questionnaire at baseline and follow-up and therefore the SF-6D tool was used in the evaluation of HRQoL outcomes.
|
39748242_p6
|
39748242
|
Introduction
| 4.121496 |
biomedical
|
Study
|
[
0.9964118599891663,
0.0032627477776259184,
0.0003255023038946092
] |
[
0.9983482360839844,
0.000742306059692055,
0.0006782450363971293,
0.00023118396347854286
] |
en
| 0.999995 |
This study is a prespecified analysis of SF-6D HSUs and dimensional scores within a prospective, randomized, open-label, blinded-endpoint study to evaluate the benefit of an absolute-risk guided proactive risk factor management strategy over best practice usual care in an Australian tertiary hospital RACPC. The trial was registered and approved by the University of Tasmania’s Human Research Ethics Committee . The Rapid Access Chest Pain Clinic research programme has been approved by the Tasmanian Health Department’s Research Governance Unit.
|
39748242_p7
|
39748242
|
Prespecified quality of life analysis within a clinical trial
| 3.838582 |
biomedical
|
Other
|
[
0.7539879083633423,
0.24066226184368134,
0.005349836312234402
] |
[
0.48438239097595215,
0.5035447478294373,
0.00205294624902308,
0.01001993753015995
] |
en
| 0.999998 |
The study protocol is detailed in the principal findings . In brief, patients presenting to the RACPC between July 2014 and December 2017 were screened for enrolment through assessment of cardiovascular risk factors and calculation of 5-year risk scores using the Australian Absolute Risk Calculator (cvdcheck.org.au) developed by the National Vascular Disease Prevention Alliance for the purpose of estimating cardiovascular event risk in primary prevention settings . The calculator is based on the Framingham Risk Equation .
|
39748242_p8
|
39748242
|
Patient recruitment
| 4.006154 |
biomedical
|
Study
|
[
0.98795086145401,
0.011561507359147072,
0.0004875536833424121
] |
[
0.9869558811187744,
0.011888554319739342,
0.0004982079844921827,
0.0006572878337465227
] |
en
| 0.999998 |
Patients aged over 18 presenting to the RACPC between July 2014 and December 2017 with estimated 5-year absolute cardiovascular risk ≥ 8% were invited to participate. Additionally, ACR was categorised as low risk (8 – < 10%), intermediate risk (10 – 14%) and high risk ≥ 15%.
|
39748242_p9
|
39748242
|
Patient recruitment
| 2.9114 |
biomedical
|
Study
|
[
0.9547584652900696,
0.04317883402109146,
0.00206265551969409
] |
[
0.983863353729248,
0.014170408248901367,
0.0006373506039381027,
0.001328933285549283
] |
en
| 0.999998 |
Exclusion criteria were known cardiac disease, pregnancy, and patients known to be at very high risk (diabetes and age > 60 years, moderate or severe chronic kidney disease, familial hypercholesterolemia, total cholesterol > 7.5 mmol/L, systolic blood pressure ≥180 mmHg or diastolic blood pressure ≥110 mmHg), where universal intensive risk management is indicated.
|
39748242_p10
|
39748242
|
Patient recruitment
| 3.510975 |
biomedical
|
Study
|
[
0.8698858022689819,
0.1286618560552597,
0.001452279626391828
] |
[
0.7374249696731567,
0.25030991435050964,
0.003066689008846879,
0.009198417887091637
] |
en
| 0.999995 |
Patients were randomized 1:1 to best practice chest pain clinic assessment (usual care), or with the addition of an absolute risk-guided cardiovascular risk factor management strategy (intervention).
|
39748242_p11
|
39748242
|
Randomisation
| 3.207704 |
clinical
|
Other
|
[
0.3684252202510834,
0.6254642605781555,
0.006110525690019131
] |
[
0.25756192207336426,
0.7212135791778564,
0.0040924143977463245,
0.017132140696048737
] |
en
| 0.999998 |
Patients allocated to the usual care group were assessed by a physician regarding their chest pain. Absolute risk scores were not discussed. Individual risk factors were discussed at the discretion of the treating clinician, consistent with standard practice in a general cardiology outpatient clinic (for example smoking cessation recommended or general practitioner follow up suggested if blood pressure or lipids elevated).
|
39748242_p12
|
39748242
|
Randomisation
| 2.339892 |
clinical
|
Other
|
[
0.1641303449869156,
0.8317438364028931,
0.004125826060771942
] |
[
0.3236522376537323,
0.6125836968421936,
0.007424318231642246,
0.056339751929044724
] |
en
| 0.999996 |
A proactive absolute risk-guided management strategy was adopted for the intervention group. In addition to chest pain assessment, patients allocated to intervention were specifically counselled regarding their 5-year cardiovascular risk score. Individual risk factors were discussed in that context, and a strategy to improve the risk score was developed. Recommendations were consistent with current primary prevention guidelines . Where pharmacotherapy was indicated, this was prescribed in the clinic. Smokers were offered referral to a public smoking cessation service. All patients were provided with lifestyle advice by a registered nurse with cardiac rehabilitation experience. This review was a single-attendance clinic and participants were strongly encouraged to continue risk management strategies with their general practitioner.
|
39748242_p13
|
39748242
|
Randomisation
| 3.471755 |
clinical
|
Other
|
[
0.20414002239704132,
0.7930259108543396,
0.00283410819247365
] |
[
0.34782665967941284,
0.5388854146003723,
0.026746485382318497,
0.08654143661260605
] |
en
| 0.999997 |
Individual participant HSUs were generated using the SF-6D that is a prevalent multi-attribute utility instrument that uses patient-reported responses to either the SF-36 or SF-12 to derive HSUs . For our study, the SF-36 questionnaire was administered in the clinic environment at baseline and at minimum 12-month follow-up.
|
39748242_p14
|
39748242
|
SF-6D health state utilities to assess health-related quality of life
| 2.559479 |
biomedical
|
Study
|
[
0.9937226176261902,
0.002704950515180826,
0.0035724712070077658
] |
[
0.9964904189109802,
0.0030912577640265226,
0.00024806224973872304,
0.000170281738974154
] |
en
| 0.999999 |
The SF-6D health state classification system can define 18,000 potential health states, and is preferentially sensitive to both physical and psychosocial health needs when compared to other multi-attribute utility instruments that have a preponderance to either physical health (e.g. EQ-5D-5L) or psychosocial health (e.g. AQoL-8D) [ 30 – 32 ]. The SF-6D has been used in studies that aimed to understand the HRQoL impairments along with increasing cardiovascular disease severity for people with pre-existing cardiovascular disease . In this study, 11 items from the self-completed Version 1 SF-36 questionnaire were used to categorise patients in a further six domains that drive the overall HSU (namely physical functioning, role limitations, social functioning, pain, mental health and vitality), and scored using the Australian-specific utility weights obtained from a representative sample of the general population, including the Australian general population . HSUs range from 0 (representing death) to 1 (representing full health) scale, with negative HSUs indicating health states that are considered to be worse than dead. The minimal important difference (MID) for the SF-6D extracted from the published literature was 0.04 utility points, where the MID represents the smallest change in HSU which is deemed to be clinically meaningful for the SF-6D . The Australian general population norm for the SF-6D utility was mean 0.77 utility points. For older age cohorts namely 61–70 years and > 71 years the SF-6D population norms were 0.74 and 0.70 utility points respectively .
|
39748242_p15
|
39748242
|
SF-6D health state utilities to assess health-related quality of life
| 4.118209 |
biomedical
|
Study
|
[
0.9993864297866821,
0.0003439447609707713,
0.00026962082483805716
] |
[
0.9992524981498718,
0.00019138398056384176,
0.0004986016429029405,
0.00005747759496443905
] |
en
| 0.999997 |
Sociodemographic and clinical data were also collected in the clinic environment including ACR, body mass index (BMI) estimated from height (metres (m)) and weight (kilograms (kg)) using the algorithm BMI = kg/m 2 , waist circumference (cm), serum lipids (namely LDL, HDL and total cholesterol), systolic blood pressure, smoking (yes/no) and use of antihypertensive or lipid lowering medications (yes/no).
|
39748242_p16
|
39748242
|
Sociodemographic and clinical characteristics
| 3.739841 |
biomedical
|
Study
|
[
0.9973010420799255,
0.0024835627991706133,
0.00021542129979934543
] |
[
0.9969519376754761,
0.0021692945156246424,
0.0005196455749683082,
0.00035920244408771396
] |
en
| 0.999997 |
Descriptive statistics of mean and standard deviation (SD), median and interquartile range (IQR) were investigated for continuous variables. Counts and proportions expressed as percentages were assessed for categorical variables. Distribution of scores for SF-6D HSUs are generally not normally distributed and were checked for normality using the Shapirio-Wilk test of normality. Paired t-test, Wilcoxon-Rank or Chi-squared tests were performed, as appropriate, at the 5% level to test for significance. Linear regression analyses were also performed, to determine associations between clinical or sociodemographic variables and HSU.
|
39748242_p17
|
39748242
|
Statistical analyses
| 4.025753 |
biomedical
|
Study
|
[
0.9993359446525574,
0.00040414012619294226,
0.00025999380159191787
] |
[
0.999255359172821,
0.00033403237466700375,
0.00034891857649199665,
0.00006167269020806998
] |
en
| 0.999995 |
Differences in between-group summary HSUs were assessed with the SF-6D’s MID of 0.04 utility points . Subgroup analysis were conducted by adopting the ‘complete case’ sample approach (similar to the subgroup method adopted Sayah and colleagues that investigated the EQ-5D-5L and SF-6D for a study population of people living with Type 2 Diabetes) where individual and summary HSUs generated for the same people at baseline and follow up were examined .
|
39748242_p18
|
39748242
|
Statistical analyses
| 3.986701 |
biomedical
|
Study
|
[
0.9992895126342773,
0.0003499385784380138,
0.00036050594644621015
] |
[
0.9993964433670044,
0.0002834358310792595,
0.0002765011740848422,
0.000043568470573518425
] |
en
| 0.999998 |
All statistical analyses were performed using R 3.6.3 (R Foundation for Statistical Computing).
|
39748242_p19
|
39748242
|
Statistical analyses
| 1.417935 |
biomedical
|
Other
|
[
0.9516894817352295,
0.001519988407380879,
0.04679051786661148
] |
[
0.2487630993127823,
0.7464537024497986,
0.003389916382730007,
0.0013932408764958382
] |
en
| 0.999996 |
ANZCTR registration number 12617000615381 (registered 28/4/17).
|
39748242_p20
|
39748242
|
Statistical analyses
| 1.096205 |
other
|
Other
|
[
0.3954164981842041,
0.030990539118647575,
0.5735929608345032
] |
[
0.010956312529742718,
0.9865154027938843,
0.0009789431933313608,
0.0015492449747398496
] |
en
| 0.999751 |
N = 189 participants were randomised ( n = 98 intervention; n = 91 usual care) and their patient-reported responses to the SF-36 enabled the derivation of a SF-6D HSU for 96% (181/189: intervention n = 93, usual care n = 88) at baseline and 61% (115/189: intervention n = 63, usual care n = 52) at the minimum 12-month follow up mean ± SD months (control 37.8 ± 13.0 months; intervention 37.2 ± 11.8 months). The flow of patients into the study is outlined further in Supplementary Appendix A.
