A Multi-institutional Analysis of Factors Influencing the Rate of Positive MRI Biopsy Among Women with Early-Stage Breast Cancer.

BACKGROUND: The use of preoperative magnetic resonance imaging (MRI) for early-stage breast cancer (ESBC) is increasing, but its utility in detecting additional malignancy is unclear and delays surgical management (Jatoi and Benson in Future Oncol 9:347-353, 2013. https://doi.org/10.2217/fon.12.186 , Bleicher et al. J Am Coll Surg 209:180-187, 2009. https://doi.org/10.1016/j.jamcollsurg.2009.04.010 , Borowsky et al. J Surg Res 280:114-122, 2022. https://doi.org/10.1016/j.jss.2022.06.066 ). The present study sought to identify ESBC patients most likely to benefit from preoperative MRI by assessing the positive predictive values (PPVs) of ipsilateral and contralateral biopsies. METHODS: A retrospective cohort study included patients with cTis-T2N0-N1 breast cancer from two institutions during 2016-2021. A "positive" biopsy result was defined as additional cancer (PositiveCancer) or cancer with histology often excised (PositiveSurg). The PPV of MRI biopsies was calculated with respect to age, family history, breast density, and histology. Uni- and multivariate logistic regression determined whether combinations of age younger than 50 years, dense breasts, family history, and pure ductal carcinoma in situ (DCIS) histology led to higher biopsy yield. RESULTS: Of the included patients, 447 received preoperative MRI and 131 underwent 149 MRI-guided biopsies (96 ipsilateral, 53 contralateral [18 bilateral]). PositiveCancer for ipsilateral biopsy was 54.2%, and PositiveCancer for contralateral biopsy was 17.0%. PositiveSurg for ipsilateral biopsy was 62.5%, and PositiveSurg for contralateral biopsy was 24.5%. Among the contralateral MRI biopsies, patients younger than 50 years were less likely to have PositiveSurg (odds ratio, 0.02; 95% confidence interval, 0.00-0.84; p = 0.041). The combinations of age, density, family history, and histology did not lead to a higher biopsy yield. CONCLUSION: Historically accepted factors for recommending preoperative MRI did not appear to confer a higher MRI biopsy yield. To prevent delays to surgical management, MRI should be carefully selected for individual patients most likely to benefit from additional imaging.

The Association of Preoperative Magnetic Resonance Imaging (MRI) With Surgical Management in Patients With Early-Stage Breast Cancer.

INTRODUCTION: The rate of mastectomy in lumpectomy-eligible patients with unilateral breast cancer is increasing. We sought to investigate the association between magnetic resonance imaging (MRI) and surgical management of patients with early-stage breast cancer by comparing the rate of mastectomy as first surgery in patients with and without preoperative MRI. METHODS: A bi-institutional retrospective study included patients diagnosed between 2016 and 2020. Lumpectomy-eligible patients with in situ and invasive cancer were included. Those receiving preoperative therapy, MRI before diagnosis, or with known bilateral cancer were excluded. The risk factors for bilateral and multicentric disease were accounted for. Fisher's exact and chi-square tests compared categorical variables, Wilcoxon two-sample test analyzed continuous variables, and multivariate analyses were performed with Poisson regression. RESULTS: Four hundred twenty-eight participants met inclusion criteria. Patients who received MRI were younger (58 versus 67 y; P < 0.001) and had denser breasts (group 3 or 4; 61% versus 25%; P < 0.001). Mastectomy rate was twice as high in patients undergoing MRI (32% versus 15%, rate ratio 2.16; P < 0.001), which remained significant in multivariate analysis (rate ratio 2.0; P < 0.001). Contralateral mastectomy (12% versus 4%; P = 0.466) and reexcision (13% versus 12%; P = 0.519) rates were similar. Time to surgery was greater in those receiving MRI alone and MRI biopsy (34 [no MRI] versus 45 [MRI] versus 62 [MRI biopsy]; P < 0.001 for both). CONCLUSIONS: MRI receipt is associated with a doubled rate of mastectomy in lumpectomy-eligible patients. Future work is needed to standardize patient selection for MRI to those with the highest likelihood of having additional undiagnosed disease.

