Choice of Mastectomy May Increase the Extent of Axillary Surgery in Women with Breast Cancer.

INTRODUCTION: Based on the ACOSOG Z0011 trial, women who undergo breast conservation therapy (BCT) and have limited disease in the axilla on sentinel lymph node (SLN) biopsy do not require axillary lymph node dissection (ALND). In this study we investigate the incidence of ALND in patients undergoing elective mastectomy with limited disease in the axilla to identify how many women may have been spared additional axillary surgery if they chose BCT. METHODS: All women with invasive breast cancer treated at a single tertiary care breast center from 2010-2018 who were candidates for BCT but elected mastectomy and underwent SLN biopsy were identified through retrospective review of a prospectively maintained database. The primary outcome of interest was the incidence of ALND in women found to have a limited burden of disease in the axilla (1-2 positive SLNs). RESULTS: The study population comprised 151 patients with invasive breast cancer eligible for BCT who chose mastectomy. On final pathology, 34 patients had 1-2 positive SLNs, and 16 of these patients underwent completion ALND. These 16 patients out of 151 overall lumpectomy candidates electing mastectomy (10.6%) could have been spared ALND if they did not elect mastectomy. DISCUSSION: BCT candidates electing mastectomy have a 10.6% chance of undergoing more extensive axillary surgery than would have been recommended with BCT alone. The increased risk of undergoing additional axillary surgery should be incorporated into the preoperative discussion for patients choosing between BCT and mastectomy.

Diagnosis and Management of Opioid Use Disorder in Hospitalized Patients.

The diagnosis of opioid use disorder (OUD) is often overlooked or inadequately managed during the inpatient admission. When recognized, a common strategy is opioid detoxification, an approach that is often ineffective and can be potentially dangerous because of loss of tolerance and subsequent risk for overdose. Medication for addiction treatment (MAT), including methadone and buprenorphine, is effective and can be dispensed in the hospital for both opioid withdrawal and initiation of maintenance treatment. Hospitalists should be knowledgeable about diagnosing and managing patients with OUD, including how to manage acute pain or MAT during the perioperative setting.

Assessing the efficacy and experience of in-person versus telephonic psychiatric evaluations for asylum seekers in the U.S.

Psychiatric evaluations of asylum seekers in the U.S. play an important role in asylum cases; however, there are significant barriers to assessing asylum seekers' psychological trauma. Telephonic psychiatric evaluations provide an opportunity to access important resources to bolster their case. In this retrospective study, we considered the efficacy of telephonic psychiatric evaluations and assessed their potential as a solution to meet the needs of asylum seekers. Ten affidavits produced from telephonic evaluations were compared to twenty produced from in-person evaluations using a standardized scoring rubric. Providers who conducted telephonic evaluations also completed a structured interview and a qualitative assessment of themes was conducted. Overall, there was a small, but non-significant difference in overall score. The presence of descriptions of cognitive complaints, appearance, motor activity and use of checklists were, however, all significantly lower in telephonic compared to in-person affidavits. Providers agreed that despite limitations, the ability to diagnose and advocate for asylum seekers is equivalent regardless of format. This study identifies that telephonic psychiatric evaluations produce comparable results to in-person evaluations with the benefit of reaching a hard to reach population. Evaluators, lawyers, and judges should consider these results in weighing the risk-benefits of a telephonic evaluation of an asylum seeker.