Implementation of Intraoperative Ultrasound Localization for Breast-Conserving Surgery in a Large, Integrated Health Care System is Feasible and Effective.

BACKGROUND: Intraoperative ultrasound (IUS) localization for breast cancer is a noninvasive localization technique. In 2015, an IUS program for breast-conserving surgery (BCS) was initiated in a large, integrated health care system. This study evaluated the clinical results of IUS implementation. METHODS: The study identified breast cancer patients with BCS from 1 January to 31 October 2015 and from 1 January to 31 October 2019. Clinicopathologic characteristics were collected, and localization types were categorized. Clinical outcomes were analyzed, including localization use, surgeon adoption of IUS, day-of-surgery intervals, and re-excision rates. Multivariate logistic regression analysis was performed to evaluate predictors of re-excision. RESULTS: The number of BCS procedures increased 23%, from 1815 procedures in 2015 to 2226 procedures in 2019. The IUS rate increased from 4% of lumpectomies (n = 79) in 2015 to 28% of lumpectomies (n = 632) in 2019 (p < 0.001). Surgeons using IUS increased from 6% (5 of 88 surgeons) in 2015 to 70% (42 of 60 surgeons) in 2019. In 2019, 76% of IUS surgeons performed at least 25% of lumpectomies with IUS. The mean time from admission to incision was shorter with IUS or seed localization than with wire localization (202 min with IUS, 201 with seed localization, 262 with wire localization in 2019; p < 0.001). The IUS re-excision rates were lower than for other localization techniques (13.6%, vs 19.6% for seed localization and 24.7% for wire localization in 2019; p = 0.006), and IUS predicted lower re-excision rates in a multivariable model (odds ratio [OR], 0.59). CONCLUSIONS: In a high-volume integrated health system, IUS was adopted for BCS by a majority of surgeons. The use of IUS decreased the time from admission to incision compared with wire localization, and decreased re-excision rates compared with other localization techniques.

Implementation of a Post-mastectomy Home Recovery Program in a Large, Integrated Health Care Delivery System.

BACKGROUND: The number of outpatient mastectomies, with and without reconstruction, has increased nationwide. In well-selected patient populations, same-day surgery for mastectomy is a safe option. A pilot project was initiated within the Kaiser Permanente Northern California healthcare system to facilitate surgical home recovery (SHR) for mastectomy patients, including patients undergoing implant-based reconstruction and bilateral mastectomies. METHODS: Surgical home recovery for mastectomy patients was implemented in October 2017. Specific measures in this initiative included management of patient expectations at initial consultation, education about postoperative home care, multimodality pain management, and timely post-discharge follow-up. All patients undergoing mastectomy were included, except those undergoing autologous tissue reconstructions. After a 6-month implementation period, rate of same day discharge over 6 months was compared before and after the SHR initiative. We also compared emergency department (ED) visits, reoperations, and readmissions within 7 days. RESULTS: Twenty-one medical centers participated in this initiative. Before implementing SHR, 164 of the 717 (23%) mastectomies were outpatient procedures, compared with 403 of the 663 (61%) after the implementation period. Although the rate of outpatient mastectomy increased significantly, there were no statistically significant differences in ED visits (5.2% vs. 5.1%, p = 0.98), reoperation (3.5% vs. 3.5%, p = 0.99), or readmission rates (1.4% vs. 2.7%, p = 0.08). CONCLUSIONS: By implementing standard expectations and sharing best practices, there was a significant increase in the rate of home recovery for mastectomy without compromising quality of patient care. The success of this pilot program supports SHR for mastectomy.

Sex-specific Differences in Resting Oscillatory Dynamics in Children with Prenatal Alcohol Exposure.

