Perforated Peptic Ulcer: A Case Report of a Dreaded Complication of an Insidious Disease.

Perforated peptic ulcers, though relatively rare, represent critical surgical emergencies with potentially life-threatening consequences. Their significance lies not only in their acute presentation but also in the diagnostic challenges they pose, particularly in patients with complex medical histories. Here we present a case of a 71-year-old female with a complex medical history, including insulin-dependent type 2 diabetes mellitus, hypertension, hyperlipidemia, hypothyroidism, dementia, diverticulitis, and chronic back pain, who initially were unresponsive and cyanotic. Despite challenges in diagnosis due to her medical complexity and opioid use, she was ultimately diagnosed with a perforated duodenal ulcer. Tragically, despite immediate surgical intervention, she succumbed to her illness, highlighting the complexities involved in managing perforated peptic ulcers, especially in patients with multiple chronic medical conditions. Peptic ulcer disease (PUD) can often remain asymptomatic, leading to delayed diagnosis and potentially life-threatening complications like perforation. Mortality rates associated with perforated peptic ulcers vary widely, ranging from 1.3% to 20%, with risk factors including nonsteroidal anti-inflammatory drug (NSAID) use, Helicobacter pylori infection, smoking, and corticosteroid use. Diagnosis necessitates a high index of suspicion, thorough clinical examination, and imaging modalities such as computed tomography (CT) scans with oral contrast. Treatment strategies range from nonoperative management with intravenous (IV) histamine H2-receptor blockers or proton pump inhibitors (PPIs) to surgical intervention, depending on the patient's hemodynamic stability. However, the case presented underscores the challenges in timely diagnosis and intervention, particularly in patients with complex medical histories, where symptoms may be masked or attributed to other comorbidities. Recent studies indicate a demographic shift toward older age and a higher prevalence among females, emphasizing the importance of increased awareness and vigilance among healthcare providers. Early recognition of symptoms, prompt investigation, and interdisciplinary collaboration are crucial in optimizing outcomes for patients presenting with perforated peptic ulcers, especially in the context of their underlying medical conditions.

Association Between Sexually Transmitted Infections and the Urine Culture.

Introduction: Bacterial urinary tract infections (UTI) and some sexually transmitted infections (STI) can have overlapping signs and symptoms or nonspecific findings, such as pyuria on urinalysis. Furthermore, results from the urine culture and the nucleic acid amplification test for an STI may not be available during the clinical encounter. We sought to determine whether gonorrhea, chlamydia, and trichomoniasis are associated with bacteriuria, information that might aid in the differentiation of STIs and UTIs. Methods: We used multinomial logistic regression to analyze 9,650 encounters of female patients who were aged ≥18 years and who underwent testing for STIs. The ED encounters took place from April 18, 2014-March 7, 2017. We used a multivariable regression analysis to account for patient demographics, urinalysis findings, vaginal wet-mount results, and positive or negative (or no) findings from the urine culture and testing for Neisseria gonorrhoeae, Chlamydia trachomatis, or Trichomonas vaginalis. Results: In multivariable analysis, infection with T vaginalis, N gonorrhoeae, or C trachomatis was not associated with having a urine culture yielding 10,000 or more colony-forming units per mililiter (CFU/mL) of bacteria compared with a urine culture yielding less than 10,000 CFU/mL or no urine culture obtained. The diagnosis of a UTI in the ED was not associated with having a urine culture yielding 10,000 or more CFU/mL compared with a urine culture yielding less than 10,000 CFU/mL. Conclusion: After adjusting for covariates, no association was observed between urine culture results and testing positive for trichomoniasis, gonorrhea, or chlamydia. Our results suggest that having a concurrent STI and bacterial UTI is unlikely.

Imaging in a Pandemic: How Lack of Intravenous Contrast for Computed Tomography Affects Emergency Department Throughput.

