Extent of Groin Dissection in Melanoma: A Mixed-Methods, Population-Based Study of Practice Patterns and Outcomes.

Melanoma metastases to the groin are frequently managed by therapeutic lymph node dissection. Evidence is lacking regarding the extent of dissection required. Thus, we sought to describe practice patterns for the use of inguinal vs. ilioinguinal dissection, as well as the perioperative/oncologic outcomes of each procedure. A mixed-methods approach was employed to evaluate surgical practice patterns. A retrospective review of three multi-site databases was carried out, together with semi-structured interviews of melanoma surgeons. A total of 347 patients who underwent dissection were reviewed. The main indications stated for adding a "deep" ilioinguinal dissection were palpable or radiologically positive disease. There was no significant difference in complications, length of stay or lymphedema between patients having inguinal vs. ilioinguinal dissection, irrespective of method of diagnosis. There was also no significant difference in recurrence, cancer-specific survival or overall survival between groups. In conclusion, ilioinguinal dissection is a safe and well-tolerated procedure, with no significant added morbidity relative to an inguinal dissection. The indications for ilioinguinal dissection currently in use produce an appropriate deep node positivity rate and ilioinguinal dissection should continue to be used selectively. Randomized data are needed to clarify the impact of ilioinguinal dissection on regional control and survival.

Medical Immunosuppression and Outcomes in Cutaneous Melanoma: A Population-Based Cohort Study.

BACKGROUND: Melanoma and the immune system are intimately related. However, the association of immunosuppressive medications (ISMs) with survival in melanoma is not well understood. The study evaluated this at a population level. METHODS: A cohort of patients with a diagnosis of invasive cutaneous melanoma (2007-2015) was identified from the Ontario Cancer Registry and linked to identify demographics, stage at diagnosis, prescription of immunosuppressive medications (both before and after diagnosis), and outcomes. The demographics of patients with and without prescriptions for ISM were compared. Patients eligible for Ontario's Drug Benefit Plan were included to ensure accurate prescription data. The primary outcome was overall survival. Cox Proportional Hazards Regression models identified factors associated with mortality, including use of ISM as a time-varying covariate. RESULTS: Of the 4954 patients with a diagnosis of cutaneous melanoma, 1601 had a prescription for ISM. The median age of the patients was 74 years. Overall, 58.4% of the patients were men (60.5% of those without ISM and 54% of those using ISM; p < 0.001). The use of oral immunosuppression was associated with an increased hazard of death (hazard ratio, 5.84; 95% confidence interval, 5.11-6.67; p < 0.0001) when control was used for age, disease stage at diagnosis, anatomic site, comorbidity, and treatment. Other factors associated with death were increasing age, male sex, increased disease stage, truncal location of primary melanoma, and inadequate treatment. In sensitivity analysis with steroid-only ISM use excluded, survival did not differ significantly (p = 0.355). CONCLUSIONS: The use of immunosuppressive steroids for melanoma is associated with worse overall survival. Use of steroids should be limited when possible.

Outcomes of Immunosuppressed Patients Who Develop Melanoma: A Population-Based Propensity-Matched Cohort Study.

INTRODUCTION: Few studies have examined outcomes in immunosuppressed patients who develop melanoma. The purpose of this study is to compare survival in immunosuppressed patients who developed melanoma with that in patients with melanoma who are not immunosuppressed. METHODS: Immunosuppressed patients were defined as having solid organ transplant, lymphoma, leukemia, or human immunodeficiency virus prior to diagnosis of melanoma. Patients with cutaneous melanoma with and without immunosuppression were identified retrospectively from the Ontario Cancer Registry (2007-2015) and linked with administrative databases to identify demographics, treatment, and outcomes. Immunosuppressed patients were matched with non-immunosuppressed patients based on age at diagnosis, sex, birth year, stage at diagnosis, and propensity score. The primary outcome was overall survival. Multivariable Cox proportional hazard regression was used to identify factors associated with survival. RESULTS: Baseline characteristics were well balanced in 218 immunosuppressed patients matched to 436 controls. Of the patients, 186 (28.4%) were female, and median age at melanoma diagnosis was 69 (interquartile range, IQR 59-78) years. Three-year overall survival (OS) was 65% for immunosuppressed patients and 79% for non-immunosuppressed patients. Melanoma was the leading cause of death for both groups. On multivariable analysis, immunosuppression was associated with increased mortality [hazard ratio (HR) 1.70, 95% confidence interval (CI) 1.30-2.23]. Adequate treatment (HR 0.36, 95% CI 0.22-0.58) and dermatologist visits either before (HR 0.52, 95% CI 0.36-0.73) or after (HR 0.61, 95% CI 0.41-0.90) melanoma diagnosis were associated with improved OS. CONCLUSIONS: Immunosuppressed patients who develop melanoma have worse outcomes when matched to non-immunosuppressed patients. This decrease in survival appears related to the underlying condition rather than diagnosis of melanoma.

