Breast Cancer-Related Lymphedema (BCRL) and Bioimpedance Spectroscopy: Long-Term Follow-Up, Surveillance Recommendations, and Multidisciplinary Risk Factors.

BACKGROUND: Early detection and intervention for breast cancer-related lymphedema (BCRL) significantly decreases progression to persistent BCRL (pBCRL). We aimed to provide long-term follow-up on our early detection with bioimpedance spectroscopy (BIS) and early home intervention demonstrating reduced pBCRL to guide surveillance recommendations. PATIENTS AND METHODS: In total, 148 female patients with breast cancer who had axillary lymph node dissection (ALND) from November 2014 to December 2017 were analyzed. Baseline BIS measurements and postoperative follow-up occurred every 3 months for 1 year, biannual for 1 year, and then annually. An elevated BIS triggered evaluation and initiation of at-home interventions with reassessment for resolution versus persistent BCRL (pBCRL). High-risk factors and timing were analyzed. RESULTS: Mean follow-up was 55 months, and 65 (44%) patients had an abnormal BIS. Of these, 54 (82%) resolved with home intervention. The overall pBCRL rate was 8%. Average time to first abnormal BIS was 11.7 months. None of the stage 0 patients (0/34) and only 5/25 (20%) of stage 1 patients had pBCRL. All of stage 2 and stage 3 patients (7/7) had pBCRL. pBCRL correlated with number of positive nodes, percentage of positive nodes, stage of lymphedema at diagnosis, and recurring abnormal BIS measurements (p < 0.05). CONCLUSIONS: We have shown that patients undergoing ALND with early BCRL identified by BIS who performed home interventions had an 8% pBCRL rate. Patients at high risk for pBCRL should have routine surveillance starting at 9 months postoperatively to identify an opportunity for early intervention.

DHA Supplementation During Pregnancy Enhances Maternal Vagally Mediated Cardiac Autonomic Control in Humans.

BACKGROUND: DHA is an essential omega-3 (ω-3; n-3) fatty acid that has well-established benefits for the fetus. DHA also has the potential to influence the health of the mother, but this area is understudied. OBJECTIVES: The objective of this secondary analysis was to determine if DHA was related to maternal heart rate (HR) and heart rate variability (HRV) metrics in a large cohort of pregnant women. METHODS: In the parent trial (1R01HD086001) eligible participants (≥18 y old, English speaking, carrying a singleton pregnancy, 12-20 wk of gestation) were randomly assigned to consume 200 mg/d or 800 mg/d DHA for the duration of their pregnancy (n = 300). Weight, blood pressure, and magnetocardiograms (MCGs) were collected at 32 wk and 36 wk of gestation (n = 221). Measures of HR and HRV in time-, frequency-, and nonlinear-domains were determined from the isolated maternal MCG. Treatment group and timepoint were examined as predictors in association with HR and HRV metrics using random-intercept mixed-effects ANOVA unadjusted and adjusted models accounting for weight and dietary DHA intake. RESULTS: Women receiving the higher dose of DHA (800 mg/d) during pregnancy had lower HR, lower sympathetic index, higher vagally mediated HRV indices, and greater HRV complexity when compared with the women who received the lower dose (200 mg/d; all P < 0.05). All the dose relations remained significant even after controlling for the effect of time, maternal weight, and dietary DHA intake. CONCLUSIONS: DHA supplementation increases vagal tone in pregnant women. Longitudinal studies examining the potential link between DHA, enhanced vagal tone, and reported reduction in early preterm birth are warranted.

A Hands-On Surgical Event to Improve Medical Student Operating Room Confidence.

INTRODUCTION: The negative perceptions and lack of exposure to surgery and the operating room (OR) have been known to divert students away from surgical specialties. This study describes the impact of a surgical subspecialty exposure event (OR Essentials), combined with surgical faculty and M4 mentorship on preclinical medical students' confidence at an academic medical center. METHODS: OR essentials event teaches surgical skills to preclinical medical students through hands-on skill-based workshops in a simulated OR setting. Pre and postevaluations were administered to measure program impact. RESULTS: One hundred four preclinical medical students participated. Following OR essentials, students reported a significant increase in confidence in the OR (P < 0.0001) and in basic surgical skills (P < 0.0001). CONCLUSIONS: Early surgical exposure events like OR essentials provide opportunities to improve medical student confidence in the OR, which will hopefully support recruitment of future surgeons.