|
39748242_p21
|
39748242
|
Participant characteristics
| 4.033963 |
biomedical
|
Study
|
[
0.9537118077278137,
0.044888779520988464,
0.0013994090259075165
] |
[
0.9515829086303711,
0.04574768245220184,
0.0008599827997386456,
0.0018094389233738184
] |
en
| 0.999998 |
Table 1 provides baseline statistical comparisons of all means ± SD for clinical (including the ACR) and sociodemographic variables, and HSUs for the intervention and control groups. There were no statistical differences at baseline between the entire cohort’s intervention and usual care groups for age and sex with mean age 60 years and over two thirds of the cohorts were male. Additionally, the mean ± SD ACR score was categorised as intermediate for both groups (intervention 13.13 ± 4.34; usual care 12.77 ± 4.33 p = 0.56), and there were no statistical differences between the mean HSUs for the entire cohort (intervention 0.40 ± 0.26; usual care 0.45 ± 0.24, p = 0.12). Table 2 shows subgroup analyses for people for whom a HSU could be generated at baseline and follow-up for HSUs, and the ACR revealing no statistical differences. Table 1 Comparison of sociodemographic, clinical and health state utilities for intervention and usual care at baseline N = 189 Intervention n = 98 Usual care n = 91 P value SF-6D health state utility HSU 0.40 (0.26) 0.45 (0.24) p = 0.12 Mean (SD) ( n = 93) ( n = 88) Socio-demographic Age years Mean (SD) 60 (7.9) 59 (8.1) p = 0.65 Sex Male 66 (67%) 71 (78%) p = 0.14 Female 32 (33%) 20 (22%) n = x, % Clinical risk factors ACR Mean (SD) 13.13 (4.35) 12.77 (4.33) p = 0.56 Clinical BMI kg/m 2 Mean (SD) 31.7 (5.6) 29.6 (5.6) p = 0.008 Waist (cm) Mean (SD) 107.3 (12.5) 103.3 (12.2) p = 0.03 LDL (mmols/l) Mean (SD) 3.43 (1.04) 3.37 (1.0) p = 0.72 Systolic BP(mmHg) Mean (SD) 143 (15) 140 (13) p = 0.19 Current smoker 49 (50%) 48 (53%) p = 0.82 Diabetes 17 (17%) 12 (13%) P = 0.55 Wilcoxon rank sum test for health state utilities BMI and waist circumference not significant on adjustment for baseline; and for baseline and age ACR Absolute risk calculator, BMI Body mass index, waist circumference, LDL Llipids, BP Blood pressure Table 2 Statistical comparison of health state utilities (HSU) and absolute risk calculator (ACR) scores for patients for whom a utility value could be generated for baseline and follow up, including subgroup analysis where HSUs generated for the same people at baseline and follow up were examined N = 189 Intervention entire cohort baseline n = 93 Intervention subgroup baseline n = 63 Test of significance Usual care entire cohort baseline n = 91 Usual care subgroup baseline n = 52 Test of significance HSU 0.40 (0.26) 0.43 (0.27) p = 0.40 0.45 (0.24) 0.47 (0.28) p = 0.58 Mean (SD) ( n = 98) ( n = 62) ( n = 88) ( n = 52) ACR Mean (SD) 13.13 (4.35) 13.16 (4.60) p = 0.97 12.77 (4.33) 12.81 (4.50) p = 0.96
|
39748242_p22
|
39748242
|
Participant characteristics
| 4.220878 |
biomedical
|
Study
|
[
0.9963765740394592,
0.0032615449745208025,
0.0003619293274823576
] |
[
0.9982839226722717,
0.001000485965050757,
0.0004974442417733371,
0.00021813799685332924
] |
en
| 0.999997 |
Table 3 describes the summary statistics for the SF-6D HSUs for the intervention and usual care groups at baseline and follow-up for the entire and subgroup sample cohorts. For the entire cohort, both the intervention and usual care groups achieved a significant increase in HSUs with the intervention group reporting a higher increase for both mean (intervention 0.12 utility points, usual care 0.10 utility points) and median utilities (intervention 0.16 utility points, usual care 0.10 utility points). The difference in median HSU exceeded the MID. This was not reflected for the mean HSU. Table 3 Intervention and usual care SF-6D health state utility values for the entire cohort and subgroup at baseline and follow up; and exploratory health state utilities for the stratified absolute cardiac risk calculator (ACR) for high, intermediate and low ACR at baseline and follow up (entire cohort) N = 189 Intervention baseline n = 98 Intervention follow up n = 98 Difference (baseline—follow up) Usual care baseline n = 91 Usual care follow-up n = 91 Difference (baseline – follow up) Entire cohort Health state utility Mean (SD) 0.40 (0.26) 0.52 (0.26) + 0.12 0.45 (0.24) 0.55 (0.28) + 0.10 Median (IQR) 0.40 (0.20 – 0.62) 0.56 (0.31–0.78) + 0.16 * 0.48 (0.30 – 0.63) 0.58 (0.43–0.69) + 0.10 * Range −0.14, 0.88 −0.09, 0.97 (−0.36; 0.95) −0.21, 1.00 n = x ( n = 93) ( n = 63) ( n = 88) ( n = 52) Stratified by ACR at baseline (Entire cohort) ACR high Mean (SD) 0.45 (0.26) 0.44 (0.28) −0.01 0.46 (0.25) 0.59 (0.33) + 0.13 Median (IQR) 0.48 (0.35 – 0.64) 0.33 (0.22 – 0.69) −0.15 0.53 (0.19– 0.65) 0.63 (0.48 – 0.88) + 0.10 Range −0.08, 0.78 0.09 0.87 0.02, 0.79 −0.21 – 1.00 n = x ( n = 27) ( n = 11) ( n = 17) ( n = 16) ACR intermediate Mean (SD) 0.41 (0.27) 0.59 (0.26) + 0.18 0.45 (0.26) 0.55 (0.27) + 0.10 Median (IQR) 0.46 (0.19 – 0.64) 0.62 (0.34 – 0.83) + 0.16 * 0.45 (0.30– 0.63) 0.59 (0.50 – 0.69) + 0.14 Range −0.14, 0.88 0.09 – 0.97 −0.36, 0.95 −0.18 – 0.93 n = x ( n = 45) ( n = 23) ( n = 52) ( n = 24) ACR Low Mean (SD) 0.30 (0.20) 0.49 (0.24) + 0.19 0.45 (0.20) 0.47 (0.26) + 0.02 Median (IQR) 0.31 (0.14 – 0.42) 0.57 (0.34–0.64) + 0.26 * 0.41 (0.36– 0.59) 0.50 (0.40 – 0.59) + 0.09 Range 0.01 – 0.73 −0.09—0.84 0.06, 0.84 −0.05 – 0.84 n = x ( n = 21) ( n = 29) ( n = 19) ( n = 12) Subgroup analyses Health state utility Mean (SD) 0.43 (0.27) 0.52 (0.26) + 0.09 0.47 (0.28) 0.55 (0.28) + 0.08 Median (IQR) 0.46 (0.20 – 0.65) 0.56 (0.31–0.78) + 0.10 0.53 (0.29 – 0.66) 0.58 (0.43–0.69) + 0.05 Range −0.14, 0.88 −0.09, 0.97 (−0.36; 0.95) −0.21, 1.00 n = x ( n = 63) ( n = 63) ( n = 52) ( n = 52) Wilcoxon rank test for significance at p < 0.05 level of significance. High ACR ≥ 15; Intermediate ACR 10–14; Low ACR < 10 * Indicates p < 0.05
|
39748242_p23
|
39748242
|
Health-related quality of life using HSUs
| 4.197838 |
biomedical
|
Study
|
[
0.9983842372894287,
0.0012802542187273502,
0.00033554306719452143
] |
[
0.9988961219787598,
0.0006407378823496401,
0.0003598492476157844,
0.00010330319491913542
] |
en
| 0.999994 |
Subgroup analyses reflected similar between group trends of improved HRQoL revealing a median difference between the two groups of 0.05 utility points exceeding the MID for the SF-6D (intervention 0.10 utility points; usual care 0.05 utility points). For the subgroup sample, neither intervention nor usual care groups achieved significance for mean HSU improvements (intervention 0.09 utility points p = 0.06; usual care 0.08 utility points p = 0.15).
|
39748242_p24
|
39748242
|
Health-related quality of life using HSUs
| 4.123448 |
biomedical
|
Study
|
[
0.9981864094734192,
0.0013417137088254094,
0.0004718445416074246
] |
[
0.9989111423492432,
0.0006867487682029605,
0.0003130882978439331,
0.00008900008106138557
] |
en
| 0.999997 |
Table 4 reports the SF-6D’s summary dimensional scores for the entire cohort. These results show there was a broad improvement in all mean dimensions with a statistically significant improvement in mean mental health and social role for the intervention group, and mental health for the usual care group. The median scores for the subdimensions revealed one point improvements for role limitations, mental health and physical function for the intervention group, and a one point improvement in the median score for mental health only was observed. Table 4 SF-6D dimensional scores including physical functioning, pain, vitality; social functioning, role and mental health for the entire cohort at baseline and follow up N = 189 Intervention baseline n = 98 Intervention follow up n = 98 Between-group difference Usual care Baseline n = 91 Usual care follow-up n = 91 Between-group difference Dimensional scores Physical Physical functioning Mean (SD) 2.99 (1.34) 2.68 (1.31) −0.31 2.84 (1.45) 2.76 (1.56) −0.08 Median (IQR) 3.00 (2.00 – 3.25) 2.00 (2.00 – 3.00) −1.0 2.00 (2.00 – 3.75) 2.00 (1.25 – 4.00) 0.00 Range 1.00 – 6.00 1.00 – 6.00 (1.00- 6.00) (1.00- 6.00) n = x ( n = 95) ( n = 68) ( n = 89) ( n = 57) Pain Mean (SD) 3.44 (1.08) 3.10 (1.33) −0.33 3.56 (1.21) 3.24 (1.37) −0.32 Median (IQR) 3.00 (3.00 – 4.00) 3.00 (2.00 – 3.00) 0.0 3.00 (3.00 – 4.00) 3.00 (2.00 – 4.00) 0.00 Range 1.00 – 6.00 1.00 – 6.00 (1.00- 6.00) (1.00- 6.00) n = x ( n = 96) ( n = 69) ( n = 90) ( n = 57) Vitality Mean (SD) 3.34 (1.07) 3.17 (0.94) −0.17 3.11 (1.05) 2.82 (0.98) −0.29 Median (IQR) 3.00 (3.00 – 4.00) 3.00 (3.00 – 4.00) 0.0 3.00 (2.00 – 4.00) 3.00 (2.00 – 3.00) 0.00 Range 1.00 – 5.00 1.00 – 5.00 1.00 – 5.00 (1.00- 5.00) n = x ( n = 96) ( n = 68) ( n = 90) ( n = 57) Dimensional scores Physical Social functioning Mean (SD) 2.45 (1.16) 2.30 (1.21) −0.15 2.19 (1.06) 2.07 (1.06) −0.12 Median (IQR) 2.00 (1.00 – 3.00) 2.00 (1.00 – 3.00) 0.0 2.00 (1.00 – 3.00) 2.00 (1.00 – 3.00) 0.00 Range 1.00 – 5.00 1.00 – 5.00 1.00 – 5.00 1.00 – 5.00 n = x ( n = 95) ( n = 69) ( n = 89) ( n = 57) Role Mean (SD) 2.40 (1.31) 1.93 (1.12) −0.47 2.36 (1.21) 2.22 (1.27) −0.14 Median (IQR) 2.00 (1.00 – 4.00) 1.00 (1.00 – 3.00) −1.0 * 2.0 (1.0 – 3.0) 2.0 (1.0 – 3.5) 0.00 Range 1.00 – 4.00 1.00 – 4.00 1.0 – 4.0 1.0 – 4.0 n = x ( n = 94) ( n = 66) ( n = 89) ( n = 57) Mental health Mean (SD) 2.87 (1.15) 2.45 (1.17) −0.42 2.62 (1.04) 2.25 (1.21) −0.40 Median (IQR) 3.00 (2.00 – 4.00) 2.00 (1.50 – 3.00) −1.0 * 3.0 (2.0 – 3.0) 2.0 (1.0 – 3.0) −1.0 * Range 1.00, 5.00 1.00, 5.00 1.0, 5.0 1.0, 5,0 n = x ( n = 96) ( n = 66) ( n = 90) ( n = 57) * Indicates p < 0.05
|
39748242_p25
|
39748242
|
Health-related quality of life using HSUs
| 4.234521 |
biomedical
|
Study
|
[
0.9980946183204651,
0.001158574828878045,
0.0007468338590115309
] |
[
0.999139666557312,
0.0004699935088865459,
0.00032146740704774857,
0.00006888229836476967
] |
en
| 0.999998 |
Table 3 also reports the exploratory examination of summary HSUs for the patients’ ACR stratified into high, intermediate and low risk categories (according to the inclusion criteria of 5-year absolute risk > 8%) for the entire cohort sample only. The results are exploratory due to the relatively small sample sizes of the stratified scores (particularly for the follow up summary HSUs). The intervention group generated a statistically significant increase in mean HSUs for patients in the intermediate and low risk ACR categories, and HSUs remained stable for patients who were in the high-risk category (ACR ≥ 15%). Divergent results were revealed for the usual care group where patients in the high-risk category reported an increased HSU at follow up, however, this result was not statistically significant (Table 3 ).