Outcomes of surgical treatment alone in patients with superficial soft tissue sarcoma regardless of size or grade.

BACKGROUND AND OBJECTIVES: Currently, standard treatment of soft tissue sarcoma (STS) is wide local excision and adjuvant radiation, but radiation may be unnecessary in superficial STS. The primary objective is to assess local recurrence rates in patients treated with surgical management alone for superficial STS. METHODS: A retrospective cancer registry review of patients treated with surgery alone for superficial STS at the Tom Baker Cancer Center (TBCC) was performed. Patient and tumor characteristics as well as recurrence data were collected. RESULTS: Sixty-one patients met study criteria. Local and overall recurrence rates were 7/61 (11.5%) and 12/61 (19.7%), respectively. The proportion with a T2 tumor was 38.8% versus 33.3% (P = 0.69), with Grade 2 or 3 tumors was 59.2% versus 83.3% (P = 0.14), and with resection margins <1 cm was 28.6% versus 75.0% (P = 0.008) for patients without and with recurrence, respectively. Median time to recurrence was 1.7 (0.4-5.2) years. CONCLUSIONS: Surgical resection alone appears to be a viable option for superficial STS that can save patients from potential side effects of radiation. The association between recurrence and inadequate margins (<1 cm) requires additional treatment be offered to this subset of patients.

Effects of Postgraduate Medical Education "Boot Camps" on Clinical Skills, Knowledge, and Confidence: A Meta-Analysis.

BACKGROUND: Throughout their medical education, learners face multiple transition periods associated with increased demands, producing stress and concern about the adequacy of their skills for their new role. OBJECTIVE: We evaluated the effectiveness of boot camps in improving clinical skills, knowledge, and confidence during transitions into postgraduate or discipline-specific residency programs. METHODS: Boot camps are in-training courses combining simulation-based practice with other educational methods to enhance learning and preparation for individuals entering new clinical roles. We performed a search of MEDLINE, CINAHL, PsycINFO, EMBASE, and ERIC using boot camp and comparable search terms. Inclusion criteria included studies that reported on medical education boot camps, involved learners entering new clinical roles in North American programs, and reported empirical data on the effectiveness of boot camps to improve clinical skills, knowledge, and/or confidence. A random effects model meta-analysis was performed to combined mean effect size differences (Cohen's d) across studies based on pretest/posttest or comparison group analyses. RESULTS: The search returned 1096 articles, 15 of which met all inclusion criteria. Combined effect size estimates showed learners who completed boot camp courses had significantly "large" improvements in clinical skills (d  =  1.78; 95% CI 1.33-2.22; P < .001), knowledge (d  =  2.08; 95% CI 1.20-2.96; P < .001), and confidence (d  =  1.89; 95% CI 1.63-2.15; P < .001). CONCLUSIONS: Boot camps were shown as an effective educational strategy to improve learners' clinical skills, knowledge, and confidence. Focus on pretest/posttest research designs limits the strength of these findings.

Care of children isolated for infection control: a prospective observational cohort study.

BACKGROUND: Patients with community-acquired or nosocomial infections are often managed in a hospital with isolation precautions. Given the high prevalence and substantial inconvenience associated with implementation of isolation precautions in pediatric settings, we explored the impact of this intervention on the care provided to children and their families. OBJECTIVE: The purpose of this work was to compare the quantity and quality of care received by isolated patients relative to nonisolated patients. PATIENTS AND METHODS: Sixty-five consecutive newly admitted inpatients in private rooms (24 isolated, 41 nonisolated) were recruited from the general pediatric service at the Hospital for Sick Children. Interactions between a medical team with patients and their families were observed. All of the participants were blinded to the study objectives. The medical team was observed during its morning rounds, and data were collected on the quantity and quality of care. Quantity of care was determined by the amount of time that the medical team spent interacting with the patient and parents and the number of organ systems examined by the attending physician during morning rounds. Quality of care was determined by using parental completion of the Pediatric Family Satisfaction Questionnaire. RESULTS: We found no significant difference in the average amount of time spent interacting with isolated compared with nonisolated patients (516 vs 480 seconds) or the number of organ systems examined in isolated compared with nonisolated patients (3 vs 4). Isolated and nonisolated groups gave high ratings to all of the items pertaining to the facility, doctors, and nurses. CONCLUSIONS: No large differences in quality or quantity of care were observed between isolated and nonisolated patients in the first 2 days of admission to a pediatric ward.