Deidentifying Narrative Assessments to Facilitate Data Sharing in Medical Education.

PROBLEM: Narrative assessments are commonly incorporated into competency-based medical education programs. However, efforts to share competency-based medical education assessment data among programs to support the evaluation and improvement of assessment systems have been limited in part because of security concerns. Deidentifying assessment data mitigates these concerns, but deidentifying narrative assessments is time-consuming, resource intensive, and error prone. The authors developed and tested a tool to automate the deidentification of narrative assessments and facilitate their review. APPROACH: The authors met throughout 2021 and 2022 to iteratively design, test, and refine the deidentification algorithm and data review interface. Preliminary testing of the prototype deidentification algorithm was performed using narrative assessments from the University of Saskatchewan emergency medicine program. The algorithm's accuracy was assessed by the authors using the review interface designed for this purpose. Formal testing included 2 rounds of deidentification and review by members of the authorship team. Both the algorithm and data review interface were refined during the testing process. OUTCOMES: Authors from 3 institutions, including 3 emergency medicine programs, an anesthesia program, and a surgical program, participated in formal testing. In the final round of review, 99.4% of the narrative assessments were fully deidentified (names, nicknames, and pronouns removed). The results were comparable for each institution and specialty. The data review interface was improved with feedback obtained after each round of review and found to be intuitive. NEXT STEPS: This innovation has demonstrated viability evidence of an algorithmic approach to the deidentification of assessment narratives while reinforcing that a small number of errors are likely to persist. Future steps include the refinement of both the algorithm to improve its accuracy and the data review interface to support additional data set formats.

Effect of Breast Reconstruction on Kinematics and Performance during Upper Limb-Focused Functional Tasks.

BACKGROUND: Breast reconstruction after curative breast cancer surgery is becoming increasingly common. There is evidence to suggest that these surgeries have negative effects on shoulder function, but to date there have been no investigations of shoulder biomechanics during functional tasks in this group. The purpose of this study was to define and compare upper limb motion of patients with breast cancer who underwent mastectomy only or mastectomy with reconstruction with a control group without cancer during a range of work-related functional tasks. METHODS: Ninety-five women participated: 25 controls, 25 patients with breast cancer who received a mastectomy only, and 45 patients with breast cancer who received a mastectomy with reconstruction (implant, latissimus dorsi flap, or deep inferior epigastric artery perforator flap). Motion of the torso, humeri, and scapulae were tracked during arm-focused functional tasks, involving reaching, dexterity, and lifting overhead, and joint angles were calculated. Mean, maximum, and minimum angles were calculated and compared among groups using one-way analyses of variance ( p < 0.05). RESULTS: The reconstruction group had significantly different kinematics than the other two groups. Throughout task performance, patients who had reconstruction had increased scapular posterior tilt and increased humeral external rotation. These findings are consistent with reconstruction surgical procedures and may highlight muscle pattern alterations that interfere with co-contraction, stability, and functional task performance. CONCLUSIONS: The findings suggest that breast reconstruction surgery influences functional task performance. Scapular and humeral kinematics may indicate movement pattern differences that are important to address in rehabilitation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Reduced incidence of breast cancer-related lymphedema following mastectomy and breast reconstruction versus mastectomy alone.

BACKGROUND: As breast cancer survivorship has increased, so has an awareness of the morbidities associated with its treatment. The incidence of breast cancer-related lymphedema has been reported to be 8 to 30 percent in all breast cancer survivors. To determine whether breast cancer reconstruction has an impact on the incidence of breast cancer-related lymphedema, the authors compared its incidence in patients who underwent mastectomy with reconstruction versus mastectomy alone. METHODS: All patients who underwent mastectomy, with or without immediate breast reconstruction, between 2001 and 2006, were identified through a search of prospective institutional databases. To reduce variation caused by known predictive factors, the individuals were cross-matched for age, axillary intervention, and postoperative axillary irradiation. The incidence of lymphedema was based on the presence of arm edema that lasted more than 6 months and was documented clinically. RESULTS: Of the 574 cross-matched patients included in the study, 78 (6.8 percent) developed lymphedema (21 with reconstructed breasts and 57 with unreconstructed breasts). Patients who did not undergo reconstruction were significantly more likely to develop breast cancer-related lymphedema (9.9 percent versus 3.7 percent; p < 0.001). Postoperative axillary radiation therapy (p < 0.001), one or more positive lymph nodes (p = 0.010), and body mass index of 25 or greater (p = 0.021) were also associated with an increased incidence of lymphedema. Reconstruction patients developed lymphedema significantly later than nonreconstruction patients (p < 0.001). CONCLUSION: Patients who undergo breast reconstruction have a lower incidence and a delay in onset of breast cancer-related lymphedema compared with patients who undergo mastectomy alone. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Immediate breast reconstruction and lymphedema incidence.

BACKGROUND: As breast cancer survivorship increases, more women are being affected by treatment sequelae, including lymphedema. The purpose of this study was to evaluate lymphedema incidence among immediate breast reconstruction patients and determine what factors are associated with lymphedema, including reconstruction method. METHODS: The authors reviewed the outcomes of all consecutive patients who underwent immediate postmastectomy breast reconstruction at their institution between 2001 and 2006. Patient, treatment, and outcome characteristics were compared among reconstruction types: expander and implant, latissimus dorsi myocutaneous flap and implant, and autologous flap alone. Regression models were used to determine whether patient and treatment characteristics were associated with lymphedema development. RESULTS: This study included 1117 patients (1499 breasts), with a mean follow-up of 56 months. Axillary interventions (p < 0.001), high numbers of positive lymph nodes (p = 0.004), postoperative radiation therapy (p = 0.007), and body mass index of 25 kg/m or greater (p = 0.010) were strong predictors of increased lymphedema incidence. After excluding prophylactic mastectomy and reconstruction group changes, the authors found that the mean lymphedema incidence was 4.0 percent (of 1013 breasts). Reconstruction type had no significant effect on incidence of or time to lymphedema, and no interaction was found between axillary intervention and reconstruction type (p = 0.799). CONCLUSIONS: The incidence of lymphedema after immediate reconstruction was associated with high body mass index, axillary interventions, and high numbers of positive lymph nodes. The reconstructive method did not appear to affect lymphedema incidence or timing. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.