Philip N. Redlich

Carcinoma of the breast in males

Breast carcinoma in males is infrequent, and information regarding the results of modern treatment is limited. Cases of breast carcinoma in males were accrued from multiple hospitals in one region to determine treatment, survival, and prognostic factors.

BREAST CANCER IN MEN

Aside from its much lower frequency, breast cancer in men is remarkably similar to the disease in women. The cause remains equally obscure; the clinical presentation, pathology, and natural history are similar; and men are probably as curable in similar circumstances. Men are generally older and in more advanced stages than women when diagnosed, the tumors are located more often beneath the nipple and are more often responsive to hormonal therapy, but otherwise differences are negligible. Stage and axillary node status are strong prognostic indicators. Modified radical mastectomy has replaced radical mastectomy for surgical treatment of early states, and systemic adjuvant therapy appears to improve the prognosis for cases with involvement of lymph nodes.

Acquisition of surgical skills: a randomized trial of didactic, videotape, and computer-based training.

BACKGROUND Although computer-based training (CBT) can enhance didactic instruction, few studies have assessed the efficacy of CBT for basic surgical skills training. This study compares CBT with traditional methods of basic surgical skills training. METHODS Sixty-nine naive medical students were randomized into 3 treatment groups for basic surgical skills instruction: didactic, videotape, or CBT. All instructional material contained the same pictures, text, and audio. With use of a multiple-choice question examination and a series of performance stations, students were objectively assessed before, immediately after, and 1 month after skills instruction. Raters were blinded to treatment modality during the follow-up evaluation. RESULTS There were no significant differences among the groups before treatment. After treatment, the didactic group scored higher on the multiple-choice question examination. In contrast, the videotape and CBT groups demonstrated statistically significant (P < .01) enhancement of technical skills compared with the didactic group. After 1 month, a calculated performance quotient revealed statistically significant (P < .01) improvement only in the CBT group. The amount of time students spent practicing their skills was not significantly different among the groups. CONCLUSIONS CBT is as effective as, and possibly more efficient, than traditional methods of basic surgical skills training for medical students.

Impaired immune function in obstructive jaundice

Sepsis is a common and occasionally lethal complication of obstructive jaundice. The reasons for this increased susceptibility to infection are unknown. This study examines lymphocyte and reticuloendothelial (RES) function in animals with obstructive jaundice. Twelve New Zealand white rabbits (3-4 kg) were studied. Lymphocyte function was evaluated in six rabbits by phytohemagglutinin (PHA), concanavalin A (Con A), and pokeweed mitogen (PWM) stimulation. In six animals, hepatic RES function was assessed by calculating the phagocytic index (PI) using the disappearance of 99Tc sulfacolloid (5 mg/kg) iv. After baseline studies, the common bile duct was divided and ligated. The above studies and serum bilirubin were repeated at 3 weeks. Obstruction was then relieved by cholecystojejunostomy (CJ) and RES studies repeated monthly x 6. Preobstructive lymphocyte function showed a stimulation index ratio (log) of 0.85 +/- 0.25 for PHA, 0.75 +/- 0.3 for Con A, and 0.71 +/- 0.25 for PWM. With biliary obstruction, the values fell to -0.23 +/- 15 (P less than 0.006), -0.31 +/- 0.12 (P less than 0.006), and -0.29 (P less than 0.006), demonstrating impaired lymphocyte function. When tested lymphocytes were mixed with control pooled rabbit serum, however, no lymphocyte impairment was noted. Baseline hepatic PI was 6.02 +/- 0.18 and fell to 3.79 +/- 0.33 with obstruction (P less than .01) and remained low at (3.20 +/- 0.14) 1 month (P less than 0.01) and (3.33 +/- 0.23) at 3 months (P less than .01), after CJ but returned to normal (8.04 +/- 0.97) at 6 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Does breast tumor location influence success of sentinel lymph node biopsy