Intake of eggs, choline, lutein, zeaxanthin, and DHA during pregnancy and their relationship to fetal neurodevelopment.

BACKGROUND: Maternal intake of eggs and nutrients contained within eggs during pregnancy have the potential to impact fetal neurodevelopment; however, this area is understudied. The purpose of this study was to determine whether maternal egg and choline intake and nutrient interactions between choline, lutein and zeaxanthin (L/Z), and DHA predict fetal neurodevelopment in a large cohort of pregnant women (n = 202). NCT02709239. METHODS: Food frequency questionnaires were used to assess egg and nutrient intake during pregnancy. Fetal neurodevelopment was measured using fetal biomagnetometry at 32 and 36wks gestation, and fetal autonomic indices (SDNN, RMSSD) and brain maturation indices (fABAS) were calculated. Generalized linear models tested the relationships between choline intake, egg intake, and nutrient interactions with fetal neurodevelopment. RESULTS: Maternal egg intake predicted RMSSD at 32wks and fABAS at 36wks. The interaction between choline and L/Z intake predicted fABAS at 32wks and 36wks and the interaction between choline intake, L/Z intake, and DHA predicted fABAS at 36wks. At 36wks, SDNN was predicted by L/Z intake and interactions between choline and L/Z, L/Z and DHA, and choline, L/Z, and DHA. CONCLUSION: Eggs and the nutrients contained within eggs showed synergistic associations with fetal neurodevelopment, and consumption should be encouraged among pregnant women.

Change in hyper-palatable food availability in the US food system over 30 years: 1988-2018.

OBJECTIVE: To quantify the change in availability of hyper-palatable foods (HPF) in the US foods system over 30 years (1988-2018). DESIGN: Three datasets considered representative of the US food system were used in analyses to represent years 1988, 2001 and 2018. A standardised definition from Fazzino et al. (2019) that specifies combinations of nutrients was used to identify HPF. SETTING: Analysis of food-item level data was conducted. Differences in the prevalence of HPF were characterised by Cochran's Q and McNemar's tests. Generalised linear mixed models with a fixed effect for time and random intercept for food item estimated change in the likelihood that a food was classified as hyper-palatable over time. PARTICIPANTS: No participant data were used. RESULTS: The prevalence of HPF increased 20 % from 1988 to 2018 (from 49 % to 69 %; P < 0·0001). The most prominent difference was in the availability of HPF high in fat and Na, which evidenced a 17 % higher prevalence in 2018 compared with 1988 (P < 0·0001). Compared with 1988, the same food items were >2 times more likely to be hyper-palatable in 2001, and the same food items were >4 times more likely to be classified as hyper-palatable in 2018 compared with 1988 (P values < 0·0001). CONCLUSIONS: The availability of HPF in the US food system increased substantially over 30 years. Existing food products in the food system may have been reformulated over time to enhance their palatability.

Prenatal docosahexaenoic acid effect on maternal-infant DHA-equilibrium and fetal neurodevelopment: a randomized clinical trial.

INTRODUCTION: Maternal-infant equilibrium occurs when cord blood docosahexaenoic acid (DHA) is less than or equal to maternal DHA at delivery. Equilibrium may be an indicator of sufficient DHA for optimal fetal and infant neurodevelopment. The purpose of this study was to test the effect of maternal DHA supplementation on equilibrium status and fetal neurodevelopment. METHODS: Women enrolled between 12 and 20 weeks gestation and were randomized to 200 or 800 mg DHA/day until delivery. Maternal red blood cell (RBC) phospholipids were measured at enrollment, 32 weeks, delivery, and in cord blood at delivery. Fetal neurodevelopment was measured at 32 and 36 weeks gestation. Intent-to-treat analyses were conducted to test differences in equilibrium status by group. Fetal outcomes were assessed by equilibrium status and group. RESULTS: Three hundred women enrolled and 262 maternal-infant dyads provided blood samples at delivery. No maternal-infant dyads with maternal RBC-DHA ≤ 6.96% at delivery achieved equilibrium. The incidence of equilibrium was significantly higher in the 800 mg group. There was no effect of maternal group or equilibrium status on fetal neurodevelopment. CONCLUSION: The significance of maternal-infant DHA equilibrium remains unknown. Ongoing research will test the effect of treatment group, equilibrium, and nutrient status on infant behavior and brain function. IMPACT: Pregnant women who received a higher dose of docosahexaenoic acid (DHA) were more likely to achieve maternal-infant DHA equilibrium at delivery. Equilibrium status had no effect on fetal neurodevelopment in this sample. While DHA is crucial for early life neurodevelopment, the significance of achieving maternal-infant equilibrium above the lower threshold is uncertain. There is a lower threshold of maternal DHA status where maternal-infant DHA equilibrium never occurs. The lack of equilibrium associated with low maternal DHA status may indicate insufficient maternal status for optimal placental transfer.

