Rachel L. Yang

Trends in immediate breast reconstruction across insurance groups after enactment of breast cancer legislation.

To improve access to breast reconstruction for mastectomy patients, the United States enacted the Womens Health and Cancer Rights Act in January of 1999. The objective of the current study was to evaluate the impact of this legislation on patients with different insurance plans.

Tertiary hyperparathyroidism in kidney transplant recipients: characteristics of patients selected for different treatment strategies.

Background Several treatment options exist for kidney transplant patients with tertiary hyperparathyroidism. However, the decision to endorse observation (OBS), medical therapy, or parathyroidectomy (PTX) remains controversial. Methods We performed a retrospective cohort study of kidney transplant patients with tertiary hyperparathyroidism at a single institution over a 7-year period. Patients were classified by treatment mode: OBS, medical therapy with cinacalcet (CIN), or PTX. Descriptive statistics were performed. Serum calcium levels and change in serum creatinine level were compared using analysis of variance with comparisons between individual groups using the Student’s t test with a Bonferroni correction. Time to treatment was compared between CIN and PTX groups using the Student’s t test. Complication rates were compared using the Fisher exact test. Results We identified 83 patients: 52 were treated by OBS; 13 were treated with CIN, and 18 underwent PTX. Six weeks after treatment, PTX resulted in lower serum calcium level (9.28 mg/dL) compared with CIN (10.20 mg/dL) (P<0.01). There was no difference in the change in serum creatinine level 1 year after treatment initiation (P=0.98). Time to treatment was shorter (1.7 vs. 3.3 years, P<0.01), and the highest pretreatment calcium level was higher (12.2 vs. 11.7 mg/dL, P<0.01) in patients treated with PTX compared with CIN. Complication rates differed by treatment group (P<0.01). A quarter of OBS patients showed persistent hypercalcemic symptoms, compared with only 7.7% in the CIN group and 0% in the PTX group (P<0.01). Conclusions PTX led to a greater reduction in serum calcium level and lower chance of persistent hypercalcemic symptoms, without any appreciable harm to the kidney allograft.

The virtual-patient pilot: testing a new tool for undergraduate surgical education and assessment.

BACKGROUND The virtual patient (VP) is a web-based tool that allows students to test their clinical decision-making skills using simulated patients. METHODS Three VP cases were developed using commercially available software to simulate common surgical scenarios. Surgical clerks volunteered to complete VP cases. Upon case completion, an individual performance score (IPS, 0-100) was generated and a 16-item survey was administered. Surgery shelf exam scores of clerks who completed VP cases were compared with a cohort of students who did not have exposure to VP cases. Descriptive statistics were performed to characterize survey results and mean IPS. RESULTS Surgical clerks felt that the VP platform was simple to use, and both the content and images were well presented. They also felt that VPs enhanced learning and were helpful in understanding surgical concepts. Mean IPS at conclusion of the surgery clerkship was 69.2 (SD 26.5). Mean performance on the surgery shelf exam for the student cohort who had exposure to VPs was 86.5 (SD 7.4), whereas mean performance for the unexposed student cohort was 83.5 (SD 9). DISCUSSION The VP platform represents a new educational tool that allows surgical clerks to direct case progression and receive feedback regarding clinical-management decisions. Its use as an assessment tool will require further validation.

Human skin neural crest progenitor cells are susceptible to BRAF(V600E)-induced transformation.

Adult stem cells are multipotent and persist in small numbers in adult tissues throughout the lifespan of an organism. Unlike differentiated cells, adult stem cells are intrinsically resistant to senescence. It is unclear how adult stem cells in solid organs respond to oncogenic stimulation and whether these cells have a role in tumor initiation. We report here that expression of BRAFV600E in human neural crest progenitor cells (hNCPCs) did not induce growth arrest as seen in human melanocytes, but instead, increased their cell proliferation capacity. These cells (hNCPCsV600E) acquired anchorage-independent growth ability and were weakly tumorigenic in vivo. Unlike in human melanocytes, BRAFV600E expression in hNCPCs did not induce p16INK4a expression. BRAFV600E induced elevated expression of CDK2, CDK4, MITF and EST1/2 protein in hNCPCs, and also induced melanocytic differentiation of these cells. Furthermore, overexpression of MITF in hNCPCsV600E dramatically increased their tumorigenicity and resulted in fully transformed tumor cells. These findings indicate that hNCPCs are susceptible to BRAFV600E-induced transformation, and MITF potentiates the oncogenic effect of BRAFV600E in these progenitor cells. These results suggest that the hNCPCs are potential targets for BRAFV600E-induced melanocytic tumor formation.