BACKGROUND Controversy exists regarding the influence of sentinel lymph node (SLN) mapping technique or patient variables on the success rate of SLN mapping. We undertook a prospective study in a single institution series to evaluate multiple variables that could adversely affect SLN identification rates. STUDY DESIGN Data were collected on 174 patients who underwent 177 SLN mapping procedures followed by axillary dissection from October 1996 through January 2000. Patient demographics, body mass index (BMI), biopsy method, tumor size, palpability, and location were recorded. SLNs were identified by blue dye only (n = 31), Tc-99m sulfur colloid only (n = 34), or combined techniques (n = 112). Data were analyzed by logistic regression analysis and expressed as the probability of failure to map the SLN. RESULTS SLNs were identified successfully in 150 of 177 procedures (85%) with a false negative rate of 3.7%. Mapping success reached 93% using combination blue dye and isotope. Variables found to adversely affect SLN mapping success and the odds ratio of failure (OR) included lower inner quadrant (LIQ) location (OR 35.6), blue dye only (OR 42.4), BMI >30 and upper outer quadrant (UOQ) location (OR 14.6), and nonpalpable UIQ location (OR 25). LIQ location adversely affects mapping success independent of technique, tumor size, or obesity. Obesity and nonpalpability were adverse factors when tumors were located in the UOQ and UIQ, respectively. Age, biopsy technique, and tumor diameter did not affect SLN mapping success. CONCLUSIONS SLN mapping success is influenced by technique and tumor location, with best results achieved using combined techniques and for lesions located in quadrants other than the LIQ. Obesity and tumor palpability influence success in the context of tumor location.

Mapping of IFN-β Epitopes Important for Receptor Binding and Biologic Activation: Comparison of Results Achieved Using Antibody-Based Methods and Alanine Substitution Mutagenesis

The epitopes important for receptor binding and activation of human interferon-beta1a (IFN-beta1a) were mapped with monoclonal antibodies (mAb), grouped on the basis of their specificity and ability to neutralize biologic activity, and alanine scanning mutagenesis (ASM). The binding properties of nine mAb were defined, using ASM-IFN-beta mutants having alanine substituted at targeted, surface-exposed residues. The results were correlated with the mAb neutralizing potency. Of six mAb that bound either at or adjacent to the IFNAR-2 receptor chain binding site defined by the ASM epitopes, only three had measurable neutralizing activity. Two of these inhibited IFN-beta/IFNAR-2 complex formation, suggesting that steric hindrance of receptor binding constitutes their mechanism of neutralization. However, two mAb that bound to sites remote from the IFNAR-2 binding site on IFN-beta also inhibited IFN-beta/IFNAR-2 complex formation and demonstrated potent neutralizing activity. Thus, neutralizing mAb may employ mechanisms other than steric blockade to inhibit directly the binding of receptor by cytokine, limiting their usefulness as tools to define precise receptor-ligand interaction sites.

A Unique Collision Tumor in Breast Invasive Ductal Carcinoma and Mucosa-Associated Lymphoid Tissue Lymphoma

We report an extraordinary case of a collision tumor consisting of invasive ductal carcinoma with adjacent malignant lymphoma presenting as a single mass in the breast. A 79-year-old woman presented with a breast mass. A core biopsy performed at an outside hospital was interpreted as medullary carcinoma. On review of the breast core biopsy, a diagnosis of a synchronous malignant lymphoma and invasive ductal carcinoma was rendered. The patient underwent lumpectomy and axillary dissection. The excised specimen revealed a 2.1-cm, moderately differentiated invasive ductal carcinoma, partially surrounded by malignant lymphoma with areas where both tumors were intermixed. All 27 axillary lymph nodes were extensively involved by lymphoma, and 1 lymph node demonstrated metastatic carcinoma. The morphology and results of immunohistochemistry, flow cytometry, and cytogenetic analysis were consistent with extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue.

Surgery Residency Curriculum Examination Scores Predict Future American Board of Surgery In-Training Examination Performance

