Sentinel node biopsy in breast cancer revisited.

The axilla has long been a focus of clinicians' attention in the management of breast cancer. The approach to the axilla has undergone dramatic changes over the last century, from radical and extended radical excisions, through the introduction of sentinel node biopsy for node negative patients to the current situation where selective management of those with nodal involvement is being introduced. The introduction of lymphatic mapping and sentinel node biopsy in the 1990's has been key to the major changes that have occurred. In less than 20 years it has moved from a hypothesis to a situation where it is the default approach to almost all clinically node negative patients and is being considered in other situations where axillary clearance was previously considered standard. This article reviews the development and introduction of sentinel node biopsy, its current uncertainties and limitations, and possible future developments.

Comparison of Long-Term Mortality in Patients With Single Coronary Narrowing and Diabetes Mellitus to That of Patients With Multivessel Coronary Narrowing Without Diabetes Mellitus.

It is well recognized that patients with diabetes mellitus (DM) and multivessel coronary artery disease (MVD) undergoing percutaneous coronary intervention (PCI) have poorer long-term outcomes compared with those undergoing coronary artery bypass grafting. However, the relative impact of DM status and extent of coronary artery disease on long term mortality in patients undergoing PCI is unknown. We sought to compare patients with DM undergoing PCI for single and multivessel disease to their non-DM counterparts. Overall, 34,690 consecutive patients undergoing PCI from the Melbourne Interventional Group registry (2005 to 2017) were included (mean age 64.5 ± 12 years, 76.6% male). Our cohort was stratified by the presence of DM and extent of CAD (DM-SVD [single-vessel disease] [n = 2,669], DM-MVD [n = 6,118], no-DM-SVD [n = 10,993], no-DM-MVD [n = 14,910]). DM-SVD and no-DM-MVD cohorts demonstrated comparable baseline cardiovascular risk profiles, although the no-DM-MVD cohort had higher rates of prior myocardial infarction, while the DM-SVD cohort had a higher proportion of patients with renal impairment. Over a median follow-up of 4.8 (IQR 2.0 to 8.2) years, 6,031 (17.5%) patients died. Using the no-DM-SVD group as the reference category, adjusted risk of mortality was highest in the MVD-DM cohort (HR 1.90; 95% CI 1.71 to 2.09). Similar adjusted risk of long-term mortality was observed in the DM-SVD (HR 1.32, 95%CI 1.15 to 1.51) and no-DM-MVD (HR 1.30, 95%CI 1.20 to 1.40) groups. In conclusion, we found that the long-term mortality of patients with DM and SVD undergoing PCI was the risk equivalent of non-DM patients with MVD.

Cost implications of avoidable rapid response call activations in older patients.

BACKGROUND: Rapid response calls (RRCs) are designed to appropriately manage clinical deterioration. However, not all RRCs are appropriate due to medical futility or the patient's wishes. Incidence and costs associated with avoidable-RRC (ARRC) remain underexplored. AIMS: The aim of this study was to describe the incidence and costs of ARRC activations in older patients. METHODS: We retrospectively reviewed RRCs in patients aged ≥80 years over six months. We defined ARRC as RRC activations despite clear documentation confirming not for further RRCs. Data on investigations, equipment and management of each ARRC were analysed. We then micro-costed each ARRC using standard references. RESULTS: Ten percent (25/255) of RRCs were ARRC (mean age 85.6 years) with most patients (88%) admitted under medical teams. Median duration of ARRC was 22 minutes (IQR 7-38 minutes). Palliative care services were underutilised (40%). Most patients (94.4%) died soon after ARRC. The costs for investigations, equipment and management was AUD $2,267.01, opportunity costs were AUD $3,861.55, with a grand total cost of AUD $6,128.56. CONCLUSION: ARRC, noted in 10% of RRCs, are associated with increased time and financial costs. Further research is required to better understand ARRC triggers to reduce the burden of ARRC on patients, carers and hospital staff.