Arie Bitterman

Increasing examiner involvement in an objective structured clinical examination by integrating a structured oral examination

INTRODUCTION The role of physician examiners in an objective structured clinical examination (OSCE) is relatively passive. In our institution examiners criticized the passive nature of their role. This study evaluates the reliability and viability of adding a structured oral examination to an OSCE. METHOD Ten 24-minute stations consisted of three parts. Part I: 12 minutes-patient encounter. Part II: 6 minutes-oral presentation covering findings, differential diagnosis, and management plan. Part III: 6 minutes-structural oral examination (SOE), containing 5 predetermined questions. RESULTS Over 6 consecutive days, 72 graduates were assessed. Overall average score: 72.02 (SD 5.05); reliability 0.84. Part I of the OSCE average score: 69.2 (SD 7.4); reliability 0.69. Part II oral presentation average score 64 (SD 5.8) reliability 0.87. SOE average score 77.7 (SD 6.3); reliability 0.64. Eighty-nine percent of the examiners indicated satisfaction with the new format. CONCLUSIONS The SOE was a reliable component of an OSCE and contributed to the overall reliability. Examiners reported a higher degree of satisfaction with the examination.

Oral bisphosphonates and improved survival of breast cancer.

Purpose: Bisphosphonates are used for treatment or prevention of osteoporosis and of bone metastases. The use of oral bisphosphonates was suggested to be associated with reduced risk of developing breast cancer, and their positive influence on breast cancer survival was only demonstrated with third-generation bisphosphonates. We studied the association of use of oral bisphosphonates after breast cancer diagnosis on overall and breast cancer survival. Experimental Design: A nested case–control analysis was performed using data from the population-based Breast Cancer in Northern Israel Study (BCINIS). Participants were postmenopausal women with newly diagnosed breast cancer insured by Clalit. Use of second-generation bisphosphonates (alendronate and/or risedronate) was identified using computerized prescription records. The analysis was restricted to women who did not use bisphosphonates prior to diagnosis. Results: In a cohort of 3,731 postmenopausal women with breast cancer, followed up for an average of 70 months, there were 799 cases of death which were matched to 15,915 control periods of living breast cancer cases. Use of bisphosphonates after diagnosis for at least 18 months was significantly more common among survivors than among their matched controls who died, adjusted for tumor stage/grade (overall survival: OR = 0.63, 0.41–0.96, P = 0.03; breast cancer–specific survival: OR = 0.28, 0.09–0.91, P = 0.035). A similar advantageous effect, but statistically underpowered, was found in estrogen receptor (ER)-positive, ER-negative, and HER2neu-positive tumors. Conclusions: The use of oral bisphosphonates, by postmenopausal, probably osteoporotic, women initiated after diagnosis of breast cancer was associated with a significant improvement in overall and breast-specific odds of survival. Clin Cancer Res; 23(7); 1684–9. ©2016 AACR.

Laparoscopic removal of an intrauterine device following colon perforation.

Intestinal perforation by a migrating intrauterine device is a serious complication and may be corrected by using a laparoscopic approach.

Primary schwannoma of the thyroid gland presenting as an asymptomatic cold nodule.

Schwannomas are benign neoplasms that may arise from Schwann cells of the nerve sheath all over the body. Although schwannomas of the head and neck region are common, the thyroid gland is a rare site for schwannomas, with little documentation in the literature. Presented is a case of a 57-year-old woman who was evaluated in our outpatient clinic for hypothyroidism because of Hashimoto thyroiditis. Thyroid ultrasound revealed a single prominent nodule, which was cold on technetium Tc 99m thyroid scan. Fine needle aspiration of the nodule had aroused suspicion for malignant thyroid neoplasm. Complete thyroidectomy was undertaken without complications. Microscopic examination and immunohistochemical stains supported the diagnosis of a primary thyroid schwannoma.

Thyroid carcinoma presenting as a hot nodule.

Hot thyroid nodules are usually considered benign. The malignancy rate of hot thyroid nodules is 0% to 4% according to different sources, and is even lower in the presence of hyperthyroidism (hyper-functioning nodules). Vocal cord paralysis in the presence of thyroid carcinoma is an occasional complication, deriving from compression or infiltration of the recurrent laryngeal nerve. The paralysis is most commonly unilateral, involving the affected side, but cases of bilateral paralysis have been described. Importantly, hoarseness may be the presenting symptom of patients suffering from thyroid malignancy, but is uncommon in the presence of benign thyroid disease. Reported herein are three cases of patients suffering from thyroid carcinoma that presented as hot nodules on TC-99m radionuclide assessment.

Short-term complications of intra-operative radiotherapy for early breast cancer

IORT is becoming an accepted radiotherapy technique for treatment of early breast cancer. Data regarding the early complications of breast IORT are lacking.

Effect of N-Acetylserotonin on Intestinal Recovery Following Intestinal Ischemia–Reperfusion Injury in a Rat