|
39748242_p26
|
39748242
|
Health state utility values by stratified high, intermediate and low ACR
| 4.114554 |
biomedical
|
Study
|
[
0.9976202845573425,
0.002064079511910677,
0.0003155818267259747
] |
[
0.9988710284233093,
0.0006703688413836062,
0.0003150789416395128,
0.00014350788842421025
] |
en
| 0.999997 |
To our knowledge, this is the first detailed study to investigate the quantitative HRQoL impacts of proactive absolute cardiovascular risk management in a hospital-based clinic. We found that HRQoL increased more for people who received absolute cardiovascular risk intervention compared to usual care (Table 3 ). The between-group median difference exceeded the minimal important difference for the intervention group indicating a clinically meaningful difference between the two management strategies. This suggests that patient-centred tailored proactive absolute cardiac risk counselling within the RACPC environment may yield clinically meaningful change. The difference was also robust to subgroup analysis.
|
39748242_p27
|
39748242
|
Discussion
| 4.102565 |
biomedical
|
Study
|
[
0.9976077079772949,
0.002140088938176632,
0.0002522882423363626
] |
[
0.9986935257911682,
0.0005042359116487205,
0.0005927406600676477,
0.00020952915656380355
] |
en
| 0.999997 |
Examination of the health preferences literature using the SF-6D for an Australian CVD cohort revealed one study of a chronic heart disease cohort that investigated a head-to-head comparison of HSUs for the EQ-5D-3L and SF-6D multi-attribute utility instruments for ‘Young@Heart Study’ patients with a mean age of 70 years and hospitalised with chronic heart disease . The study recommended the use of the SF-6D (compared to the EQ-5D-3L) in mild CVD conditions. In contrast to our study that investigated a cardio-preventative cohort (no known cardiac disease yet increased cardiac risk factors), the Young@Heart study did not use the Australian value set to estimate the HSUs—instead using the UK value sets for both instruments to enable comparisons. Moreover, the Australian Young@Heart study was for a cohort with established cardiovascular disease . Our study is the first to investigate an Australian cardio-preventative cohort using SF-6D HSUs.
|
39748242_p28
|
39748242
|
Overall HSUs and health-related quality of life
| 4.073375 |
biomedical
|
Study
|
[
0.9992672801017761,
0.0003571129054762423,
0.00037557061295956373
] |
[
0.9989927411079407,
0.0002402295940555632,
0.0007084131357260048,
0.00005850620800629258
] |
en
| 0.999997 |
Our study established that HRQoL improved more for patients who received proactive absolute cardiac risk counselling and this difference was clinically meaningful for the median values. We noted that the difference was not clinically meaningful for the mean changes, nevertheless, the trend revealed a between group improvement for the intervention. Potential factors driving this change may be patient engagement in lifestyle changes that were systematically discussed in a patient-centred ACR counselling session for the intervention group with the aim of improving smoking cessation, blood pressure and lipid profiles, increased physical activity and weight loss. SF-6D dimensional scores also suggested increased patient engagement through significant improvements in mental health and social role for the intervention group. Proactive ACR counselling about modifiable lifestyle factors including increased physical activity, smoking cessation and weight loss could be driving these dimensional improvements. Overall the findings are exploratory and our conclusions call for a larger confirmatory study.
|
39748242_p29
|
39748242
|
Overall HSUs and health-related quality of life
| 4.110527 |
biomedical
|
Study
|
[
0.9980841875076294,
0.001660422421991825,
0.0002555024402681738
] |
[
0.9986554384231567,
0.00044091028394177556,
0.0007388056255877018,
0.00016476541350129992
] |
en
| 0.999996 |
An additional exploratory finding was the investigation of summary HSU changes for stratified absolute cardiac risk scores. Patients in the intervention group’s high cardiac risk category recorded a stable HRQoL whereas those in the usual care group’s high cardiac risk category recorded a counter-intuitive increased HRQoL.
|
39748242_p30
|
39748242
|
Divergence of HSUs with stratified ACR for intervention and usual care
| 3.160233 |
biomedical
|
Study
|
[
0.9947351813316345,
0.003958009649068117,
0.0013067862018942833
] |
[
0.9965194463729858,
0.002948933746665716,
0.00033009075559675694,
0.00020143878646194935
] |
en
| 0.999994 |
A recent systematic review that examined the impact of the provision of cardiovascular disease risk estimates to healthcare professionals and patients concluded that the challenges to the communication of risk are well known and that further research is required to better understand these challenges . Another study examined the use of effective communication by clinicians to convey cardiac risk information to patients and concluded that effective communication strategies translate to improved accuracy of cardiac risk perception and subsequent improved uptake of cardioprotective measures . A further study that examined the influence of risk perception, risk preferences and information processing on cardiovascular risk counselling found that high-risk individuals ranked by biomarkers (e.g., obese, diabetes or hypertension) set a target risk lower than others by about 1% point, potentially reflecting an over-optimism bias in this group . Importantly, this study concluded that given the global pandemic of CVD, there are public health gains to be made from personalised risk communication if it is better tailored to account for individuals’ preferences and risk perception .
|
39748242_p31
|
39748242
|
Divergence of HSUs with stratified ACR for intervention and usual care
| 4.042463 |
biomedical
|
Review
|
[
0.9924027919769287,
0.00408013304695487,
0.003517000935971737
] |
[
0.01861192099750042,
0.0006927135982550681,
0.9803869128227234,
0.00030838194652460515
] |
en
| 0.999996 |
Our exploratory findings have attempted to answer the call to provide an interventional strategy to implement formal and tailored CVD calculation into consultation . This study embedded the SF-6D multi-attribute utility instrument into a clinical trial to improve understanding of the impacts on HRQoL regarding the communication of absolute cardiac risk. These results suggest that when patients are provided with proactive, consistent, tailored and effectively communicated absolute cardiac risk there could be an enhanced understanding of this risk, leading to the adoption of strategies to improve risk profile. The intervention group revealed a significant increase in HSUs for low and intermediate risk categories – suggesting that patients responded positively to ACR counselling and management. Moreover, the HSUs for people in the high-risk ACR category remained stable. On the other hand, the usual care group’s HSUs in the high cardiac risk category increased at follow up (albeit not statistically significant). This may reflect a lack of insight into cardiovascular risk within the control group, however, we caution that the finding is exploratory and requires further evaluation in a larger confirmatory study.
|
39748242_p32
|
39748242
|
Divergence of HSUs with stratified ACR for intervention and usual care
| 4.100226 |
biomedical
|
Study
|
[
0.9958289265632629,
0.0038005744572728872,
0.00037047371733933687
] |
[
0.997500479221344,
0.0018155587604269385,
0.0004091840237379074,
0.0002748060505837202
] |
en
| 0.999997 |
Both doctors and patients have been found to inaccurately estimate cardiovascular risk in a primary care setting , with a tendency towards systematic under-estimation of risk – so-called ‘optimistic bias’ . It has been recommended that future studies develop strategies to implement formal CVD risk calculation into consultation and test the strategies in actual consultations . There may be additional benefit in adding a generic and preferentially sensitive HRQoL assessment tool to ACR assessment to investigate HSUs and the drivers of these HSUs particularly through the psychosocial dimensions of health.
|
39748242_p33
|
39748242
|
Divergence of HSUs with stratified ACR for intervention and usual care
| 3.829715 |
biomedical
|
Study
|
[
0.9985097050666809,
0.0008913193014450371,
0.0005990206846036017
] |
[
0.6098511219024658,
0.026543740183115005,
0.36273643374443054,
0.000868693517986685
] |
en
| 0.999997 |
Since we conducted our clinical RACPC evaluations , and now this detailed HRQoL study regarding the benefits of proactive cardiac risk counselling for a cardio-preventative cohort that has presented to a RACPC, COVID-19 has resulted in millions of deaths worldwide particularly for people with cardiac risk factors . The emergence of Long COVID is also set to take an additional toll on an already burdened healthcare system .
|
39748242_p34
|
39748242
|
COVID-19: the role of RACPC’s
| 2.384662 |
biomedical
|
Other
|
[
0.9901720881462097,
0.0061835721135139465,
0.00364447059109807
] |
[
0.23114201426506042,
0.7619711756706238,
0.003160459455102682,
0.003726347116753459
] |
en
| 0.999997 |
During the ongoing COVID-19 pandemic, there may be a particular role for RACPC clinics through reducing emergency department re-attendances and facilitating opportunistic management of cardiovascular risk factors. Optimizing cardiovascular health may reduce health system utilization and may also prevent some of the serious morbidity associated with COVID-19 infection.
|
39748242_p35
|
39748242
|
COVID-19: the role of RACPC’s
| 2.148368 |
biomedical
|
Other
|
[
0.9577217102050781,
0.029427219182252884,
0.012850980274379253
] |
[
0.003277376526966691,
0.992879331111908,
0.002615903504192829,
0.0012273442698642612
] |
en
| 0.999996 |
The International Society for Quality of Life Research has developed a clinical users guide to encourage the routine collection of patient reported outcomes which “are rarely collected in routine clinical practice” . Recent evidence has also found that integrating patient-reported outcomes in clinical practice has the potential to enhance patient-centred care, including for people with complex risk factors that can be modified with lifestyle changes . Within this broader and evolving context of patient-centredness in clinical care, our study has highlighted the clinical relevance of multi-attribute utility instrument and HSU analyses in the cardioprotective clinical setting. There may be a role within RACPCs for the adoption of a generic and preferentially sensitive multi-attribute utility instrument in routine clinical care. Evaluation of the clinical predictive utility of the instrument in this setting is required.