Effect of prior radiation on stage, differentiation, and survival in bladder cancer.

PURPOSE: Clinically significant differences in radiation-related bladder tumors are not well-characterized, and survival analyses are needed. In this study, we aimed to utilize a national cancer database to evaluate the effect of prior radiation on tumor characteristics and survival in bladder cancer patients. METHODS: The Surveillance, Epidemiology, and End Results (SEER) 9 database was queried to identify patients diagnosed with bladder cancer as a second malignancy. Patients having undergone radiation prior to developing bladder cancer were selected for comparative analysis. Logistic regression was used to generate odds ratios to evaluate differences in differentiation, stage, grade, and tumor size. Kaplan-Meier analysis and Cox non-proportional hazards regression models were used to assess the association between previous radiation and bladder cancer survival. RESULTS: A total of 25,408 patients were identified, of which 14,570 patients had sufficient data for analysis. Of these, 5968 (41.0%) received radiation for their primary malignancy. Prior radiation conferred a lower risk of developing moderately- or poorly-differentiated bladder tumors and muscle invasive or node-positive disease. An increased risk of squamous cell carcinoma was noted (OR 1.43, CI 1.06-1.93). Prior radiation led to an increased risk of bladder cancer-specific (HR 1.13, CI 1.03-1.24) mortality at 5 years. The greatest effect of prior radiation was an increased risk of bladder cancer-specific mortality for carcinoma in situ at 5 years (OR 2.37, CI 1.45-3.86). CONCLUSION: Prior radiation is associated with lower grade and stage of bladder tumors in addition to worse cancer-specific survival.

Rethinking Routine Surgical Excision for all Radial Sclerosing Lesions of the Breast.

INTRODUCTION: The need for routine surgical excision of a radial sclerosing lesions (RSL) of the breast identified on percutaneous biopsy remains controversial, as contemporary upgrade rates are lower than historically cited. MATERIALS AND METHODS: A prospectively-maintained database of high-risk breast biopsies undergoing multidisciplinary review at a single institution was queried to identify cases of RSL from 2/2015 to 11/2020. Demographic, radiologic, and pathologic variables were summarized using frequencies and analyzed in association with RSL excision status using mixed-effects logistic regression or Fisher's exact tests. RESULTS: 217 RSL were identified, diagnosed at a mean age of 57 y. The median imaging size was 1.3 cm and the majority had estimated >50% of the target removed by core needle biopsy. 32.3% underwent surgical excision of the RSL biopsy site and 2/70 (2.9%) upgraded to ductal carcinoma in situ (DCIS) on final surgical pathology. Upgrade was significantly higher for atypical RSL (P = 0.02). None of the RSL (n = 60) without atypia who had undergone excision were upgraded. For those omitting surgical excision, there was no subsequent breast cancer diagnosis at the RSL site over a mean follow-up of 23 mo. CONCLUSIONS: Surgical excision may be omitted for RSL without atypia as this group has 0% risk of upgrade after multidisciplinary review.

Comparison of two validated instruments to measure financial hardship in cancer survivors: comprehensive score for financial toxicity (COST) versus personal financial wellness (PFW) scale.