OBJECTIVE N-acetylserotonin (NAS) is a naturally occurring chemical intermediate in the biosynthesis of melatonin. Extensive studies in various experimental models have established that treatment with NAS significantly protects heart and kidney injury from ischemia-reperfusion (IR). The purpose of the present study was to examine the effect of NAS on intestinal recovery and enterocyte turnover after intestinal IR injury in rats. METHODS Male Sprague-Dawley rats were divided into four experimental groups: (1) Sham rats underwent laparotomy, (2) sham-NAS rats underwent laparotomy and were treated with intraperitoneal (IP) NAS (20 mg/kg); (3) IR rats underwent occlusion of both superior mesenteric artery and portal vein for 30 minutes, followed by 48 hours of reperfusion, and (4) IR-NAS rats underwent IR and were treated with IP NAS (20 mg/kg) immediately before abdominal closure. Intestinal structural changes, Park injury score, enterocyte proliferation, and enterocyte apoptosis were determined 24 hours following IR. The expression of Bax, Bcl-2, p-ERK, and caspase-3 in the intestinal mucosa was determined using real-time polymerase chain reaction, Western blot, and immunohistochemistry. A nonparametric Kruskal-Wallis analysis of variance test was used for statistical analysis with p less than 0.05 considered statistically significant. RESULTS Treatment with NAS resulted in a significant increase in mucosal weight in jejunum and ileum, villus height in the ileum, and crypt depth in jejunum and ileum compared with IR animals. IR-NAS rats also had a significantly proliferation rates as well as a lower apoptotic index in jejunum and ileum which was accompanied by higher Bcl-2 levels compared with IR animals. CONCLUSIONS Treatment with NAS prevents gut mucosal damage and inhibits programmed cell death following intestinal IR in a rat.

Breast Cancer in Nuns

To the Editor: An understanding of the etiologic factors in cancer has been aided by the epidemiologic study of different occupation groups. For more than two centuries, members of religious orders have been the subject of inquiries to assess whether characteristics common to religious life have a role in causing or preventing cancer. The differences among the groups are evaluated in light of the marital environment prevailing in each population; namely, the presence or absence of sexual and reproductive factors associated with the single versus married state. Several reports from the past (1) have indicated that in both sexes, the unmarried have higher death rates from all causes than the married. As an indicator of the environmental effect of marital status on cancer mortality, epidemiologic study of nuns would seem ideal. Several studies have shown that Catholic nuns have a different mortality experience than women of similar age in the general population. A review of the literature with regard to Catholic religious orders, with special reference to the cancer experience of nuns, reveals a number of studies, some of which date back to the early 18th century. Morin Doody et al. (2) had a unique opportunity to evaluate mortality patterns of nuns identified in an occupational study of nearly 145,000 radiologic technologists (73% female). A total of 1103 women were classified as nuns based on their titles of “Sister” or “SR.” Their mortality experience was compared to other female radiologic technologists and to white U.S. females. Compared with the general population, the mortality experience of nuns was favorable and reflected the “healthy worker effect” commonly seen in occupational studies. Patterns observed for breast and cervical cancer possibly indicate differences in reproductive and sexual activities associated with belonging to a religious order. The possibility of a radiation-related excess for breast cancer among nuns certified before 1940 cannot be completely discounted, although there was no dose certified. When their mortality experience was compared with other radiologic technologists, the influence of lifestyle factors was not apparent. Meurer et al. (3) concluded that a 20% greater risk of breast cancer compared to U.S. females agrees with previous studies based on general population comparisons, and is consistent with an increased risk associated with nulliparity. The lack of an increased overall risk for nuns compared to other technologists may reflect similarities in reproductive risk factors, since women in the labor force are more likely than nonworking women to be nulliparous or to delay childbearing, as well as socioeconomic and educational status. Fraumeni et al. (4) showed that the sisters showed a significant excess in mortality from breast cancer over the age span 40 to 74 years and had consistently higher rates than controls for each age group older than 39 years. A summary of this research indicates that further, updated research on religious sisters and the incidence of breast cancer would be in order.

Clinical and Pathological Characteristics of Incidental Diagnostic Early Occult Malignancy After Risk-Reducing Salpingo-Oophorectomy in BRCA Mutation Carriers.

Objective Carriers of familial BRCA mutations are at high risk of early development of ovarian tubal or peritoneal cancers. The definite preventative treatment for these cases is early, risk-reducing, bilateral salpingo-oophorectomy (BSO). The aims of the study were to describe the incidence and source of early occult malignancy after risk-reducing salpingo-oophorectomy in carriers of Ashkenazi Jewish BRCA mutations and to characterize the clinical and pathological features of this unique population. Methods Data were collected retrospectively regarding women who underwent BSO in our gynecologic oncology unit from January 2002 through July 2012, after a positive test for a BRCA1 or BRCA2 mutation. Results The following 92 cases of BRCA mutations were included: 53 BRCA1, 37 BRCA2, and 2 with both mutations. After risk-reducing salpingo-oophorectomy, 5 (5.4%) of the patients were found to have early occult adnexal malignancy upon pathology study. All 5 had the BRCA1 185 del-AG mutation. Three of the 5 malignancies originated from the ovaries and 2 in the fallopian tubes with no involvement of the ovaries. Conclusions A 5.4% incidence of early occult malignancy in adnexal pathology of BSO was found in carriers of Ashkenazi Jewish BRCA mutations. Two cases with malignant origins within the fallopian tube, while sparing the ovaries in their entirety, support the fallopian tubes as the originating organ for some ovarian or peritoneal malignancies in BRCA mutation carriers.

Management of invasive extramammary Paget’s disease of the axilla—a case report

Extramammary Paget’s disease (EMPD) is a rare dermatosis affecting the epidermis. This lesion has a predilection to areas of skin which are rich with apocrine glands, such as the vulva and male genitalia, and often has a more favorable prognosis than mammary Paget disease [1]. A Medline search has revealed that Paget’s disease of the axilla had been reported only in few clinical cases. The guidelines for staging and treatment of EMPD as well as the indications for sentinel lymph node biopsy and lymph node dissection have not yet been established [2]. This report describes an unusual case in which an EMPD has invaded the dermis and was treated by wide local excision and sentinel lymph node biopsy followed by an axillary lymph node dissection (ALND). The reconstruction of the soft tissue defect was successfully achieved by employing a thoracodorsal artery perforator (TDAP) flap which enabled to preserve a complete range of motion of the upper limb. To our knowledge, the reconstruction of a large axillary skin defect due to EMPD employing a TDAP flap has not been reported.