|
39748242_p36
|
39748242
|
Integrating patient reported outcomes in clinical practice
| 3.948736 |
biomedical
|
Study
|
[
0.9924290776252747,
0.0068351286463439465,
0.0007357146241702139
] |
[
0.9895260334014893,
0.005336430389434099,
0.004566216841340065,
0.000571238633710891
] |
en
| 0.999997 |
A randomised control trial study design was a strength for our health preferences study. Use of the SF-6D multi-attribute utility instrument was a strength given the instrument’s sensitivity in other CVD populations. Nevertheless, use of a multi-attribute utility instrument that is preferentially sensitive to psychosocial health (such as the AQoL-8D or the recently released SF-6Dv2 ) may have revealed additional information regarding the individual dimensions of psychosocial health (and some cues regarding enhanced patient understanding). The main weakness of our study was the incomplete SF-36 data for almost one-third of the cohort at the follow up timepoint. However, we also conducted subgroup analysis and this methodology is also reflected in other studies .
|
39748242_p37
|
39748242
|
Strengths and limitations
| 4.057718 |
biomedical
|
Study
|
[
0.9992088675498962,
0.0005014598136767745,
0.000289730989607051
] |
[
0.9993473887443542,
0.0003048928629141301,
0.00028109835693612695,
0.00006659927021246403
] |
en
| 0.999998 |
Challenges regarding the communication of ACR are well-known. Our HRQoL study has established that proactive ACR guided management in the RACPC improves HRQoL.
|
39748242_p38
|
39748242
|
Conclusions
| 2.167557 |
biomedical
|
Study
|
[
0.9904997944831848,
0.005092088133096695,
0.004408163018524647
] |
[
0.9528546929359436,
0.04380732774734497,
0.0021714891772717237,
0.001166500966064632
] |
en
| 0.999995 |
We recommend a larger confirmatory study with increased follow-up to particularly investigate HSUs with stratified ACR using both the SF-6D and the AQoL-8D instrument (which has a more detailed evaluation of psychosocial health) to further assess the impact of patient behaviour through HSUs and super and individual dimensional scores and the predictive capabilities of the patient-reported outcome measures.
|
39748242_p39
|
39748242
|
Conclusions
| 3.930046 |
biomedical
|
Study
|
[
0.9993102550506592,
0.0002983414742629975,
0.000391489447792992
] |
[
0.9905745387077332,
0.008465292863547802,
0.0008446644060313702,
0.00011555304809007794
] |
en
| 0.999995 |
Supplementary Material 1.
|
39748242_p40
|
39748242
|
Supplementary Information
| 1.448591 |
biomedical
|
Other
|
[
0.922401487827301,
0.0025136268232017756,
0.07508479803800583
] |
[
0.12988820672035217,
0.8624334335327148,
0.0056608328595757484,
0.002017532242462039
] |
en
| 0.857138 |
Autologous “free flap” breast reconstruction (ABR) is a highly regarded option for women undergoing breast cancer surgery due to its natural feel, aesthetic appeal, and ability to maintain sensory function. The positive psychosocial benefits of this approach have been extensively acknowledged, making it a valuable option for a multitude of patients. 1 , 2 In addition, ABR is a durable option that can endure the effects of aging, without the risk of implant-related complications or necessity for prothesis replacements. 3 ABR procedures are now common in healthcare clinics worldwide, with various surgical methods described in the literature. 2 , 4 , 5 Ongoing research into new imaging modalities and recovery optimization techniques aims to enhance the efficacy of these procedures. 6 , 7 However, there is no centralized international consensus on ABR preparation and perioperative care, resulting in a dependence on nonstandardized national or intramural guidelines. Therefore, this study aimed to gain insight into the global practice patterns of ABR experts worldwide, focusing on flap choice, imaging modalities, monitoring devices, perioperative care, and additional surgical possibilities such as direct contralateral symmetrical reduction and surgical lymphedema treatment. The purpose of this study is to provide novice and experienced plastic surgeons with a global perspective on ABR practices, based on the collective insights from surgeons worldwide. This can serve as a reference point when implementing ABR in their hospitals or clinics, encouraging critical assessment, informed decision-making, and potential refinements of their local ABR guidelines.
|
PMC11697778_p0
|
PMC11697778
|
Introduction
| 4.132011 |
biomedical
|
Study
|
[
0.9913033246994019,
0.008239208720624447,
0.00045746914111077785
] |
[
0.9860497117042542,
0.0019419153686612844,
0.011119718663394451,
0.0008885769639164209
] |
en
| 0.999997 |
This research is a descriptive quantitative study conducted by the Department of Plastic Surgery at Radboud University Nijmegen in the Netherlands. The aim was to gather information worldwide using a questionnaire consisting of 42 multiple-choice and 10 open-ended questions. The survey covered topics such as donor site selection, surgical approaches, imaging modalities, and perioperative care. Information about the participating surgeons’ details, practice settings, and experience were also collected. The survey questions are available in the appendix. The researchers extensively searched the PubMed and SciELO databases to identify plastic surgeons involved in articles related to ABR. A total of 280 subjects and 39 international societies of plastic and reconstructive surgery were contacted by mail for inclusion in this study. They were asked to complete an online survey using the LimeSurvey application (version 2.06+). Nonresponders were sent reminder emails 2 and 4 weeks after the initial email. If no response was received, a phone call was made to inquire about their interest in participating. This research targeted plastic surgeons who are directly involved with ABR procedures and those affiliated with healthcare centers where these procedures are performed.
|
PMC11697778_p1
|
PMC11697778
|
Method
| 4.015212 |
biomedical
|
Study
|
[
0.9975610971450806,
0.0019170476589351892,
0.0005218659644015133
] |
[
0.9992689490318298,
0.0003266184066887945,
0.0002666821819730103,
0.00013767661585006863
] |
en
| 0.999996 |
The objective of this study was to collect data through an online questionnaire with subquestions directed to the respondents on the previous answers, assisting in providing an individual-centered questionnaire. Consequently, different sample sizes were taken for carrying out the analyses on specific segments of the data. The data were coded anonymously to ensure confidentiality and the analysis was carried out using IBM SPSS Statistics 27. Moreover, frequency analysis and crosstabulation tests were used to assess the demographics and relationship between multiple variables. Further, the Chi-squared test of independence was employed to determine the relationships between the categorical variables in the study. Although all responses were reviewed and analyzed, we prioritized presenting only the results with sufficient response rates. Data with low response rates or incomplete answers were excluded from the final analysis when they did not contribute meaningfully to the overall findings. This selective approach allowed us to focus on presenting reliable and representative trends, ensuring a more robust and comprehensive overview of global practices in autologous breast reconstruction.
|
PMC11697778_p2
|
PMC11697778
|
Method
| 4.05478 |
biomedical
|
Study
|
[
0.9987586736679077,
0.0004780390008818358,
0.000763329619076103
] |
[
0.9995482563972473,
0.00015015044482424855,
0.0002590811636764556,
0.00004247905235388316
] |
en
| 0.999998 |
A total of 82 responses were received, with 71% (n=58) being completed questionnaires. The tailored design of the study enabled respondents to respond to only questions that were applicable to them, resulting in varied sample sizes across subsections. Out of all 82 respondents who completed the demographic subsection, 59% (n=48) practiced only in an academic setting, 25% (n=21) in a nonacademic setting, 10% (n=8) in private clinics, 4% (n=3) in a both academic and private settings, and 2% (n=2) in all three settings.
|
PMC11697778_p3
|
PMC11697778
|
Results
| 2.127532 |
biomedical
|
Study
|
[
0.9464940428733826,
0.004298551939427853,
0.0492074228823185
] |
[
0.9960022568702698,
0.0035668343771249056,
0.000242834139498882,
0.00018812018970493227
] |
en
| 0.999996 |
Among these respondents, 33% (n=27) were from North America, 1% (n=1) from South America, 43% (n=35) from Europe, 19% (n=16) from Asia, and 4% (n=3) from Australia. Unfortunately, there were no respondents from Africa.
|
PMC11697778_p4
|
PMC11697778
|
Results
| 1.439641 |
other
|
Other
|
[
0.45806413888931274,
0.0023030280135571957,
0.5396327972412109
] |
[
0.4107826352119446,
0.5869300961494446,
0.001391167170368135,
0.0008961489656940103
] |
en
| 0.999997 |
Among all the respondents, 74% (n=60) were microsurgeons performing ABR as principal surgeons and 75% (n=45) had less than 15 years of experience.
|
PMC11697778_p5
|
PMC11697778
|
Results
| 2.233998 |
biomedical
|
Study
|
[
0.9817330837249756,
0.01197246927767992,
0.006294438149780035
] |
[
0.8716070055961609,
0.12548094987869263,
0.0011060796678066254,
0.0018059718422591686
] |
en
| 0.999998 |
Data from 60 respondents were analyzed to understand the prevalence and preferences of imaging techniques used in the preoperative phase. Among these respondents, approximately 75% (n=44) used preoperative imaging routinely, with most of them preferring CTA (82%, n=36). No association was observed between not using imaging and the unavailability of imaging modalities at the respondents’ healthcare centers. Among the 16 respondents who reported not using preoperative imaging, the majority (80%, n=12) stated that imaging would not make any difference in the outcomes.
|
PMC11697778_p6
|
PMC11697778
|
Preoperative imaging
| 3.467171 |
biomedical
|
Study
|
[
0.9952524900436401,
0.0038073468022048473,
0.0009401026763953269
] |
[
0.9990214109420776,
0.0005974999512545764,
0.00022530238493345678,
0.00015573100245092064
] |
en
| 0.999998 |
Among the respondents who used imaging modalities preoperatively, 52% (n=23) used a combination of modalities. Sixty-one percent (n=14) used CTA with a handheld Doppler as their preferred combination, primarily to confirm the location of perforators and reduce intraoperative identification time. The use of a single imaging modality and a combination of modalities were evenly distributed across all healthcare centers: academic, nonacademic, and private clinics.
|
PMC11697778_p7
|
PMC11697778
|
Preoperative imaging
| 3.326988 |
biomedical
|
Study
|
[
0.9884560108184814,
0.010477734729647636,
0.0010662238346412778
] |
[
0.9926943778991699,
0.006170422304421663,
0.0006194017478264868,
0.000515858584549278
] |
en
| 0.999996 |
In the preoperative phase, insights were gathered from 77 respondents regarding preventive measures for perfusion problems. A substantial minority (41%, n=31) reported taking proactive preventive actions. Twenty-three respondents (74%, n=23) used low molecular weight heparin (LMWH), whereas 7 (23%, n=7) used mono-antiplatelet therapy.
|
PMC11697778_p8
|
PMC11697778
|
Preventive actions
| 2.928741 |
biomedical
|
Study
|
[
0.9759584665298462,
0.022746745496988297,
0.0012948078801855445
] |
[
0.9896601438522339,
0.00820385105907917,
0.0005136480904184282,
0.0016223466955125332
] |
en
| 0.999997 |
Regarding intraoperative planning for ABR, data from 60 respondents were analyzed. Most respondents preferred to use abdominal donor site flaps, with the DIEP flap being the most commonly used (85%, n=51), followed by the transverse rectus abdominis myocutaneous (TRAM) flap (13%, n=8), and superficial inferior epigastric artery (SIEA) flap (2%, n=1). Among the 51 respondents who indicated having an alternative option, the SIEA- and the transverse upper gracilis flap were the most commonly used second-choice flaps, each used by 22% (n=13) of the respondents, followed by the TRAM flap in 17% (n=10) of the cases ( Table 1 ). Table 1 Respondents’ preferential donor site and their second choice donor site preferences in case their first choice was unavailable/unsuitable. Table 1 Donor site Preferential donor site (%) (n=60) Second choice (%) (n=51) Deep Inferior Epigastric Pedicle Flap (DIEP) 85% (n=51) 7% (n=4) Transverse Rectus Myocutaneous Flap (TRAM) 13% (n=8) 23% (n=14) Superficial Inferior Epigastric Artery Flap (SIEA) 2% (n=1) 22% (n=13) Latissimus Dorsi Flap (LD) 0% 2% (n=1) Thoracodorsal Artery Perforator Flap (TDAP) 0% 2% (n=1) Superior Gluteal Artery Perforator Flap (SGAP) 0% 5% (n=3) Inferior Gluteal Artery Perforator Flap (IGAP) 0% 3% (n=2) Transverse Upper Gracilis Flap (TUG) 0% 22% (n=13) Profunda Artery Perforator Flap (PAP) 0% 7% (n=4)
|
PMC11697778_p9
|
PMC11697778
|
Donor site
| 4.157703 |
biomedical
|
Study
|
[
0.9948987364768982,
0.004556228872388601,
0.0005451233591884375
] |
[
0.9983171224594116,
0.0007643241551704705,
0.0006747308652848005,
0.0002437771763652563
] |
en
| 0.999996 |
The internal mammary artery was the most commonly used recipient vessel (90%, n=54), followed by the thoracodorsal artery (82%, n=49) in case the internal mammary artery was unsuitable.