PURPOSE: Financial distress and financial toxicity are recognized challenges in cancer survivorship. Financial toxicity includes both objective measures of hardship and subjective distress. We hypothesized that subjective financial distress is correlated to overall holistic financial toxicity. We compared two widely accepted instruments to measure financial distress and financial toxicity. METHODS: Patients in the follow-up phase of care at a single institution were surveyed regarding demographic and economic status. Financial toxicity was measured using the comprehensive score for financial toxicity-functional assessment of chronic illness (COST-FACIT) and financial distress using the personal financial wellness (PFW) scale. Surveys were analyzed for correlation and internal consistency. Patient score distributions were compared. Associations between survey scores and patient factors were assessed using multivariable linear regression models. RESULTS: A total of 116 patients were included. Scores from the COST-FACIT showed a strong correlation with PFW scores (r = 0.90, p < 0.0001). Scale reliability was high for both the COST-FACIT (α = 0.92) and PFW (α = 0.97) surveys. Score distributions exhibited left skew for both surveys, with 9.5% of patient scores falling in the worst quartile of possible scores on each respective survey. The strongest predictors of financial distress and financial toxicity included young age, lower monetary savings, lower household income, and less perceived social support during cancer treatment. CONCLUSIONS: The COST-FACIT measure of financial toxicity correlated strongly with PFW measure of financial distress. Although these instruments were designed to assess different concepts (financial distress vs financial toxicity), they gave strikingly similar results. Either instrument may be used as a meaningful patient-reported outcome for study of financial distress in cancer survivors. However, the COST-FACIT construct of financial toxicity does not appear to add additional information beyond financial distress.

The need to study rural cancer outcome disparities at the local level: a retrospective cohort study in Kansas and Missouri.

BACKGROUND: Rural residence is commonly thought to be a risk factor for poor cancer outcomes. However, a number of studies have reported seemingly conflicting information regarding cancer outcome disparities with respect to rural residence, with some suggesting that the disparity is not present and others providing inconsistent evidence that either urban or rural residence is associated with poorer outcomes. We suggest a simple explanation for these seeming contradictions: namely that rural cancer outcome disparities are related to factors that occur differentially at a local level, such as environmental exposures, lack of access to care or screening, and socioeconomic factors, which differ by type of cancer. METHODS: We conducted a retrospective cohort study examining ten cancers treated at the University of Kansas Medical Center from 2011 to 2018, with individuals from either rural or urban residences. We defined urban residences as those in a county with a U.S. Department of Agriculture Urban Influence Code (UIC) of 1 or 2, with all other residences defines a rural. Inverse probability of treatment weighting was used to create a pseudo-sample balanced for covariates deemed likely to affect the outcomes modeled with cumulative link and weighted Cox-proportional hazards models. RESULTS: We found that rural residence is not a simple risk factor but rather appears to play a complex role in cancer outcome disparities. Specifically, rural residence is associated with higher stage at diagnosis and increased survival hazards for colon cancer but decreased risk for lung cancer compared to urban residence. CONCLUSION: Many cancers are affected by unique social and environmental factors that may vary between rural and urban residents, such as access to care, diet, and lifestyle. Our results show that rurality can increase or decrease risk, depending on cancer site, which suggests the need to consider the factors connected to rurality that influence this complex pattern. Thus, we argue that such disparities must be studied at the local level to identify and design appropriate interventions to improve cancer outcomes.

Stroma modifies relationships between risk factor exposure and age-related epithelial involution in benign breast.

Delayed age-related lobular involution has been previously associated with elevated breast cancer risk. However, intraindividual variability in epithelial involution status within a woman is undefined. We developed a novel measure of age-related epithelial involution, density of epithelial nuclei in epithelial areas using digital image analysis in combination with stromal characteristics (percentage of section area comprising stroma). Approximately 1800 hematoxylin and eosin stained sections of benign breast tissue were evaluated from 416 participants having breast surgery for cancer or benign conditions. Two to sixteen slides per woman from different regions of the breast were studied. Epithelial involution status varied within a woman and as a function of stromal area. Percentage stromal area varied between samples from the same woman (median difference between highest and lowest stromal area within a woman was 7.5%, but ranged from 0.01 to 86.7%). Restricting to women with at least 10% stromal area (N = 317), epithelial nuclear density decreased with age (-637.1 cells/mm2 per decade of life after age 40, p < 0.0001), increased with mammographic density (457.8 cells/mm2 per increasing BI-RADs density category p = 0.002), and increased non-significantly with recent parity, later age at first pregnancy, and longer and more recent oral contraceptive use. These associations were attenuated in women with mostly fat samples (<10% stroma (N = 99)). Thirty-one percent of women evaluated had both adequate stroma (≥10%) and mostly fat (<10% stroma) regions of breast tissue, with the probability of having both types increasing with the number breast tissue samplings. Several breast cancer risk factors are associated with elevated age-related epithelial content, but associations depend upon stromal context. Stromal characteristics appear to modify relationships between risk factor exposures and breast epithelial involution.

Breast cancer biologic and etiologic heterogeneity by young age and menopausal status in the Carolina Breast Cancer Study: a case-control study.