Predictors of elbow torque among professional baseball pitchers.

BACKGROUND: Overuse injuries of the shoulder and elbow continue to be prevalent in elite baseball pitchers. Pitch velocity has been shown to impact medial elbow torque in adolescent baseball pitchers. However, the determinants of medial elbow torque in professional baseball pitchers are not known. PURPOSE: To determine the influence of pitch type, velocity, and player characteristics on medial elbow torque in professional baseball pitchers. METHODS: Professional baseball pitchers were recruited for participation. Height, weight, body mass index (BMI), and throwing arm measurements were obtained for all study participants. While wearing a gyroscopic sensor equipped with an accelerometer, participants were instructed to throw a standard, randomized sequence of fastballs, changeups, and curveballs. Elbow torque, arm slot, arm speed, shoulder rotation, and ball velocity were recorded for each pitch. A linear mixed model was used to evaluate the association of pitch type with each pitch parameter, adjusting for pitchers' demographics. RESULTS: A total of 12 professional baseball pitchers were included in this study. Among the pitch types, medial elbow torque was significantly higher in fastballs than in curveballs (P = .001). An increased BMI value was independently associated with decreased elbow torque in pitchers (P = .035). CONCLUSION: Fastballs place significantly higher torque on the medial elbow than do curveballs, which is consistent with previous studies done on high school and collegiate populations. Pitchers with a higher BMI experience significantly less torque across the medial elbow.

General surgery textbooks and surgical disparities.

INTRODUCTION: Some academic textbooks have previously disseminated simplistic or even incorrect conceptions of race. Propagation of such ideas in General Surgery could contribute to gaps in quality of care received by minority patients. This study aims to determine whether General Surgery textbooks provide a thorough understanding of racial disparities. METHODS: General Surgery texts were drawn from Doody's list, an industry-standard list of textbooks for medical education. Technical guides, atlases, and books for non-General Surgery professionals were excluded. Passages mentioning medical differences amongst racial and ethnic groups were extracted. Six binary classifications were made, based on whether passages (a) described interventions to alleviate difference; (b) addressed environmental mediators of difference; (c) described the contribution of racism or discrimination; (d) used causal language to connect race to difference; (e) referred to known, heritable genetic mechanisms; and (f) directly provided a reference. Types of intervention were also extracted. A heuristic scale was calculated granting one point each for classifications a-c and losing one point for classification d. Three authors performed classifications, and raw agreement and Cohen's kappa were used to assess inter-rater reliability. RESULTS: Thirteen textbooks from Doody's list contained 511 passages discussing medical differences among racial/ethnic groups. Among passages, 25% discussed white people, 22% Black people/African Americans, 19% Asians, 9% Latinos, 4% Jewish/Ashkenazi people, 3% Native Americans, and 18% other. Fifteen passages (2.9%) used language indicating race was the cause of medical difference, and only two explicitly discussed racism or discrimination. Most passages (370, 72.3%) received a scale of 0. 120 (23.5%) received a scale of 1, eight (1.2%) received a scale of 2, and zero received a scale of 3. The mean passage scale was 0.24 and is not changing with time (regression coefficient -0.006/year, p = 0.538). Agreement was 91.2% across all categories and overall Kappa was 0.62. CONCLUSIONS: General Surgery textbooks do not provide readers with scientifically thorough understanding of health disparities. Teaching more comprehensive conceptions, including systemic causes and the role of racism, may prevent reflexive association of minority patients with poor outcomes. Future editions should include these details where disparities are discussed in an independent, comprehensive section.

The association between perioperative opioids and breast cancer recurrence: a narrative review of the literature.