|
PMC11697778_p10
|
PMC11697778
|
Recipient vessels
| 3.559789 |
biomedical
|
Study
|
[
0.9853476881980896,
0.013834896497428417,
0.0008174566319212317
] |
[
0.9473488330841064,
0.049080874770879745,
0.0007432447746396065,
0.0028271405026316643
] |
en
| 0.999996 |
The distribution of perforators used was roughly even among the 51 respondents who preferentially used the DIEP flap: 47% (n=24) used one perforator and 51% (n=26) used two perforators. These preferences were consistent across academic, nonacademic, and private clinics.
|
PMC11697778_p11
|
PMC11697778
|
Number of perforators
| 2.371231 |
biomedical
|
Study
|
[
0.9812842011451721,
0.013613981194794178,
0.005101790186017752
] |
[
0.9547742009162903,
0.043186403810977936,
0.0007463895017281175,
0.0012930226512253284
] |
en
| 0.999998 |
Data from 58 respondents were analyzed to examine the utilization trends of intraoperative imaging and their confidence levels in performing ABR. Approximately one-third (33%, n=19) used imaging to locate perforator vessels during surgery, with the majority (89%, n=17) using handheld Doppler. During ABR, 60% (n=35) of the respondents reported always feeling confident, while the remaining respondents indicated usually feeling confident during free flap harvesting. Notably, all respondents who reported feeling confident without intraoperative imaging usually used an imaging modality preoperatively.
|
PMC11697778_p12
|
PMC11697778
|
Intraoperative imaging
| 3.921792 |
biomedical
|
Study
|
[
0.9961835741996765,
0.0032064788974821568,
0.000609877984970808
] |
[
0.9991494417190552,
0.0004155860806349665,
0.00026488571893423796,
0.00017011977615766227
] |
en
| 0.999996 |
The respondents also reported their confidence in flap harvesting without preoperative imaging. The confidence levels of the 43 respondents who completed the subsection on flap harvesting without preoperative imaging were analyzed and the majority reported moderate (28%, n=12) to very high (35%, n=15) levels of confidence. Respondents who reported always feeling confident in performing ABR used more frequent preoperative imaging (48%, n=28) than those who reported usually feeling confident (25%, n=15). However, no significant association was found between the confidence level during flap harvesting and preoperative imaging usage (p=0.21). The respondents’ confidence levels were self-estimated in this survey.
|
PMC11697778_p13
|
PMC11697778
|
Intraoperative imaging
| 3.396998 |
biomedical
|
Study
|
[
0.9967285394668579,
0.0015935301780700684,
0.0016780172009021044
] |
[
0.9992272853851318,
0.0005519951810128987,
0.0001393589482177049,
0.00008133720984915271
] |
en
| 0.999997 |
Data from 60 respondents were analyzed to identify the current intraoperative surgical methods in ABR surgeries. These procedures included contralateral symmetrical breast reduction, lymphedema treatment, and direct nipple reconstruction. Contralateral symmetrical breast reduction during initial ABR is not a standard procedure. One-third of the respondents (33%, n=20) never performed contralateral symmetrical breast reduction during the initial ABR, whereas approximately a quarter (23%, n=14) performed this in less than 25% of the cases. Approximately one-fifth (18%, n=11) always performed breast reduction in case of asymmetry. Furthermore, 8% (n=5) of the respondents performed it in more than 75% of the cases, 17% (n=8) in 25%-75% of the cases, and 3% (n=2) did so rarely or not at all. In academic and nonacademic settings, approximately half of the respondents performed contralateral reductions during the initial ABR, indicating a similar trend.
|
PMC11697778_p14
|
PMC11697778
|
Additional surgical possibilities
| 3.99987 |
biomedical
|
Study
|
[
0.9964750409126282,
0.0028101387433707714,
0.0007147496799007058
] |
[
0.998788058757782,
0.00046661350643262267,
0.0006023570895195007,
0.00014296745939645916
] |
en
| 0.999997 |
A minority of respondents (16%, n=10) treated lymphedema during ABR using vascularized lymph node transplantation (VLNT). All of them were working in an academic setting.
|
PMC11697778_p15
|
PMC11697778
|
Additional surgical possibilities
| 2.111173 |
biomedical
|
Study
|
[
0.9833433628082275,
0.012150644324719906,
0.004505991004407406
] |
[
0.7859265804290771,
0.20789550244808197,
0.001486562890931964,
0.004691281355917454
] |
en
| 0.999996 |
As for direct nipple reconstruction, the vast majority never performed this during the initial ABR (88%, n=53). There was no difference in the frequency of this supplementary procedure among academic, nonacademic, and private clinics.
|
PMC11697778_p16
|
PMC11697778
|
Additional surgical possibilities
| 2.188183 |
biomedical
|
Study
|
[
0.9439000487327576,
0.04910290241241455,
0.0069970847107470036
] |
[
0.9374234676361084,
0.057593587785959244,
0.001473278971388936,
0.003509673522785306
] |
en
| 0.999995 |
The intraoperative preventive measures for perfusion issues were based on data from 77 respondents. Intraoperative preventive actions were reported by 43% (n=33) of the respondents. The most commonly reported actions included the application of warmth (42% n=14), followed by the administration of anticoagulant such as LMWHs (33%, n=11) and mono-antiplatelets (18%, n=6). Popular combinations included LMWH plus warmth application (18%, n=6) and LMWH plus mono-antiplatelet therapy (18%, n=6).
|
PMC11697778_p17
|
PMC11697778
|
Prophylactic actions
| 3.618276 |
biomedical
|
Study
|
[
0.9900689721107483,
0.009223815985023975,
0.000707155151758343
] |
[
0.9956724643707275,
0.0033245545346289873,
0.00047048385022208095,
0.0005325581296347082
] |
en
| 0.999999 |
Intraoperative challenges were evaluated based on the data from the 58 respondents, highlighting the most challenging aspects of ABR. Respondents were asked to rate the challenges on a scale of 1 to 5, with 1 indicating “not a challenge” and 5 indicating “very challenging.” Among the 35 respondents who experienced challenges during ABR, achieving symmetry was rated as the most challenging, with a mean score of 2.8. Achieving proportional body dimensions in bilateral reconstructions was the second most challenging, with a mean score of 2.6, followed by donor site wound healing, which had a mean score of 2.4 . Figure 1 Level of reported difficulty in ABR in academic, nonacademic, and private clinics. The difficulty level is rated on a scale of 1 (not a challenge) to 5 (very challenging). Figure 1
|
PMC11697778_p18
|
PMC11697778
|
Challenges and practice settings
| 3.567367 |
biomedical
|
Study
|
[
0.9929990768432617,
0.00568882143124938,
0.0013120775111019611
] |
[
0.9976900815963745,
0.0017366891261190176,
0.0003191481519024819,
0.0002540920686442405
] |
en
| 0.999997 |
Flap failure and its management were analyzed based on the data from the 58 respondents, providing insights into the frequency and types of anastomotic revisions performed postoperatively. Among the 58 respondents, 79% (n=46) acknowledged experiencing postoperative flap failure to varying extents. In cases where anastomotic revisions were deemed necessary, 91% (n=42) of the respondents indicated the need to revise the venous anastomoses, while 76% (n=35) reported the need to revise the arterial anastomoses at various frequencies. The specific percentages and distribution of these revision frequencies are detailed in Table 2 . Table 2 Frequency with which venous or arterial anastomosis revisions were required when revision was deemed necessary. Table 2 Revision likelihood Venous revisions Arterial revisions Rarely (1%-5% of cases) 28 (61%) 31 (68%) Occasionally (6%-10% of cases) 7 (15%) 1 (2%) Sometimes (11%-20% of cases) 0 (0%) 1 (2%) Often (>20% of cases) 7 (15%) 2 (4%) Total respondents 42 (91%) 35 (76%)
|
PMC11697778_p19
|
PMC11697778
|
Flap failure
| 4.105348 |
biomedical
|
Study
|
[
0.9963716268539429,
0.003156542545184493,
0.0004718775162473321
] |
[
0.9989407658576965,
0.0005096375825814903,
0.0003687412536237389,
0.0001808019878808409
] |
en
| 0.999997 |
Notably, most respondents who experienced flap failure did not take preventive actions for perfusion problems preoperatively (60%, n=35) or intraoperatively (72%, n=42). However, no significant correlation was found between the incidence of flap failures and absence of preventive actions taken preoperatively (p=0.73) or intraoperatively (p=0.49).
|
PMC11697778_p20
|
PMC11697778
|
Flap failure
| 3.678594 |
biomedical
|
Study
|
[
0.9963054656982422,
0.0029171493370085955,
0.0007773718098178506
] |
[
0.9989173412322998,
0.0006439098506234586,
0.0002788481942843646,
0.00015983183402568102
] |
en
| 0.999997 |
Postoperative preventive actions and their implications were assessed based on the data from 77 respondents. Among these respondents, 75% (n=58) reported taking postoperative preventive actions. Medicinal treatments were predominantly administered in the postoperative phase, with 67% (n=39) administering LMWHs and 28% (n=16) using mono-antiplatelet therapy. The most common combinations of preventive actions were LMWHs with warmth application (10%, n=6) or LMWHs with mono-antiplatelet therapy (10%, n=6).
|
PMC11697778_p21
|
PMC11697778
|
Preventive actions
| 3.887089 |
biomedical
|
Study
|
[
0.9949448704719543,
0.004496063571423292,
0.0005591626977548003
] |
[
0.9987358450889587,
0.0007087384001351893,
0.00034053571289405227,
0.00021496806584764272
] |
en
| 0.999998 |
Flap viability assessment was analyzed postoperatively based on the data from 72 respondents, offering insights into the frequency, methods, and personnel involved in the assessments. Flap viability was primarily monitored by ward personnel such as nurses alone in 86% (n=62) of the cases, together with a plastic surgeon in 19% (n=14), and alongside a plastic surgeon and resident in 15% (n=11) of the cases.
|
PMC11697778_p22
|
PMC11697778
|
Flap viability assessment
| 3.401022 |
biomedical
|
Study
|
[
0.9729968905448914,
0.02558622881770134,
0.001416892628185451
] |
[
0.9949009418487549,
0.003681056434288621,
0.000592864234931767,
0.0008250342798419297
] |
en
| 0.999998 |
Monitoring was conducted hourly (67%, n=48) on the first day, every 2 h (49%, n=35) on the second day, and every 4 h (46%, n=33) on the third day after surgery. The viability of the flaps was assessed based on the following parameters: temperature (85%, n=61), color (97%, n=70), capillary refill (92%, n=66), and edema (53%, n=38). Most plastic surgeons (85%, n=61) used monitoring devices to assess flap perfusion. Handheld Doppler (74%, n=53) was the most commonly used device, followed by local SpO 2 sensors (14%, n=10), implantable Dopplers (11%, n=8), and temperature sensors (11%, n=8).