Introduction: During the coronavirus 2019 pandemic, hospitals in the United States experienced a shortage of contrast agent, much of which is manufactured in China. As a result, there was a significantly decreased amount of intravenous (IV) contrast available. We sought to determine the effect of restricting the use of IV contrast on emergency department (ED) length of stay (LOS). Methods: We conducted a single-institution, retrospective cohort study on adult patients presenting with abdominal pain to the ED from March 7-July 5, 2022. Of 26,122 patient encounters reviewed, 3,028 (11.6%) included abdominopelvic CT with a complaint including "abdominal pain." We excluded patients with outside imaging and non-ED scans. Routine IV contrast agent was administered to approximately 74.6% of patients between March 7-May 6, 2022, when we altered usage guidelines due to a nationwide shortage. Between May 6-July 5, 2022, 32.8% of patients received IV contrast after institutional recommendations were made to limit contrast use. We compared patient demographics and clinical characteristics between groups with chi-square test for frequency data. We analyzed ED LOS with nonparametric Wilcoxon rank-sum test for continuous measures with focus before and after new ED protocols. We also used statistical process control charts and plotted the 1, 2 and 3 sigma control limits to visualize the variation in ED LOS over time. The charts include the average (mean) of the data and upper and lower control limits, corresponding to the number of standard deviations away from the mean. Results: After use of routine IV contrast was discontinued, ED LOS (229.0 vs 212.5 minutes, P = <0.001) declined by 16.5 minutes (95% confidence interval -10, -22). Conclusion: Intravenous contrast adds significantly to ED LOS. Decreased use of routine IV contrast in the ED accelerates time to CT completion. A policy change to limit IV contrast during a national shortage significantly decreased ED LOS.

Prevention of persistent pain with lidocaine infusions in breast cancer surgery (PLAN): study protocol for a multicenter randomized controlled trial.

BACKGROUND: Persistent pain is a common yet debilitating complication after breast cancer surgery. Given the pervasive effects of this pain disorder on the patient and healthcare system, post-mastectomy pain syndrome (PMPS) is becoming a larger population health problem, especially as the prognosis and survivorship of breast cancer increases. Interventions that prevent persistent pain after breast surgery are needed to improve the quality of life of breast cancer survivors. An intraoperative intravenous lidocaine infusion has emerged as a potential intervention to decrease the incidence of PMPS. We aim to determine the definitive effects of this intervention in patients undergoing breast cancer surgery. METHODS: PLAN will be a multicenter, parallel-group, blinded, 1:1 randomized, placebo-controlled trial of 1,602 patients undergoing breast cancer surgery. Adult patients scheduled for a lumpectomy or mastectomy will be randomized to receive an intravenous 2% lidocaine bolus of 1.5 mg/kg with induction of anesthesia, followed by a 2.0 mg/kg/h infusion until the end of surgery, or placebo solution (normal saline) at the same volume. The primary outcome will be the incidence of persistent pain at 3 months. Secondary outcomes include the incidence of pain and opioid consumption at 1 h, 1-3 days, and 12 months after surgery, as well as emotional, physical, and functional parameters, and cost-effectiveness. DISCUSSION: This trial aims to provide definitive evidence on an intervention that could potentially prevent persistent pain after breast cancer surgery. If this trial is successful, lidocaine infusion would be integrated as standard of care in breast cancer management. This inexpensive, widely available, and easily administered intervention has the potential to reduce pain and suffering in an already afflicted patient population, decrease the substantial costs of chronic pain management, potentially decrease opioid use, and improve the quality of life in patients. TRIAL REGISTRATION: This trial has been registered on clinicaltrials.gov (NCT04874038, Dr. James Khan. Date of registration: May 5, 2021).

Emergency department responses to nursing shortages.

BACKGROUND: The COVID-19 pandemic exacerbated the nursing shortage, which is predicted to continue to worsen with significant numbers of nurses planning to retire within the next 5 years. There remains a lack of published information regarding recommended interventions for emergency departments (EDs) facing a sudden nursing shortage. METHODS: We queried emergency department leaders from the American College of Emergency Physicians to examine the impact of nursing shortages on EDs and to gather real-world interventions employed to mitigate the effects of the shortage. RESULTS: Most respondents (98.5%) reported nursing shortages, with 83.3% describing prolonged shortages lasting more than 12 months, with negative impacts such as misses/near-misses (93.9%) and increasing left without being seen rates (90.9%). ED leaders reported a range of interventions, including operational flow changes, utilizing alternative staff to fill nurse roles, recruitment of new nurses, and retention strategies for existing nurses. They employed temporary and permanent pay increases as well as efforts to improve the ED work environment and techniques to hire new nurses from atypical pipelines. CONCLUSION: We report a patchwork of solutions ED leaders utilized which may have variable efficacy among different EDs; personalization is essential when selecting interventions during a sudden nursing shortage.