IMPORTANCE A protected block curriculum (PBC) with postcurriculum examinations for all surgical residents has been provided to assure coverage of core curricular topics. Biannual assessment of resident competency will soon be required by the Next Accreditation System. OBJECTIVE To identify opportunities for early medical knowledge assessment and interventions, we examined whether performance in postcurriculum multiple-choice examinations (PCEs) is predictive of performance in the American Board of Surgery In-Training Examination (ABSITE) and clinical service competency assessments. DESIGN Retrospective single-institutional education research study. SETTING Academic general surgery residency program. PARTICIPANTS A total of 49 surgical residents. INTERVENTION Data for PGY1 and PGY2 residents participating in the 2008 to 2012 PBC are included. Each resident completed 6 PCEs during each year. MAIN OUTCOME MEASURES The results of 6 examinations were correlated to percentage-correct ABSITE scores and clinical assessments based on the 6 Accreditation Council for Graduate Medical Education core competencies. Individual ABSITE performance was compared between PGY1 and PGY2. Statistical analysis included multivariate linear regression and bivariate Pearson correlations. RESULTS A total of 49 residents completed the PGY1 PBC and 36 completed the PGY2 curriculum. Linear regression analysis of percentage-correct ABSITE and PCE scores demonstrated a statistically significant correlation between the PGY1 PCE 1 score and the subsequent PGY1 ABSITE score (p = 0.037, β = 0.299). Similarly, the PGY2 PCE 1 score predicted performance in the PGY2 ABSITE (p = 0.015, β = 0.383). The ABSITE scores correlated between PGY1 and PGY2 with statistical significance, r = 0.675, p = 0.001. Performance on the 6 Accreditation Council for Graduate Medical Education core competencies correlated between PGY1 and PGY2, r = 0.729, p = 0.001, but did not correlate with PCE scores during either years. CONCLUSIONS AND RELEVANCE Within a mature PBC, early performance in a PGY1 and PGY2 PCE is predictive of performance in the respective ABSITE. This information can be used for formative assessment and early remediation of residents who are predicted to be at risk for poor performance in the ABSITE.

Evaluating handoffs in the context of a communication framework

Background. The implementation of mandated restrictions in resident duty hours has led to increased handoffs for patient care and thus more opportunities for errors during transitions of care. Much of the current handoff literature is empiric, with experts recommending the study of handoffs within an established framework. Methods. A prospective, single‐institution study was conducted evaluating the process of handoffs for the care of surgical patients in the context of a published communication framework. Evaluation tools for the source, receiver, and observer were developed to identify factors impacting the handoff process, and inter‐rater correlations were assessed. Data analysis was generated with Pearson/Spearman correlations and multivariate linear regressions. Rater consistency was assessed with intraclass correlations. Results. A total of 126 handoffs were observed. Evaluations were completed by 1 observer (N = 126), 2 observers (N = 23), 2 receivers (N = 39), 1 receiver (N = 82), and 1 source (N = 78). An average (±standard deviation) service handoff included 9.2 (±4.6) patients, lasted 9.1 (±5.4) minutes, and had 4.7 (±3.4) distractions recorded by the observer. The source and receiver(s) recognized distractions in >67% of handoffs, with the most common internal and external distractions being fatigue (60% of handoffs) and extraneous staff entering/exiting the room (31%), respectively. Teams with more patients spent less time per individual patient handoff (r = −0.298; P = .001). Statistically significant intraclass correlations (P ≤ .05) were moderate between observers (r ≥ 0.4) but not receivers (r < 0.4). Intraclass correlation values between different types of raters were inconsistent (P > .05). The quality of the handoff process was affected negatively by presence of active electronic devices (&bgr; = −0.565; P = .005), number of teaching discussions (&bgr; = −0.417; P = .048), and a sense of hierarchy between source and receiver (&bgr; = −0.309; P = .002). Conclusion. Studying the handoff process within an established framework highlights factors that impair communication. Internal and external distractions are common during handoffs and along with the working relationship between the source and receiver impact the quality of the handoff process. This information allows further study and targeted interventions of the handoff process to improve overall effectiveness and patient safety of the handoff.

Learning Activities and Third-Year Medical Student Ratings of High Quality Teaching Across Different Clerkships

Objective: To identify and compare learning activities that students associate with high quality teaching across clerkships. Methods: For six months, 110 third year medical students recorded data on learning activities and teaching quality using personal digital assistants (PDAs) during five different required clinical clerkships. Univariate and multivariate analyses were performed to assess the association between learning activities and student ratings of high teaching quality. Results: 11,450 teaching interactions were recorded. Univariate analysis revealed that feedback was associated with perceptions of high quality teaching in all clerkships. Proposing a plan, formulating an assessment and giving an oral case presentation were associated with high quality teaching in 80% of the clerkships (p < 0.01). Multivariate analysis demonstrated that receiving high quality feedback was an independent predictor of student ratings of high quality teaching for all clerkships. Conclusion: Receiving high quality feedback is the learning activity most strongly associated with students’ ratings of high quality teaching across four different clerkships