The surgery clerkship: an opportunity for preclinical credentialing in urinary catheterization

BACKGROUND At our hospital, medical students lost privileges to perform urinary catheterization because of concern regarding catheter-associated urinary tract infections. We hypothesized that trained medical students could perform urinary catheterization with the same proficiency as licensed practitioners. METHODS Medical students completed a credentialing program in urinary catheterization. Prospectively, the rate of catheter-associated urinary tract infections after urinary catheterization performed by medical students was compared with the health system-wide rate of catheter-associated urinary tract infections after urinary catheterization performed by non-medical students using an incidence rate ratio (IRR). RESULTS Over 9 months, a total of 432 and 55,401 catheter days accrued in patients who underwent urinary catheterization by medial students and non-medical students, resulting in 1 and 129 catheter-associated urinary tract infections, respectively. The incidence rate of catheter-associated urinary tract infections per 1,000 catheter days was 2.31 in the medical student-placed catheters and 2.33 in the non-MS-placed catheters (IRR = .99, P = .55). CONCLUSIONS Preclinical credentialing in urinary catheterization resulted in the reinstatement of urinary catheterization privileges to qualified medical students. Student proficiency in urinary catheterization can match that of licensed practitioners.

Racial disparities in the use of outpatient mastectomy.

BACKGROUND Racial disparities exist within many domains of cancer care. This study was designed to identify differences in the use of outpatient mastectomy (OM) based on patient race. METHODS We identified patients in the American College of Surgeons National Surgical Quality Improvement Program Participant Use File (during the years 2007-2010) who underwent a mastectomy. The association between mastectomy setting, patient race, patient age, American Society of Anesthesiology physical status classification, functional status, mastectomy type, and hospital teaching status was determined using the chi-square test. A multivariable logistic regression analysis was developed to assess the relative odds of undergoing OM by race, with adjustment for potential confounders. RESULTS We identified 47,318 patients enrolled in the American College of Surgeons National Surgical Quality Improvement Program Participant Use File who underwent a mastectomy during the study time frame. More than half (62.6%) of mastectomies were performed in the outpatient setting. All racial minorities had lower rates of OM, with 63.8% of white patients; 59.1% of black patients; 57.4% of Asian, Native Hawaiian, or Pacific Islander patients; and 43.9% of American Indian or Alaska Native patients undergoing OM (P < 0.001). After adjustment for multiple confounders, black patients, American Indian or Alaska Native patients, and those of unknown race were all less likely to undergo OM (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.80-0.93; OR, 0.55; 95% CI, 0.41-0.72; and OR, 0.70; 95% CI, 0.64-0.76, respectively) compared with white patients. CONCLUSIONS Disparities exist in the use of OM among racial minorities. Further studies are needed to identify the role of cultural preferences, physician attitudes, and insurer encouragements that may influence these patterns of use.

Expression of Oncodrivers HER-3 and C-MET during Breast Tumorigenesis in BRCA Mutation Carriers

BRCA1 and BRCA2 germ line mutations confer a substantial risk of breast cancer, with studies reporting an average cumulative risk of breast cancer by age 70 years as 57-65% in BRCA1-mutation carriers 45-47% in BRCA2-mutation carriers [1,2]. Today, the prevention of breast cancer among mutation carriers has focused on surgical options such as risk-reducing bilateral mastectomy and bilateral salpingooophorectomy [3,4] which have significant associated morbidity. In the general population chemoprevention strategies have been developed to target the known phenotypes of spontaneous DCIS in order to prevent the development of invasive breast cancer [5-7]. As such, evaluation of the pre-invasive progression pathways of BRCA-associated tumors is critical in the effort to develop directed prevention therapies for this vulnerable population.