Adult Congenital Heart Disease in the Emergency Department.

While congenital heart disease historically was a pathology primarily restricted to specialized pediatric centers, advances in technology have dramatically increased the number of people living into adulthood, the number of complications faced by these patients, and the number of patients visiting non-specialized emergency departments for these concerns. Clinicians need to be aware of the issues specific to patients' individual congenital defects but also have an understanding of how typical cardiac pathology may manifest in this special group of patients. This manuscript attempts to provide an overview of this diverse but increasingly common group of adult patients with congenital heart diseases, including a review of their anatomical variants, the complications they face at the highest rates, and ways that emergency physicians may need to manage these patients differently to avoid causing harm.

Impact of 18F-Labeled Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography Versus Conventional Staging in Patients With Locally Advanced Breast Cancer.

PURPOSE: Patients with locally advanced breast cancer (LABC) typically undergo staging tests at presentation. If staging does not detect metastases, treatment consists of curative intent combined modality therapy (neoadjuvant chemotherapy, surgery, and regional radiation). Positron emission tomography-computed tomography (PET-CT) may detect more asymptomatic distant metastases, but the evidence is based on uncontrolled studies. METHODS: For inclusion, patients had histological evidence of invasive ductal carcinoma of the breast and TNM stage III or IIb (T3N0, but not T2N1). Consenting patients from six regional cancer centers in Ontario were randomly assigned to 18F-labeled fluorodeoxyglucose PET-CT or conventional staging (bone scan, CT of the chest/abdomen and pelvis). The primary end point was upstaging to stage IV. A key secondary outcome was receiving curative intent combined modality therapy (ClinicalTrials.gov identifier: NCT02751710). RESULTS: Between December 2016 and April 2022, 184 patients were randomly assigned to whole-body PET-CT and 185 patients to conventional staging. Forty-three (23%) PET-CT patients were upstaged to stage IV compared with 21 (11%) conventional staged patients (absolute difference, 12.3% [95% CI, 3.9 to 19.9]; P = .002). Consequently, treatment was changed in 35 (81.3%) of 43 upstaged PET-CT patients and 20 (95.2%) of the 21 upstaged conventional patients. Subsequently, 149 (81%) patients in the PET-CT group received combined modality treatment versus 165 (89.2%) patients in the conventional staging group (absolute difference, 8.2% [95% CI, 0.1 to 15.4]; P = .03). CONCLUSION: In patients with LABC, PET-CT detected more distant metastases than conventional staging, and fewer PET-CT patients received combined modality therapy. Our randomized trial demonstrates the utility of the PET-CT staging strategy.

Clue Cells on Vaginal Wet Preparation Are Not Associated with Urinary Tract Infections or Positive Urine Cultures.

INTRODUCTION: Clue cells result from aberrant vaginal microflora and are associated with an increased vaginal pH, which can allow colonization of uropathogens in the vaginal introitus, increasing the risk for urinary tract infections (UTI). We sought to determine whether clue cells on vaginal wet preparation in the emergency department (ED) are associated with emergency physician diagnoses of UTIs and positive urine cultures. METHODS: We conducted a retrospective analysis examining a dataset of women (≥18 years of age) who received both a genital wet preparation and urine testing in the ED. Both chi-square and multivariable regression analysis were performed. RESULTS: We analyzed 14,952 encounters. On both univariable and multivariable analyses, emergency physicians diagnosed significantly fewer clue cell-positive women with a UTI (10.9% diagnosed with UTI vs 13.1% without UTI) (P <.001). Women with clue cells on vaginal wet preparation were not more likely to have a positive urine culture or have a urine culture growing Escherichia coli. Pregnant women with clue cells on vaginal wet preparation were not more likely to have a UTI or have a positive urine culture. CONCLUSION: Emergency physicians diagnosed significantly fewer women with UTIs when they found clue cells on vaginal wet preparation. Clue cells on vaginal wet preparation were not associated with an increased likelihood of a positive urine culture or having E. coli growing in the urine.

Adoption of High-sensitivity Troponin Testing and Emergency Physician Ordering Behavior.