|
PMC11697778_p23
|
PMC11697778
|
Flap viability assessment
| 4.071839 |
biomedical
|
Study
|
[
0.9845671057701111,
0.01503672543913126,
0.0003962484188377857
] |
[
0.9954711198806763,
0.002463576151058078,
0.0013012735871598125,
0.0007639972609467804
] |
en
| 0.999997 |
Data from 74 respondents were used to analyze the length of postoperative stay in the hospital. Sixty-eight percent (n=51) of the respondents discharge their patients within 5 days postoperatively . The average length of hospital stay was 5 days for academic hospitals and private clinics and 4 days for nonacademic hospitals. Figure 2 Duration of hospital stays for patients following autologous breast reconstruction in healthcare centers worldwide. Figure 2
|
PMC11697778_p24
|
PMC11697778
|
Hospital stays
| 2.175968 |
biomedical
|
Study
|
[
0.9542794823646545,
0.0378333181142807,
0.007887252606451511
] |
[
0.9719616174697876,
0.02503899484872818,
0.0009298703516833484,
0.0020695882849395275
] |
en
| 0.999997 |
ABR is increasingly being considered as an option for women undergoing breast cancer surgery. This study assessed the current practices in ABR on a global scale. Despite the rising demand and technological advancements in ABR, the consensus on perioperative care remains elusive. Through a tailored survey approach, this research aimed to provide an overview of how ABR are performed worldwide.
|
PMC11697778_p25
|
PMC11697778
|
Discussion
| 2.657761 |
biomedical
|
Study
|
[
0.9937472343444824,
0.0018866839818656445,
0.004366147797554731
] |
[
0.9865821599960327,
0.0065886774100363255,
0.0063788252882659435,
0.00045033489004708827
] |
en
| 0.999997 |
A preoperative vascular map assists in selecting the appropriate perforator. Most plastic surgeons use CTA imaging as it has been shown to be the most accurate and precise method for visualizing perforators. 8 Furthermore, recent studies have revealed that CTA imaging can also assess the suitability of flap tissue for mobilization. 9 However, for patients who need to minimize their exposure to radiation or contrast, alternative imaging techniques such as MRA and handheld Doppler are valuable alternatives. 10
|
PMC11697778_p26
|
PMC11697778
|
Discussion
| 3.881132 |
biomedical
|
Review
|
[
0.9969848990440369,
0.0026075306814163923,
0.00040748881292529404
] |
[
0.25550249218940735,
0.31150734424591064,
0.42937859892845154,
0.003611551597714424
] |
en
| 0.999997 |
In this study, most respondents (89%, n=17) used handheld Doppler alongside preoperative imaging to locate perforator vessels during surgery. The literature further identifies several real-time perforators imaging techniques, including duplex, fluorescence near-infrared angiography, and dynamic infrared thermography. Additionally, techniques such as image-guided stereotactic navigational systems and 3D-printed anatomical models are reported to enhance precision when paired with volumetric imaging. 6
|
PMC11697778_p27
|
PMC11697778
|
Discussion
| 4.054758 |
biomedical
|
Study
|
[
0.9993910789489746,
0.0003947736695408821,
0.00021408847533166409
] |
[
0.9976117610931396,
0.0003100690373685211,
0.001984301721677184,
0.00009397290705237538
] |
en
| 0.999994 |
The reported usage rate of intraoperative imaging modalities was 33% (n=19), which was lower than initially anticipated. 10 This discrepancy could be due to certain complementary techniques, such as the handheld Doppler, which were described and categorized as imaging modalities. Although the handheld Doppler is frequently used as a complementary technique to identify perforator vessels and assess anastomosis patency intraoperatively, it is technically not an imaging modality. Consequently, the reported use of “complementary techniques” might be understated compared to their actual usage.
|
PMC11697778_p28
|
PMC11697778
|
Discussion
| 3.992774 |
biomedical
|
Study
|
[
0.9989388585090637,
0.0008194996626116335,
0.00024156698782462627
] |
[
0.9930046200752258,
0.001417600316926837,
0.005357231013476849,
0.0002206066419603303
] |
en
| 0.999998 |
Consistent with the findings of previous studies, this study's findings reaffirm that the abdomen remains the predominant donor site for microvascular ABR, with the DIEP flap often considered as the gold standard. 3 A secondary benefit of selecting the abdominal donor site is the more aesthetic abdominal contour observed postoperatively. 11 Notably, as with several studies, the choice of donor site remains a highly individualized decision, contingent on a patient's unique needs, circumstances, and body dimensions.
|
PMC11697778_p29
|
PMC11697778
|
Discussion
| 4.046301 |
biomedical
|
Study
|
[
0.9988710284233093,
0.0008590796496719122,
0.00026976512162946165
] |
[
0.9982743263244629,
0.0005538887926377356,
0.0010480113560333848,
0.00012372832861728966
] |
en
| 0.999998 |
Regarding intraoperative challenges, muscle preservation during ABR was reported as a significant challenge, ranking it as the fourth most challenging aspect. Despite proper soft tissue management, this remains a critical issue. 7 Although the literature claims limited donor site morbidity, clinically significant bulges or hernias are reported as complications of DIEP flap reconstructions. 12 A promising robotic approach to DIEP flap harvest has been described in the literature, aiming to minimize abdominal wall disruption and optimize muscle preservation. 7 Another major challenge in ABR is achieving proportional body dimensions and symmetry. Although the current techniques largely depend on the surgeon's judgment, a study by Hummelink et al. proposed a virtual flap planning method using 3D stereophotogrammetry and CTA, potentially assisting surgeons in accurately harvesting the correct flap volume. 5
|
PMC11697778_p30
|
PMC11697778
|
Discussion
| 4.015851 |
biomedical
|
Study
|
[
0.9989824891090393,
0.0006355422083288431,
0.000381878693588078
] |
[
0.9504087567329407,
0.0007291864021681249,
0.04862188920378685,
0.0002401910605840385
] |
en
| 0.999999 |
Regarding preventive actions against perfusion problems occurring postoperatively, 67% (n=39) of the surgeons administered LWMHs whereas 28% (n=16) used mono-antiplatelet therapy intraoperatively; a combination of both was observed in 10% (n=6) of the cases. LMWH has been described in the literature as an essential thromboprophylactic measure during surgery. 13 Although LWMH is recommended, the use of a combination of LMWH and mono-antiplatelet therapy is debatable, especially for low-risk cardiovascular patients. Enajat et al., in their retrospective review, found no significant difference in the incidence of microvascular complications between patients who received both medications and those who received only LMWH perioperatively. 14 Moreover, considering the known risks and significantly higher incidence of hematoma in patients receiving both medications, they recommended discontinuing the administration of mono-antiplatelet therapy postoperatively.
|
PMC11697778_p31
|
PMC11697778
|
Discussion
| 4.036454 |
biomedical
|
Study
|
[
0.9967709183692932,
0.002744683064520359,
0.00048436044016852975
] |
[
0.8264857530593872,
0.0015576855512335896,
0.1711479127407074,
0.0008087237947620451
] |
en
| 0.999998 |
In cases of flap failure, venous anastomoses were revised more frequently (91%, n=42) than arterial anastomoses (76%, n=35), reflecting a higher likelihood of venous thrombosis over arterial occlusion as the cause of flap failure. Interestingly, a study conducted by Masoomi et al. revealed that venous thrombosis has a higher rate of successful treatment upon re-exploration compared to arterial occlusion. 15 Given the urgency of timely interventions, 85% (n=61) of plastic surgeons use devices for postoperative neo-mamma monitoring, predominantly the handheld Doppler (74%, n=53), followed by local SpO 2 sensors, implantable dopplers, and temperature sensors. With ongoing advancements, there is growing interest in innovative flap assessment methods. In recent literature, promising techniques such as near-infrared spectroscopy and implantable Doppler have been described for flap assessment, providing continuous objective physiological data on tissue perfusion. 16 , 17
|
PMC11697778_p32
|
PMC11697778
|
Discussion
| 4.066679 |
biomedical
|
Study
|
[
0.9988149404525757,
0.0008606877527199686,
0.00032436189940199256
] |
[
0.9359087347984314,
0.0008344973321072757,
0.06290518492460251,
0.0003516077995300293
] |
en
| 0.999996 |
Regarding supplementary surgical interventions, a minority of respondents reported performing intraoperative lymphedema treatment using VLNTs. The limited implementation of this procedure may be due to it primarily being performed in academic settings and the logistical challenge of the additional operation time required. Nevertheless, the incidence of lymphedema following breast cancer treatment is relatively high, ranging from 24% to 49% after mastectomy. 18 Research has shown that combining VLNT with DIEP flap breast reconstruction can significantly improve lymphedema-related quality of life rate. 19 Regarding this supplementary procedure, this study focused solely on whether lymphedema treatment was performed during initial surgery. A further in-depth analysis of lymphedema treatment was not conducted.
|
PMC11697778_p33
|
PMC11697778
|
Discussion
| 4.021809 |
biomedical
|
Study
|
[
0.9990347623825073,
0.0007004384533502162,
0.0002649099042173475
] |
[
0.9988839030265808,
0.00036191754043102264,
0.0006624425295740366,
0.0000917951765586622
] |
en
| 0.999998 |
Postoperatively, patients typically stay hospitalized for an average of 5 days. Prior research, including the one by Frey et al., associate microsurgical ABR with longer operative times and extended hospital stays. 20 To address this, an enhanced recovery after surgery protocol has been introduced to optimize recovery of patients after DIEP flap reconstructions. 21 , 22
|
PMC11697778_p34
|
PMC11697778
|
Discussion
| 3.443441 |
biomedical
|
Study
|
[
0.9936581254005432,
0.0050100302323699,
0.0013319108402356505
] |
[
0.8400489687919617,
0.12596763670444489,
0.032342296093702316,
0.0016409921227023005
] |
en
| 0.999996 |
In this study, 75% of the respondents had less than 15 years of experience as a surgeon. This suggests that the results represent the perspectives of relatively young and potentially recently trained group of surgeons. Furthermore, approximately three-quarters of the respondents were microsurgeons performing ABR procedures by themselves, indicating that the findings reflect current practices.
|
PMC11697778_p35
|
PMC11697778
|
Discussion
| 2.28174 |
biomedical
|
Study
|
[
0.9924335479736328,
0.0038187354803085327,
0.0037477645091712475
] |
[
0.9904698133468628,
0.008683324791491032,
0.00045979596325196326,
0.0003870430518873036
] |
en
| 0.999999 |
To ensure data accuracy for each subsection, all individual question responses were considered for each subsection, regardless of the survey completion status. Although this approach improved the understanding across topics, it led to varying sample sizes across the data subsections. To provide clarity, the specific sample sizes have been explicitly stated for each subsection. Additionally, the customized design of this study enabled respondents to answer only the questions that were applicable to them, contributing to the variability in sample sizes. Cross-continental comparisons were hindered by limited samples from different continents. This uneven distribution of data across continents highlights where ABR research or practices are the most common and also suggests potential geographical biases in the dataset. Accuracy in calculating the response rate was compromised by emails sent to individual plastic surgeons and societies of unknown sizes. Consequently, a reliable response percentage could not be determined and is therefore not reported.