At rest children with prenatal alcohol exposure (PAE) exhibit impaired static and dynamic functional connectivity, along with decreased alpha oscillations. Sex-specific information regarding the impact of PAE on whole-brain resting-state gamma spectral power remains unknown. Eyes-closed and eyes-open MEG resting-state data were examined in 83 children, ages 6-13 years of age. Using a matched design, the sample consisted of 42 typically developing children (TDC) (22 males/20 females) and 41 children with PAE and/or a fetal alcohol spectrum disorders (FASD) diagnosis (21 males/20 females). Whole-brain source resting-state spectral power was examined to determine group and sex specific relationships. Within gamma, we found sex and group specific changes such that female participants with PAE/FASD had increased gamma power when compared to female TDC and male participants with PAE/FASD. These differences were detected in most source regions analyzed during both resting-states, and were observed across the age spectrum examined. Within delta, we found sex and group specific changes such that female participants with PAE/FASD had decreased delta power when compared to female TDC and male participants with PAE/FASD. The reduced delta oscillations in female participants with PAE/FASD were detected in several source regions during eyes-closed rest and were evident at younger ages. These results indicate PAE alters neural oscillations during rest in a sex-specific manner, with females with PAE/FASD showing the largest perturbations. These results further demonstrate PAE has global effects on resting-state spectral power and connectivity, creating long-term consequences by potentially disrupting the excitation/inhibition balance in the brain, interrupting normative neurodevelopment.

Primary visual response (M100) delays in adolescents with FASD as measured with MEG.

Fetal alcohol spectrum disorders (FASD) are debilitating, with effects of prenatal alcohol exposure persisting into adolescence and adulthood. Complete characterization of FASD is crucial for the development of diagnostic tools and intervention techniques to decrease the high cost to individual families and society of this disorder. In this experiment, we investigated visual system deficits in adolescents (12-21 years) diagnosed with an FASD by measuring the latency of patients' primary visual M100 responses using MEG. We hypothesized that patients with FASD would demonstrate delayed primary visual responses compared to controls. M100 latencies were assessed both for FASD patients and age-matched healthy controls for stimuli presented at the fovea (central stimulus) and at the periphery (peripheral stimuli; left or right of the central stimulus) in a saccade task requiring participants to direct their attention and gaze to these stimuli. Source modeling was performed on visual responses to the central and peripheral stimuli and the latency of the first prominent peak (M100) in the occipital source timecourse was identified. The peak latency of the M100 responses were delayed in FASD patients for both stimulus types (central and peripheral), but the difference in latency of primary visual responses to central vs. peripheral stimuli was significant only in FASD patients, indicating that, while FASD patients' visual systems are impaired in general, this impairment is more pronounced in the periphery. These results suggest that basic sensory deficits in this population may contribute to sensorimotor integration deficits described previously in this disorder.

Delays in auditory processing identified in preschool children with FASD.

BACKGROUND: Both sensory and cognitive deficits have been associated with prenatal exposure to alcohol; however, very few studies have focused on sensory deficits in preschool-aged children. As sensory skills develop early, characterization of sensory deficits using novel imaging methods may reveal important neural markers of prenatal alcohol exposure. METHODS: Participants in this study were 10 children with a fetal alcohol spectrum disorder (FASD) and 15 healthy control (HC) children aged 3 to 6 years. All participants had normal hearing as determined by clinical screens. We measured their neurophysiological responses to auditory stimuli (1,000 Hz, 72 dB tone) using magnetoencephalography (MEG). We used a multidipole spatio-temporal modeling technique to identify the location and timecourse of cortical activity in response to the auditory tones. The timing and amplitude of the left and right superior temporal gyrus sources associated with activation of left and right primary/secondary auditory cortices were compared across groups. RESULTS: There was a significant delay in M100 and M200 latencies for the FASD children relative to the HC children (p = 0.01), when including age as a covariate. The within-subjects effect of hemisphere was not significant. A comparable delay in M100 and M200 latencies was observed in children across the FASD subtypes. CONCLUSIONS: Auditory delay revealed by MEG in children with FASDs may prove to be a useful neural marker of information processing difficulties in young children with prenatal alcohol exposure. The fact that delayed auditory responses were observed across the FASD spectrum suggests that it may be a sensitive measure of alcohol-induced brain damage. Therefore, this measure in conjunction with other clinical tools may prove useful for early identification of alcohol affected children, particularly those without dysmorphia.