INTRODUCTION: Emergency departments (ED) are rapidly replacing conventional troponin assays with high-sensitivity troponin tests. We sought to evaluate emergency physician utilization of troponin tests before and after high-sensitivity troponin introduction in our ED. METHODS: We retrospectively examined 9,477 ED encounters, identifying the percentage in which physicians ordered a serum troponin both before and after our institution adopted a high-sensitivity troponin test. RESULTS: After introduction of high-sensitivity troponin testing, the percentage of ED encounters in which physicians ordered troponin studies decreased (28.3% before vs 22% after; P <.001), with the drop most pronounced in admitted patients (decrease of 10.9% [95% confidence interval [CI]: 7.3%-14.5%] in admitted patients vs decrease of 3.6% [95% CI: 1.7%-5.4%] in discharged patients; P<.001) CONCLUSION: Introduction of high-sensitivity troponin testing was associated with a decrease in troponin ordering. While the reasons for this are unclear, it is possible that physicians became more selective in their ordering behavior because of the lower specificity of high-sensitivity troponin.

Postneoadjuvant Pure and Predominantly Pure Intralymphatic Breast Carcinoma: Case Series and Literature Review.

Locally advanced breast cancer is typically treated with neoadjuvant chemotherapy to decrease tumor size and optimize surgical results. Cases of pathologic complete response, are associated with favorable long-term outcomes. The American Joint Committee on Cancer (AJCC) defines pathologic complete response as a lack of residual invasive disease in the breast or lymph nodes or only residual ductal carcinoma in situ. Three studies have examined the unique pattern of postneoadjuvant pure or predominantly pure intralymphatic carcinoma. These studies are small and the prognosis associated with this disease pattern is still unclear. The current study aims to describe clinicopathologic findings associated with pure and predominantly pure intralymphatic carcinoma postneoadjuvant chemotherapy. Electronic medical records were searched to identify patients treated with postneoadjuvant mastectomy between 2010 and 2017. Cases were included if they met the previously defined definitions for pure or predominantly pure intralymphatic carcinoma. Of 479 postneoadjuvant mastectomies, 5 patients had pure intralymphatic carcinoma and 6 patients had predominantly pure. Overall, 50% (3/6) of patients with predominantly pure pattern died of metastatic disease within 14 months of mastectomy, whereas 1 patient with pure intralymphatic carcinoma (ypN0) died of metastatic disease 25 months postmastectomy, revealing a better prognosis associated with pure intralymphatic carcinoma when compared with predominantly pure. The diligent gross examination is required to identify patients with both patterns of residual disease. A standardized approach to incorporating lymphovascular invasion into postneoadjuvant staging may be useful from both a clinical and research perspective. The published case numbers remain small and understanding the true clinical significance still depends on additional studies.

Patient Assignment Models in the Emergency Department.

Early assignment of patients to specific treatment teams improves length of stay, rate of patients leaving without being seen, patient satisfaction, and resident education. Multiple variations of patient assignment systems exist, including provider-in-triage/team triage, fast-tracks/vertical pathways, and rotational patient assignment. The authors discuss the theory behind patient assignment systems and review potential benefits of specific models of patient assignment found in the current literature.

Increased Inpatient Length of Stay After Early Unplanned Transfer to Higher Levels of Care.

Patients admitted to a medical-surgical unit infrequently require early transfer to higher level care, although how their inpatient length of stay compares to untransferred patients, or those directly admitted to intermediate care, is unknown. We sought to compare the inpatient length of stay of these groups. DESIGN: Single-site retrospective analysis. SETTING: An academic hospital specializing in complex care. PATIENTS: We evaluated 23,694 patients admitted to the Hospital Internal Medicine service over a 4-year period (January 1, 2013, to December 31, 2016). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Using 6- and 24-hour definitions of early transfer, we categorized patients as admitted to medical-surgical unit without early transfer (medical-surgical unit), transferred (TX) early to higher level care, or initially admitted to an intermediate care unit. We report patient characteristics and inpatient length of stay adjusted for patient demographics (age and sex) and initial acuity (measured by Emergency Severity Index). There were significant increases in both unadjusted inpatient length of stay (6 hr: medical-surgical unit = 73.4 hr, TX = 137.9 hr, intermediate care unit = 101.1 hr; 24 hr: medical-surgical unit = 72.4 hr, TX = 141.9 hr, intermediate care unit = 98.2 hr; p < 0.01 for all groups) and adjusted inpatient length of stay (6-hr definition: medical-surgical unit = 50.9 hr [95% CI, 50.3-51.6 hr], TX = 100.4 hr [90.4-112.0 hr], intermediate care unit = 72.3 hr [70.6-74.0 hr]; 24-hr definition: medical-surgical unit = 50.3 hr [49.7-50.9 hr], TX = 108.3 hr [101.5-116.0 hr], intermediate care unit = 70.7 hr [69.0-72.3 hr]; p < 0.0001 for comparison of TX to medical-surgical unit and intermediate care unit in both groups). The increases in inpatient length of stay for the TX groups were not explained by differences in demographics or acuity. CONCLUSIONS: In a single facility study, patients admitted to a medical/surgical unit who require early transfer to intermediate care unit have a significant and unexplained increase in inpatient length of stay. This unexplained increased inpatient length of stay suggests that triage to the appropriate inpatient unit significantly affects inpatient length of stay.