|
PMC11697778_p36
|
PMC11697778
|
Limitations
| 3.065902 |
biomedical
|
Study
|
[
0.9948331117630005,
0.0007218453101813793,
0.0044449553824961185
] |
[
0.9987578392028809,
0.0009362671407870948,
0.00023188019986264408,
0.00007392792031168938
] |
en
| 0.999998 |
Lastly, relying solely on self-assessments by respondents may introduce recall bias, especially regarding confidence in performing ABR or flap failure incidence. However, this approach also captures real-world perceptions and experiences, adding authenticity to the findings.
|
PMC11697778_p37
|
PMC11697778
|
Limitations
| 2.617388 |
biomedical
|
Study
|
[
0.9943251013755798,
0.0011363514931872487,
0.004538482055068016
] |
[
0.9763351082801819,
0.02089451625943184,
0.002496365923434496,
0.00027394137578085065
] |
en
| 0.999998 |
This study provides valuable insights into the current practices of ABR worldwide, serving as a comprehensive overview for novice and experienced plastic surgeons. By broadening horizons beyond the local methodologies, it will aid in making well-informed decisions during the preparation and perioperative care of ABR, and underscores the potential areas for innovation in breast surgery. Although not a definitive guide, this study provides a state-of-the-art portrayal of how ABR is performed worldwide.
|
PMC11697778_p38
|
PMC11697778
|
Conclusion
| 3.872657 |
biomedical
|
Study
|
[
0.9987720847129822,
0.0009367596940137446,
0.0002910557377617806
] |
[
0.9795181155204773,
0.005896147806197405,
0.014083070680499077,
0.0005025766440667212
] |
en
| 0.999997 |
The authors declare no conflicts of interest as this study received no financial support, and the study report was not influenced by personal relationships of the authors.
|
PMC11697778_p39
|
PMC11697778
|
Conflict of Interest
| 0.96143 |
other
|
Other
|
[
0.010521167889237404,
0.0008816422196105123,
0.9885972142219543
] |
[
0.003111340804025531,
0.9953357577323914,
0.0008868470904417336,
0.000666172883938998
] |
en
| 0.999996 |
None disclosed.
|
PMC11697841_p0
|
PMC11697841
|
Conflicts of interest
| 0.821417 |
other
|
Other
|
[
0.12993422150611877,
0.006952665746212006,
0.8631131649017334
] |
[
0.018993327394127846,
0.9769129753112793,
0.002008478157222271,
0.002085266401991248
] |
it
| 0.857138 |
Plastics, predominantly derived from fossil fuels, have undeniably become a fundamental component of contemporary society . However, the accumulation of end-of-life plastics in the environment is causing a profound ecological crisis worldwide . In the pursuit of a circular economy, plastic waste is increasingly recognized as a valuable carbon resource that can be reintegrated into the chemical/material industry . Consequently, devising efficient methods for chemically transforming plastic waste into original precursors or a variety of functional and high-value chemicals is of paramount importance . Notably, chemical upcycling, which differs from traditional recycling techniques focused on monomer recovery, presents an advantageous route for enhancing plastic waste management by converting waste into value-added chemicals [ 7–10 ]. For example, polyolefins, known for their stability, are difficult to be transformed, but also versatile in their transformation capabilities. They can be converted into various mixture compounds such as mixture of alkanes , olefins , aromatics , or oxygenates . Notably, an elegant and innovative method has been recently reported which allows polyethylene (PE) to react with ethylene, producing a highly valuable single chemical, propene . Similarly, there has been substantial progress in developing new methods for the catalytic upcycling of different types of plastic wastes, as evidenced by various studies and advancements in the field [ 11–22 ].
|
PMC11697979_p0
|
PMC11697979
|
INTRODUCTION
| 4.071029 |
biomedical
|
Study
|
[
0.7320061326026917,
0.0011260765604674816,
0.2668676972389221
] |
[
0.9489529132843018,
0.00464928662404418,
0.04623003676533699,
0.00016772271192166954
] |
en
| 0.999998 |
Polyurethane (PU), containing urethane bonds and accounting for ∼6% of all plastic waste , is typically synthesized from isocyanates and polyols and comes in various forms, including foams, adhesives, and elastomers, depending on the monomers and additives used . Although PU can be relatively easily segregated from waste streams, the complexity of its monomers and its robust cross-linked structure make recycling or upcycling challenging. Techniques such as pyrolysis, hydrolysis, alcoholysis, aminolysis, acidolysis, and glycolysis have been explored for PU recycling [ 25–31 ], with methanolysis being a straightforward approach for depolymerization . Yet, the resulting low-value polyols and non-virgin monomers (methyl carbamates) from the cleavage of the –C(=O)–O– in urethane bonds make this method less attractive for further PU reproduction. An alternative, more effective method is catalytic hydrogenation, which breaks both –NH–C(=O)– and –C(=O)–O– bonds in an atom-efficient manner to recover basic monomers or derivatives. Several transformation systems have been successfully developed based on homogeneous catalytic hydrogenation [ 34–37 ], although their low thermal stability and the challenges in separating catalysts for reuse from reaction systems may limit their practical applications.
|
PMC11697979_p1
|
PMC11697979
|
INTRODUCTION
| 4.266163 |
biomedical
|
Study
|
[
0.9877336025238037,
0.0006218015914782882,
0.011644534766674042
] |
[
0.9538124799728394,
0.0009166527888737619,
0.04513616859912872,
0.00013480395136866719
] |
en
| 0.999999 |
We suggest that an effective upcycling strategy for PU should incorporate a carefully engineered heterogeneous catalytic system, which integrates methanolysis with hydrogenation processes. In this context, our proposed strategy involves using CO 2 /H 2 as the reaction medium along with a heterogeneous catalyst. This catalyst is uniquely designed to facilitate both the conversion of CO 2 to methanol and the hydrogenation of plastic depolymerization reaction intermediates. This comprehensive approach is anticipated not only to improve the depolymerization efficiency of PU waste and the utilization of CO 2 waste, but also enable a complete recovery of the designated components. Importantly, we aim to transform these components into valuable materials for the valorization of plastic waste.
|
PMC11697979_p2
|
PMC11697979
|
INTRODUCTION
| 4.102337 |
biomedical
|
Study
|
[
0.9562477469444275,
0.000526293006259948,
0.04322589188814163
] |
[
0.9907060265541077,
0.00863147433847189,
0.0005851316964253783,
0.00007749267388135195
] |
en
| 0.999996 |
Here we introduce a novel two-step reaction construct to convert polyurethane (PU), containing urethane and ester bonds, into two valuable polymers: polyimide (PI, an engineering plastic) and polylactone (P(BL- co -CL), a biodegradable plastic), as illustrated in Fig. 1 . During the initial heterogeneous depolymerization step of PU, we employed a mixture of CO 2 /H 2 , a highly effective combination for the catalytic hydrogenative depolymerization of PU into diamines, diols, and lactones. This process achieved a total product yield of 86% using an inverse ZnO-ZrO 2 /Cu catalyst at 200°C. Subsequently, the produced 1,4-butanediol (BDO) was further converted into γ-butyrolactone (BL) using the same catalyst at 220°C. In the subsequent step, the obtained diamine and lactones were utilized to synthesize PI and P(BL- co -CL), respectively. Remarkably, from 5 g of waste tyre material, predominantly composed of PU, we successfully produced ∼2.2 g of PI films. These films demonstrated excellent energy-storage capabilities, functioning as dielectric capacitors with a discharge energy density ( U e ) of 6.0 J cm −3 at 150°C. Concurrently, we also generated ∼0.44 g of polylactone, exhibiting both satisfactory chemical recyclability and ductile properties. This innovative approach not only paves a new path for upcycling PU waste into a range of valuable and functional polymers but also contributes to the realization of a sustainable future.
|
PMC11697979_p3
|
PMC11697979
|
INTRODUCTION
| 4.281963 |
biomedical
|
Study
|
[
0.9991105198860168,
0.0003669118450488895,
0.0005225464701652527
] |
[
0.998388409614563,
0.0005212221876718104,
0.0009941868484020233,
0.0000962623453233391
] |
en
| 0.999997 |
First, we synthesized an inverse ZnO-ZrO 2 /Cu catalyst using a method similar to a previously reported procedure , with the characterizations presented in Figs S1 and S2 ( Supplementary data , XRD and N 2 physisorption analysis). This catalyst was selected for testing the hydrogenative depolymerization of PU in a CO 2 /H 2 environment, motivated by the known efficacy of inverse Cu-based catalysts in converting CO 2 to methanol and hydrogenating polyesters .
|
PMC11697979_p4
|
PMC11697979
|
RESULTS AND DISCUSSION
| 4.068074 |
biomedical
|
Study
|
[
0.9986043572425842,
0.00025915412697941065,
0.0011364936362951994
] |
[
0.9996034502983093,
0.00024026208848226815,
0.00012031121150357649,
0.00003600151103455573
] |
en
| 0.999998 |
We then evaluated this catalyst for degrading two types of polyurethane: a synthetic PU1, composed of urethane bonds created from the reaction of 4,4'-methylenedianiline with triethylene glycol (TEG), and a commercial PU2, containing both urethane and ester bonds . These were chosen as model feedstocks, with PU1 representing a simpler urethane-only structure and PU2 being more representative of real-world plastics. Remarkably, both PU1 and PU2 were completely converted within 4 hours at 200°C under CO 2 /H 2 conditions (1/3, v/v, 3 MPa) over inverse ZnO-ZrO 2 /Cu catalyst, leaving no residual PUs as confirmed by Fig. 2a, b , and Figs S3–S6 . The catalytic depolymerization yielded three types of products: aromatic amines (4,4′-methylenedianiline ( a ); 4-(4-aminobenzyl)- N -methylaniline ( b ); 4,4′-methylenebis( N -methylaniline) ( c )), diols (TEG from PU1; BDO and dipropylene glycol (DPG) from PU2), and lactones (BL and ε-caprolactone (CL) from PU2), as shown in Fig. 2a . The product yields were impressive, at 89% for PU1 and 82% for PU2 under condition 1 . Additionally, methanol formation was observed, arising from the CO 2 hydrogenation reaction . This indicates that an effective heterogeneous catalytic system for the degradation of polyurethanes has been successfully established. The mass balance of the catalytic process was calculated through dividing the mass of obtained products related to monomers by the total mass input of polyurethane. Although the calculation does not exclude the involed mass of hydrogen and methyl group from CO 2 , the mass balance is still appropriate to evaluate the efficiency of recovered products from depolymerization of polyurethane. The lower yield of obtained products from depolymerization of polyurethane at higher temperature may be due to the formation of N -alkylated byproducts between diamines and diols.
|
PMC11697979_p5
|
PMC11697979
|
RESULTS AND DISCUSSION
| 4.239669 |
biomedical
|
Study
|
[
0.9992818236351013,
0.00035671761725097895,
0.0003614679735619575
] |
[
0.9993878602981567,
0.0001855864975368604,
0.0003549661487340927,
0.0000716209615347907
] |
en
| 0.999997 |
We envision that CO 2 plays a crucial role in generating methanol, which in turn accelerates the hydrogenative depolymerization of PU. To test this hypothesis, we conducted depolymerization studies under various reaction conditions . Initially, we assessed the catalytic depolymerization performance using either hydrogen (2.2 MPa) or a stoichiometric amount of methanol (2 mmol) alone . In both scenarios, we observed a significant reduction in product yields, underscoring the efficacy of the CO 2 /H 2 combination for efficient catalytic degradation. Notably, the yields in hydrogen (PU1: 51%; PU2: 36%) were substantially higher compared to those in methanol (PU1: 31%; PU2: 21%), suggesting hydrogen's primary role in the hydrogenative deconstruction of PU.