BACKGROUND: Young-onset breast cancer (<40 years) is associated with worse prognosis and higher mortality. Breast cancer risk factors may contribute to distinct tumor biology and distinct age at onset, but understanding of these relationships has been hampered by limited representation of young women in epidemiologic studies and may be confounded by menopausal status. METHODS: We examined tumor characteristics and epidemiologic risk factors associated with premenopausal women's and young women's breast cancer in phases I-III of the Carolina Breast Cancer Study (5309 cases, 2022 control subjects). Unconditional logistic regression was used to assess heterogeneity by age (<40 vs. ≥40 years) and menopausal status. RESULTS: In both premenopausal and postmenopausal strata, younger women had more aggressive disease, including higher stage, hormone receptor-negative, disease as well as increased frequency of basal-like subtypes, lymph node positivity, and larger tumors. Higher waist-to-hip ratio was associated with reduced breast cancer risk among young women but with elevated risk among older women. Parity was associated with increased risk among young women and reduced risk among older women, while breastfeeding was more strongly protective for young women. Longer time since last birth was protective for older women but not for young women. In comparison, when we stratified by age, menopausal status was not associated with distinct risk factor or tumor characteristic profiles, except for progesterone receptor status, which was more commonly positive among premenopausal women. CONCLUSIONS: Age is a key predictor of breast cancer biologic and etiologic heterogeneity and may be a stronger determinant of heterogeneity than menopausal status. Young women's breast cancer appears to be etiologically and biologically distinct from that among older women.

US tobacco companies selectively disseminated hyper-palatable foods into the US food system: Empirical evidence and current implications.

BACKGROUND AND AIMS: US tobacco companies owned leading US food companies from 1980 to 2001. We measured whether hyper-palatable foods (HPF) were disproportionately developed in tobacco-owned food companies, resulting in substantial tobacco-related influence on the US food system. DESIGN: The study involved a review of primary industry documents to identify food brands that were tobacco company-owned. Data sets from the US Department of Agriculture were integrated to facilitate longitudinal analyses estimating the degree to which foods were formulated to be hyper-palatable, based on tobacco ownership. SETTING AND CASES: United States Department of Agriculture data sets were used to identify HPF foods that were (n = 105) and were not (n = 587) owned by US tobacco companies from 1988 to 2001. MEASUREMENTS: A standardized definition from Fazzino et al. (2019) was used to identify HPF. HPF items were identified overall and by HPF group: fat and sodium HPF, fat and sugar HPF and carbohydrates and sodium HPF. FINDINGS: Tobacco-owned foods were 29% more likely to be classified as fat and sodium HPF and 80% more likely to be classified as carbohydrate and sodium HPF than foods that were not tobacco-owned between 1988 and 2001 (P-values = 0.005-0.009). The availability of fat and sodium HPF (> 57%) and carbohydrate and sodium HPF (> 17%) was high in 2018 regardless of prior tobacco-ownership status, suggesting widespread saturation into the food system. CONCLUSIONS: Tobacco companies appear to have selectively disseminated hyper-palatable foods into the US food system between 1988 and 2001.

Advanced degrees, gender, and professional rank in surgery, disparities in academic medicine.

INTRODUCTION: Women comprise nearly half of all residents in training, yet there is a significant disparity of women in academic leadership. Surgical subspecialties are dominated by men in both percentages of physicians and leadership positions. We sought to examine the association of advanced non-medical degrees with academic rank and gender in academic surgery departments. METHODS: Faculty from 126 ACGME-accredited academic medical centers were analyzed to identify faculty gender as described in online biographical information, advanced non-medical degrees, academic rank, and additional leadership positions held. Descriptive statistics and logistic regression models were used for statistical analyses. RESULTS: 4536 surgeons were identified, 69.3% men, 27.3% female, and 3.3% unlisted. Female surgeons were more likely to hold advanced non-doctoral degrees than men (18.2% vs. 13.8%, p â€‹< â€‹0.002). Among those with advanced degrees, PhDs were held by 3.3% of women and 5.7% of men (p â€‹< â€‹0.001). Female surgeons were less likely to hold the rank of Professor than male surgeons (15.8% vs 30.3%, p â€‹< â€‹0.001), and more likely to hold the rank of Assistant Professor than male surgeons (51.9% vs 36.1%, p â€‹< â€‹0.001). This likelihood remained true when analyzing only surgeons with one or more advanced non-medical degrees. Men were more likely to be Chair of Surgery (3.0%), Division Chief (9.6%), and Research Chair (0.5%); compared to women (1.3%; 4.8%; 0.2%; p â€‹= â€‹0.001, <0.001, 0.21 respectively). CONCLUSIONS: There continues to be a significant male predominance in general surgery. Gender discrepancy is also seen in professional rank and academic title despite women holding more advanced degrees. Advanced degrees are currently considered academic qualifications, but this does not reflect surgical academic leadership roles or rank.