Benign breast papillary lesions diagnosed on core biopsy: upgrade rate and risk factors associated with malignancy on surgical excision.

Evaluation of radiologically detected breast lesions is a common task in surgical pathology. Some benign lesions on biopsy are associated with an upgrade to in situ or invasive carcinoma on excision. The non-atypical breast papilloma has published upgrade rates of 0 to 29%. Traditionally, papillomas have been managed surgically, but the wide range of upgrade rates has raised uncertainty about the need for routine surgical excision. This study aims to identify risk factors associated with upgrade and determine the upgrade rate of non-atypical papillomas at our institution. In a retrospective review of pathology reports, we identified 266 patients with a diagnosis of benign papilloma on breast core biopsy. One hundred eighty-two patients underwent surgical resection. The final surgical pathology reports of all patients were reviewed and divided into one of two groups-benign or malignant. Twenty-one patients had a final diagnosis of in situ or invasive carcinoma, resulting in an upgrade rate of 12%. Radiologically detected lesions with calcifications were at higher risk for upgrade (OR = 4.45, 95% CI 1.08-18.27) than lesions without calcifications. Additionally, advanced patient age (OR = 1.07, 95% CI 1.03-1.13) and lesion size greater than 0.5 cm (OR = 2.59, 95% CI 0.38-17.48) was associated with upgrade to malignancy. Routine surgical excision of all papillomas is not recommended. Younger patients without high-risk features may benefit from clinical and radiologic follow-up alone. Accurate risk stratification will spare low-risk women unnecessary surgery.

Association of Vital Signs and Process Outcomes in Emergency Department Patients.

INTRODUCTION: We sought to determine the association of abnormal vital signs with emergency department (ED) process outcomes in both discharged and admitted patients. METHODS: We performed a retrospective review of five years of operational data at a single site. We identified all visits for patients 18 and older who were discharged home without ancillary services, and separately identified all visits for patients admitted to a floor (ward) bed. We assessed two process outcomes for discharged visits (returns to the ED within 72 hours and returns to the ED within 72 hours resulting in admission) and two process outcomes for admitted patients (transfer to a higher level of care [intermediate care or intensive care] within either six hours or 24 hours of arrival to floor). Last-recorded ED vital signs were obtained for all patients. We report rates of abnormal vital signs in each group, as well as the relative risk of meeting a process outcome for each individual vital sign abnormality. RESULTS: Patients with tachycardia, tachypnea, or fever more commonly experienced all measured process outcomes compared to patients without these abnormal vitals; admitted hypotensive patients more frequently required transfer to a higher level of care within 24 hours. CONCLUSION: In a single facility, patients with abnormal last-recorded ED vital signs experienced more undesirable process outcomes than patients with normal vitals. Vital sign abnormalities may serve as a useful signal in outcome forecasting.

Perioperative Pregabalin and Intraoperative Lidocaine Infusion to Reduce Persistent Neuropathic Pain After Breast Cancer Surgery: A Multicenter, Factorial, Randomized, Controlled Pilot Trial.