|
PMC11697979_p6
|
PMC11697979
|
RESULTS AND DISCUSSION
| 4.137025 |
biomedical
|
Study
|
[
0.9985748529434204,
0.00033870962215587497,
0.0010865036165341735
] |
[
0.9996349811553955,
0.00018321983225177974,
0.0001425587252015248,
0.00003925745113519952
] |
en
| 0.999998 |
Subsequently, we conducted a control reaction with both hydrogen (2.2 MPa) and a stoichiometric amount of methanol (2 mmol) . While the activities were comparable, the product yields (PU1: 81%; PU2: 76%) were slightly lower than under condition 1. However, it confirmed the pivotal role of methanol generated in-situ from CO 2 in the depolymerization process. Moreover, in experiments using only hydrogen or tetrahydrofuran (THF) solvent without the catalyst , only lactone products were obtained from PU2. This indicates that hydrogenative depolymerization predominantly occurs over the ZnO-ZrO 2 /Cu catalyst and that the ester bond in PU2 can be partially broken down in THF solvent. To further discriminate the catalytic active sites in the reduction of CO 2 to methanol, the methanolysis and hydrogenolysis reactions of PU, we carefully investigated the catalytic processes by changing different reaction conditions . In the CO 2 reduction process, Cu species were the main active sites, and a Zn additive promoted the catalytic reduction activity. In the catalytic hydrogenolysis processes, Cu species were the main catalytic active sites for the cleavage of urethane bonds.
|
PMC11697979_p7
|
PMC11697979
|
RESULTS AND DISCUSSION
| 4.205776 |
biomedical
|
Study
|
[
0.9992483258247375,
0.00033377084764651954,
0.000417912844568491
] |
[
0.9995161294937134,
0.00016722198051866144,
0.0002528070181142539,
0.00006385181768564507
] |
en
| 0.999997 |
The efficiency of the depolymerization processes for PU1 and PU2 was thoroughly analyzed using gel permeation chromatography (GPC) to measure the materials recovered from the reactions . A distinctive observation was that, under CO 2 /H 2 reaction conditions , no polymer signals were detected. This highlights the exceptional capability of the designed catalytic system for effective PU degradation. Intriguingly, the process also yielded valuable methylated amines , which are known to play a crucial role in modulating biological and pharmaceutical activities in life science molecules . The methyl groups in these compounds are believed to originate from CO 2 , as evidenced by experiments under various reaction conditions . This suggests a sustainable carbon-fixation process, further emphasizing the environmental and industrial relevance of this catalytic method.
|
PMC11697979_p8
|
PMC11697979
|
RESULTS AND DISCUSSION
| 4.138556 |
biomedical
|
Study
|
[
0.9994320273399353,
0.00027111469535157084,
0.0002967463806271553
] |
[
0.9992873072624207,
0.000187918238225393,
0.0004678578407038003,
0.00005700465408153832
] |
en
| 0.999998 |
To further understand the cleavage of urethane bonds during the hydrogenative depolymerization process, a small model compound (Model 1, propyl p -tolylcarbamate) was synthesized . Since the compound only contains –NH–C(=O)– and –C(=O)–O– bonds that can be cleaved, it can be effectively converted into aromatic amines (4-methylaniline (MA), N ,4-dimethylaniline (DMA), and 4-methyl- N -propylaniline (MPA)) and 1-propanol (Pol) with a total yield of 98% over ZnO-ZrO 2 /Cu in the presence of CO 2 /H 2 . The formation of DMA and MPA indicates that N-alkylation occurred during the process. Obviously, the total product yield decreased to 80% under the hydrogen atmosphere , suggesting the lower efficiency of catalytic hydrogenation of the ester bonds. In addition, an excessive amount of methanol was used to visualize its effect during catalytic hydrogenation of the urethane bond under an inert atmosphere. In contrast, the total product yield toward MA and Pol was only 47%. The process was achieved along with formation of other N -methylated products (DMA and N,N ,4-trimethylaniline (TMA)) and methanolysis products (methyl p -tolylcarbamate (MTC) and N - p -tolylformamide (TFA)) with a yield of 43% . The formations of MTC and TFA can present intermediates for insight into the reaction mechanism during catalytic depolymerization of polyurethane, demonstrating that the effective cleavage of –C(=O)–O– bond precedes the –NH–C(=O)– bond in the presence of methanol. Moreover, the generated N -methylated products suggest that excessive methanol in the catalytic system is unfavorable for producing primary amines.
|
PMC11697979_p9
|
PMC11697979
|
RESULTS AND DISCUSSION
| 4.322716 |
biomedical
|
Study
|
[
0.9990212917327881,
0.0005268070381134748,
0.00045178952859714627
] |
[
0.9992927312850952,
0.0002566069015301764,
0.00035601985291577876,
0.00009462691377848387
] |
en
| 0.999997 |
Considering that the complex composition and additives in commercial PU plastics could potentially affect the efficiency of our designed catalytic system, we evaluated its robustness using four different commercial PU products: a shoe sole, a tube, a tyre, and a safety strip . The catalytic degradation of each of these PU plastics (400 mg each) was assessed, and the results are displayed in Fig. 3b . The total product yields from the catalytic depolymerization were found to be 77%, 80%, 86%, and 82% for the shoe sole, tube, tyre, and safety strip, respectively . These results underscore the effectiveness of our catalytic method in hydrogenatively depolymerizing various commercial PU plastics, despite their differing compositions. Taking the PU tyre as a case study, which contained the highest proportion of urethane linkage ( Table S1 ), we observed consistent catalytic performance over six repeated cycles of transformation . This consistent performance is a testament to the excellent stability of our catalytic system, indicating its potential for practical applications in recycling and upcycling commercial PU plastics.
|
PMC11697979_p10
|
PMC11697979
|
RESULTS AND DISCUSSION
| 4.084858 |
biomedical
|
Study
|
[
0.9765356183052063,
0.0006672034505754709,
0.022797171026468277
] |
[
0.9994440674781799,
0.00024007217143662274,
0.00027709139976650476,
0.00003866672341246158
] |
en
| 0.999996 |
We subsequently conducted a scaled-up deconstruction of a 5 g PU tyre sample to extract basic chemicals for further processing . This procedure was executed with exceptional catalytic efficiency, as shown in Fig. 3e . Following purification by flash column chromatography, we isolated 0.90 g of compound a , 0.71 g of compound b , 0.95 g of BDO, and 0.45 g of lactones (BL and CL) . Given the value of BL as a precursor for biodegradable plastics, we converted the obtained BDO into BL using a straightforward dehydrogenation method . This reaction employed the same ZnO-ZrO 2 /Cu catalyst at 220°C under a nitrogen atmosphere, resulting in a BL yield of 96% over 12 hours . This BL was then combined with the lactones obtained in the initial step, yielding a total of 1.3 g of lactones (BL/CL ratio of 11/1, mol/mol) . Additionally, both the fresh and spent ZnO-ZrO 2 /Cu catalysts underwent comprehensive characterization using techniques such as XRD, X-ray photoelectron spectroscopy (XPS), X-ray absorption near-edge structure (XANES) spectroscopy, extended X-ray absorption fine-structure (EXAFS), and transmission electron microscopy (TEM) . These analyses revealed no significant changes, confirming that the crystalline phase, chemical valence, coordination environment, and morphology of the ZnO-ZrO 2 /Cu catalyst remains highly stable throughout the catalytic processe.
|
PMC11697979_p11
|
PMC11697979
|
RESULTS AND DISCUSSION
| 4.168892 |
biomedical
|
Study
|
[
0.9993570446968079,
0.00033422798151150346,
0.0003086825890932232
] |
[
0.9995086193084717,
0.00017029994342010468,
0.0002455911599099636,
0.00007548594294348732
] |
en
| 0.999996 |
Aromatic diamines and lactones are key building blocks for diverse applications. In our strategy, the aromatic diamines and lactones obtained from the process were utilized to synthesize two high-value polymers: polyimide (PI) and polylactone (P(BL- co -CL)). As depicted in Fig. 1 , the 4,4′-methylenedianiline (0.9 g) derived from the PU tyre was reacted with dianhydrides—specifically, pyromellitic dianhydride (PMDA) and 4,4′-(hexafluoroisopropylidiene)diphthalic anhydride (6FDA)—to produce two types of PI films (PI1 and PI2, respectively) as shown in Fig. 4a and b . PI is a crucial engineering plastic, prized for its exceptional thermal stability, electrical insulation, and high mechanical strength .
|
PMC11697979_p12
|
PMC11697979
|
RESULTS AND DISCUSSION
| 4.031372 |
biomedical
|
Study
|
[
0.9964206218719482,
0.00023122462152969092,
0.0033481651917099953
] |
[
0.9987394213676453,
0.0010949926218017936,
0.00012261704250704497,
0.00004299618740333244
] |
en
| 0.999997 |
The successful synthesis of PI films was confirmed by infrared (IR) analysis, which revealed characteristic vibration peaks: at 710 cm −1 (imide ring), 1365 cm −1 (C–N stretch), 1715 cm −1 (C=O symmetric stretch), 1780 cm −1 (C=O asymmetric stretch), and between 2850 and 2950 cm −1 (C–H stretch associated with the –CH 2 – moiety) . The properties of the synthesized PI1, PI2, and commercial Kapton films were compared. All films demonstrated excellent solvent resistance, remaining insoluble in various solvents (DCM, NMP, DMF, THF, and DMSO) as shown in Fig. S20 . Their thermal stability was assessed using thermal gravimetric analysis (TGA) and dynamic mechanical analysis (DMA) . The findings showed that the 5% weight loss temperatures and glass transition temperature ( T g ) of all films were above 450°C and 300°C, respectively, indicating superior thermal resistance. Additionally, the dielectric properties of the films, including the dielectric constant and loss tangent, were evaluated at a high temperature of 150°C . These properties remained stable across a frequency range of 10 to 10 7 Hz, demonstrating excellent dielectric stability and endurance under high voltage conditions.
|
PMC11697979_p13
|
PMC11697979
|
RESULTS AND DISCUSSION
| 4.203373 |
biomedical
|
Study
|
[
0.9990704655647278,
0.0003168973489664495,
0.0006126418593339622
] |
[
0.999479353427887,
0.00013492886500898749,
0.0003329278843011707,
0.0000529004137206357
] |
en
| 0.999999 |
The PI1 and PI2 films synthesized in our study show great promise as dielectric materials for high-temperature capacitors. In comparison to commercial Kapton, the synthetic PI1 and PI2 films demonstrated notably higher maximum discharge energy densities ( U e ) of 2.4 and 6.0 J cm −3 , respectively, with charge-discharge efficiencies ( ƞ ) exceeding 90% at 150°C . This superior performance is likely attributable to their larger band gap compared to commercial Kapton, as evidenced in Fig. S22b . Furthermore, the PI2 film maintained its excellent performance, with a U e of 2.6 J cm −3 and η >90%, even under more challenging conditions at 200°C . This resilience under extreme temperatures highlights the potential of PI2 for advanced applications. Thus, the aromatic diamine recovered from the catalytic degradation of PU plastic waste is not just recycled but significantly upgraded into PI films with competitive properties, as shown in Fig. S23b . This transformation represents a major stride forward in converting waste materials into high-performance products.
|
PMC11697979_p14
|
PMC11697979
|
RESULTS AND DISCUSSION
| 4.14178 |
biomedical
|
Study
|
[
0.8986709713935852,
0.0009159967303276062,
0.10041311383247375
] |
[
0.9986522793769836,
0.0007715573301538825,
0.0005215713172219694,
0.0000546234477951657
] |
en
| 0.999996 |
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