Assessing Second Debridement Timing and Mortality in Necrotizing Soft Tissue Infections.

BACKGROUND: Patients with necrotizing soft tissue infection undergo an average of 4-5 debridements per hospital admission. Optimal timing for initial debridement is emergent. Second debridement is universally recommended to occur within 24 hours of the first, but no studies have successfully evaluated this time frame. Prior work has suggested that delays in second debridement are associated with increased mortality, and that few patients receive second debridement within 24 hours. METHODS: We performed a retrospective cohort study at a single center from 01/01/08 to 09/01/2021. The explanatory variable was whether the subject received second debridement within 24 hours of initial debridement. The primary outcome was in-hospital mortality. Baseline characteristics were collected. Subjects were stratified into 2 groups by time between first and second debridement: <24 and ≥24 hours. Variables were compared using Fisher's exact and Wilcoxon rank-sum tests. RESULTS: 77 patients met inclusion criteria. The median overall time to second debridement was 40 hours. 12 subjects received second debridement within 24 hours (15.6%). There was no difference in in-hospital mortality between the <24 (n = 3, 25.0%) and ≥24-hour second debridement groups (n = 4, 6.2%; P = .07). The 2 groups did not differ by secondary outcomes, including total number of debridements, ICU LOS, or wound closure. CONCLUSION: No difference in mortality was observed between subjects undergoing second debridement within 24 vs after 24 hours. Only 16% of subjects received second debridement within the recommended 24-hour time interval. Further study is required to identify the optimal timing of second debridement.

Evaluation of learning curve with Indocyanine Green (IcG) versus blue dye for sentinel lymph node biopsy in breast cancer.

BACKGROUND: Indocyanine green (IcG) is an alternative to isosulfan blue (IB) for sentinel lymph node (SLN) mapping in breast cancer (BC). IcG carries improved cost and safety, but oncologic data upon implementation in practice is limited. We evaluated the learning curve defined as oncologic yield and operative (OR) time for IcG in SLN mapping in BC. METHODS: Retrospective review of patients >18 years with cTis-2 cN0 BC undergoing surgery first with SLN biopsy using IB or IcG. Analysis compared IB versus IcG across three time cohorts. RESULTS: Of 278 patients, 77 received IB and 201 received IcG. OR time was longer for IcG (p â€‹= â€‹0.022). There was no difference in oncologic yield between groups (p â€‹= â€‹0.35, p â€‹= â€‹0.61). CONCLUSIONS: Surgeons may be able to safely transition from IB to IcG for patients with early-stage breast cancer undergoing surgery first. Individuals should track their own data to confirm safety of the technique.

Desirability of Outcome Ranking and Response Adjusted for Antibiotic Risk (DOOR/RADAR) Post Hoc Analysis Supports Equipoise for Antibiotic Initiation Strategies in Intensive Care Unit-Acquired Pneumonia.