Persistent postsurgical pain is defined as pain localized to the area of surgery of a duration of ≥2 months and is, unfortunately, a common complication after breast cancer surgery. Although there is insufficient evidence to support any preventative strategy, prior literature suggests the possible efficacy of intravenous lidocaine and perioperative pregabalin in preventing persistent pain after surgery. To determine feasibility of conducting a larger definitive trial, we conducted a multicenter 2 × 2 factorial, randomized, placebo-controlled pilot trial of 100 female patients undergoing breast cancer surgery. Patients were randomized to receive an intraoperative lidocaine infusion (1.5 mg/kg bolus followed by 2 mg/kg/h) or placebo and perioperative pregabalin (300 mg preoperatively, 75 mg twice daily for 9 days) or placebo. All feasibility criteria were surpassed; recruitment of 100 patients was accomplished within 42 weeks, with a follow-up rate of 100% and study drug compliance of ≥80%. At 3 months, 53% of patients reported persistent neuropathic pain. Although there was no interaction between lidocaine and pregabalin, lidocaine decreased the development of persistent neuropathic pain (43.1% vs 63.3%; relative risk = .68; 95% confidence interval = .47-1.0). Pregabalin did not reduce persistent pain (60% vs 46%; relative risk = 1.3; 95% confidence interval = .90-1.90) and neither pregabalin nor lidocaine impacted acute postoperative pain, opioid consumption, pain interference, or quality of life. Our pilot trial successfully demonstrated feasibility and provided promising data for conducting further trials of intraoperative lidocaine infusions during breast cancer surgeries. Clinical trial number: NCT02240199 PERSPECTIVE: This article reports the findings of a pilot randomized, controlled trial evaluating the effects of perioperative pregabalin and intraoperative lidocaine infusions in patients undergoing breast cancer surgery. This trial demonstrated the feasibility of conducting a larger trial and provided promising data that these interventions may decrease the development of persistent pain.

Relation between socioeconomic variables and surgical, systemic and radiation treatment in a cohort of patients with breast cancer in an urban Canadian centre

Background: Studies have shown an association between socioeconomic status and breast cancer treatment. We examined the relation between socioeconomic status and the treatment of breast cancer (surgical, systemic and radiation) in a universal health care system. Methods: Data from a single urban Canadian centre were collected for consecutive patients who received a diagnosis of breast cancer from January 2010 to December 2011. Variables included patient and disease factors, surgery type, systemic and radiation treatment, and breast reconstruction. Socioeconomic variables were obtained from 2006 Canadian census data. We used multivariable logistic regression to identify predictors of breast cancer treatment. Results: A total of 721 patients were treated for breast cancer during the study period. Socioeconomic variables were not related to type of breast surgery for breast cancer. Age less than 50 years, having a first-degree relative with breast cancer and income status were predictors of breast reconstruction. Employment status was a consistent predictor of systemic and radiation treatment. Conclusion: Employment consistently predicted systemic and radiation treatment, and age and income were predictors of breast reconstruction in a universal health care system. Further research is required to determine precisely how socioeconomic factors affect care and to minimize possible disparities in delivery of health care services.

Contexte: Des études ont montré un lien entre la situation socio-économique et le traitement du cancer du sein. Nous avons analysé ce lien entre la situation socioéconomique et le traitement (chirurgie, chimiothérapie, radiothérapie) du cancer du sein dans un système de santé universel. Méthodes: Les données d'un seul centre urbain canadien ont été compilées pour les patientes consécutives ayant reçu un diagnostic de cancer du sein entre janvier 2010 et décembre 2011. Les variables incluaient des facteurs propres aux patientes et à la maladie, le type de chirurgie, la chimiothérapie, la radiothérapie et la reconstruction mammaire. Les variables socio-économiques proviennent des données du recensement canadien de 2006. Nous avons utilisé la régression logistique multivariée pour identifier les prédicteurs du traitement du cancer du sein. Résultats: En tout, 721 patientes ont été traitées pour un cancer du sein durant la période de l'étude. Les variables socio-économiques n'ont pas influé sur le type de chirurgie mammaire pour cancer du sein. L'âge inférieur à 50 ans, un cancer du sein chez une parente au premier degré et le revenu ont été des prédicteurs de la reconstruction mammaire. La situation professionnelle a été un prédicteur fiable du traitement systémique et de la radiothérapie. Conclusion: L'emploi a été un prédicteur fiable du traitement systémique et de la radiothérapie, et l'âge et le revenu ont été des prédicteurs de la reconstruction mammaire, dans un système de santé universel. Il faudra approfondir la recherche pour déterminer plus précisément l'influence des facteurs socio-économiques sur les soins et pour réduire les possibles disparités dans leur prestation.

Adoption and outcomes of radioguided seed localization for non-palpable invasive and in-situ breast cancer at three academic tertiary care centers.

INTRODUCTION: Radioguided seed localization (RSL) is an alternative technique to wire-guided localization (WL) for localizing non-palpable breast lesions for breast conserving surgery. The purpose of this study was to assess adoption and outcomes of RSL at 3 academic hospitals in our city. METHODS: Data for consecutive invasive and in-situ breast cancer cases localized with RSL or WL at 3 hospitals between January 2012 and February 2016 were abstracted. Data analysis was conducted using the Student's t-test, ANOVA with Tukey's HSD test for post-hoc multiple comparisons, and chi-squared test. RESULTS: There were 803 consecutive cases. Hospital 1 exclusively used RSL (247 cases), whereas H2 adopted RSL (109 cases), but continued to use WL (347 cases). Hospital 3 exclusively used WL (100 cases). There was no difference between RSL and WL groups in positive margin rate (p = 0.337), re-operation (p = 0.413), or mean specimen volume (p = 0.190). DISCUSSION: There has been variable adoption of RSL in our city. Despite this, relevant surgical outcomes have been similar across groups. The causes of variable adoption of this novel technique merit further investigation.

Are testers also admitters? Comparing emergency physician resource utilization and admitting practices.

OBJECTIVE: To describe the relationship between emergency department resource utilization and admission rate at the level of the individual physician. METHODS: Retrospective observational study of physician resource utilization and admitting data at two emergency departments. We calculated observed to expected (O/E) ratios for four measures of resource utilization (intravenous medications and fluids, laboratory testing, plain radiographs, and advanced imaging studies) as well as for admission rate. Expected values reflect adjustment for patient- and time-based variables. We compared O/E ratios for each type of resource utilization to the O/E ratio for admission for each provider. We report degree of correlation (slope of the trendline) and strength of correlation (adjusted R2 value) for each association, as well as categorical results after clustering physicians based on the relationship of resource utilization to admission rate. RESULTS: There were statistically significant positive correlations between resource utilization and physician admission rate. Physicians with lower resource utilization rates were more likely to have lower admission rates, and those with higher resource utilization rates were more likely to have higher admission rates. CONCLUSIONS: In a two-facility study, emergency physician resource utilization and admission rate were positively correlated: those who used more ED resources also tended to admit more patients. These results add to a growing understanding of emergency physician variability.

Time-resolved fluorescence (TRF) and diffuse reflectance spectroscopy (DRS) for margin analysis in breast cancer.

PURPOSE: One of the major problems in breast cancer surgery is defining surgical margins and establishing complete tumor excision within a single surgical procedure. The goal of this work is to establish instrumentation that can differentiate between tumor and normal breast tissue with the potential to be implemented in vivo during a surgical procedure. METHODS: A time-resolved fluorescence and reflectance spectroscopy (tr-FRS) system is used to measure fluorescence intensity and lifetime as well as collect diffuse reflectance (DR) of breast tissue, which can subsequently be used to extract optical properties (absorption and reduced scatter coefficient) of the tissue. The tr-FRS data obtained from patients with Invasive Ductal Carcinoma (IDC) whom have undergone lumpectomy and mastectomy surgeries is presented. A preliminary study was conducted to determine the validity of using banked pre-frozen breast tissue samples to study the fluorescence response and optical properties. Once the validity was established, the tr-FRS system was used on a data-set of 40 pre-frozen matched pair cases to differentiate between tumor and normal breast tissue. All measurements have been conducted on excised normal and tumor breast samples post surgery. RESULTS: Our results showed the process of freezing and thawing did not cause any significant differences between fresh and pre-frozen normal or tumor breast tissue. The tr-FRS optical data obtained from 40 banked matched pairs showed significant differences between normal and tumor breast tissue. CONCLUSION: The work detailed in the main study showed the tr-FRS system has the potential to differentiate malignant from normal breast tissue in women undergoing surgery for known invasive ductal carcinoma. With further work, this successful outcome may result in the development of an accurate intraoperative real-time margin assessment system. Lasers Surg. Med. 50:236-245, 2018. © 2018 Wiley Periodicals, Inc.