Background: Pneumonia is the most common intensive care unit (ICU)-acquired infection and source of potential sepsis in ICU populations but can be difficult to diagnose in real-time. Despite limited data, rapid initiation of antibiotic agents is endorsed by society guidelines. We hypothesized that a post hoc analysis of a recent randomized pilot study would show no difference between two antibiotic initiation strategies. Patients and Methods: The recent Trial of Antibiotic Restraint in Presumed Pneumonia (TARPP) was a pragmatic cluster-randomized pilot of antibiotic initiation strategies for patients with suspected ICU-acquired pneumonia. Participating ICUs were cluster-randomized to either an immediate initiation protocol or a specimen-initiated protocol where a gram stain was required for initiation of antibiotics. Patients in the study were divided into one of seven mutually exclusive outcome rankings (desirability of outcome ranking; DOOR): (1) Survival, No Pneumonia, No adverse events; (2) Survival, Pneumonia, No adverse events; (3) Survival, No Pneumonia, ventilator-free-alive days ≤14; (4) Survival, Pneumonia, ventilator-free-alive days ≤14; (5) Survival, No Pneumonia, Subsequent episode of suspected pneumonia; (6) Survival, Pneumonia, Subsequent episode of suspected pneumonia; and (7) Death. These rankings were further refined using the duration of antibiotics prescribed for pneumonia (response adjusted for antibiotic risk; RADAR). Results: There were 186 patients enrolled in the study. After applying the DOOR analysis, a randomly selected patient was equally likely to have a better outcome in specimen-initiated arm as in the immediate initiation arm (DOOR probability: 50.8%; 95% confidence interval [CI], 42.7%-58.9%). Outcome probabilities were similar after applying the RADAR analysis (52.5%; 95% CI, 44.2%-60.6%; p = 0.31). Conclusions: We found that patients for whom antibiotic agents were withheld until there was objective evidence (specimen-initiated group) had similar outcome rankings to patients for whom antibiotic agents were started immediately. This supports the findings of the TARPP pilot trial and provides further evidence for equipoise between these two treatment strategies.

Interactive multidisciplinary pilot workshop to improve medical student perception of and interest in breast surgical oncology.

BACKGROUND: Exposure to breast surgical oncology (BSO) and the multidisciplinary management of patients with breast cancer is limited in medical school. The purpose of this study was to assess changes in student perceptions of BSO as a career following an interactive multidisciplinary workshop. METHODS: Pre-clinical medical students participated in a multidisciplinary, hands-on workshop, composed of breast radiology (BR), breast surgical oncology (BSO) and breast plastic reconstructive surgery (B-PRS). BR presented students screening and diagnostic breast imaging followed by hands-on ultrasound-guided biopsy on phantom simulators. BSO demonstrated lumpectomy, mastectomy, sentinel lymph node biopsy, and axillary lymph node dissections while B-PRS demonstrated oncoplastic techniques and autologous flap reconstruction with cadavers. Pre-and post-workshop surveys assessed student opinions on surgery and BSO. Results were compared using Wilcoxon Signed Rank, Wilcoxon Rank Sum, and Fisher's Exact. RESULTS: The workshop was attended by twenty-four students. There was a statistically significant increase in interest in BSO from 52% to 86% after the workshop (p = 0.003). The event improved understanding of the work and lifestyle in BSO for 79% (19/24). All students (100%) expressed interest to further explore BSO. The most common attractors to a career in BSO were impacts on patients' lives (N = 23), intellectual stimulation (N = 22), and earnings (N = 20). The most reported deterrents were lack of personal time (N = 18) and stress (N = 15). CONCLUSION: An interactive, anatomically based exposure to multidisciplinary breast cancer surgery improves medical student perception and interest in BSO. Medical schools should consider incorporating similar events to foster interest in BSO and other surgical subspecialties.

Provider Perceptions of Antibiotic Initiation Strategies for Hospital-Acquired Pneumonia.

Background: The practice of rapidly initiating antibiotic therapy for patients with suspected infection has recently been criticized yet remains commonplace. Provider comfort level has been an understudied aspect of this practice. Hypothesis: We hypothesized that there would be no significant differences in provider comfort level between the two treatment groups. Methods: We prospectively surveyed critical care intensivists who provided care for patients enrolled in the Trial of Antibiotic Restraint in Presumed Pneumonia (TARPP), which was a multicenter cluster-randomized crossover trial that evaluated an immediate antibiotic initiation protocol compared with a protocol of specimen-initiated antibiotic initiation in ventilated patients with suspected new-onset pneumonia. At the end of each enrollment arm, physicians at each center were surveyed regarding their overall comfort level with the recently completed treatment arm, and perception of adherence. Both a paired and unpaired analysis was performed. Results: We collected 51 survey responses from 31 unique participants. Providers perceived a higher rate of adherence to the immediate initiation arm than the specimen-initiated arm (Always Adherent: 37.5% vs. 11.1%; p = 0.045). Providers were less comfortable waiting for objective evidence of infection in the specimen-initiated arm than with starting antibiotic agents immediately (Very Comfortable: 83.3% vs. 40.7%; p = 0.004). For the smaller paired analysis, there was no longer a difference in comfort level. Conclusions: There may be differences in provider comfort levels and perceptions of adherence when considering two different antibiotic initiation strategies for suspected pneumonia in ventilated patients. These findings should be considered when planning future studies.