Background and Objective: Opioid use disorder is an evolving crisis, and 17.2% of postsurgical patients continue to fill an opioid prescription one year after surgery. Preclinical studies suggest perioperative opioid use, defined here as opioids used in the setting of operative pain, may be linked to inferior oncologic outcomes. If this were true, opioid minimization strategies for surgical patients may reduce opioid-related deaths in more than one way. This review aims to describe the association between perioperative opioid use and breast cancer recurrence. Methods: On November 1, 2021, we searched the Ovid and EMBASE databases for the terms "breast neoplasm", "opioid analgesics", "neoplasm recurrence", and "neoplasm metastasis". Of the 350 articles retrieved, 11 met our inclusion criteria. The review was undertaken using the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) checklist for quality. Key Content and Findings: Clinical studies report no clear association between perioperative opioid use and local or distant breast cancer recurrence. Mixed results were found when assessing perioperative opioid use and overall survival. Multiple studies paradoxically found opioid use to be associated with lower recurrence rates, despite higher mortality rates. Most studies showed no difference in recurrence or survival in breast cancer surgery patients who did or did not receive opioid-containing analgesia, although most findings were limited by study design and low event rates in patients with breast cancer. Conclusions: The lack of a clear connection between perioperative opioid use and breast cancer recurrence contradicts some preclinical data, which describes mechanisms through which opioids upregulate tumor proliferation which might worsen oncologic outcomes. Existing clinical literature is limited to mostly retrospective studies in patients with predominantly early-stage breast cancers, with low event rates. Given the worsening opioid epidemic and preclinical study findings, opioid minimization strategies should still be explored. Future work should be prospective and examine cancer recurrence in high-risk patients with more advanced tumor pathologies.

Using Smartphone-Based Accelerometer Data to Objectively Assess Outcomes in Spine Surgery.

BACKGROUND: In order to deliver optimal patient care, spine surgeons must integrate technological changes to arrive at novel measures of functional outcomes. Historically, subjective patient-reported outcome (PRO) surveys have been used to determine the relative benefit of surgical treatments. Using smartphone-based accelerometers, surgeons now have the ability to arrive at objective outcome metrics. OBJECTIVE: To use Apple Health (Apple Inc, Cupertino, California) data to approximate physical activity levels before and after spinal fusion as an objective outcome measurement. METHODS: Personal activity data were acquired retrospectively from the cellphones of consenting patients. These data were used to measure changes in activity level (daily steps, flights climbed, and distance traveled) before and after patients underwent spine surgery at a single institution by a single surgeon. After data collection, we investigated the demographic information and daily physical activity pre- and postoperatively of participating patients. RESULTS: Twenty-three patients were included in the study. On average, patients first exceeded their daily 1-yr average distance walked, flights climbed, and steps taken at 10.3 ± 14, 7.6 ± 21.1, and 8 ± 9.9 wk, respectively. Mean flights climbed, distance traveled, and steps taken decreased significantly from 6 mo prior to surgery to 2 wk postoperatively. Distance traveled and steps taken significantly increased from 6 mo prior to surgery to 7 to 12 mo postoperatively. CONCLUSION: We demonstrated a valuable supplement to traditional PROs by using smartphone-based activity data. This methodology yields a rich data set that has the potential to augment our understanding of patient recovery.

The Remote Completion Rate of Electronic Patient-Reported Outcome Forms Before Scheduled Clinic Visits-A Proof-of-Concept Study Using Patient-Reported Outcome Measurement Information System Computer Adaptive Test Questionnaires.

INTRODUCTION: Patient-Reported Outcome Measurement Information System (PROMIS) questionnaires are amenable to remote administration. This study sought to determine remote completion rates of PROMIS questionnaires before clinic visits. METHODS: Patients were e-mailed a set of PROMIS forms. Completion rates were analyzed by visit type, provider seen, and patient demographics. RESULTS: Seven hundred forty total appointments were included. Sixty-seven percent of encounters had previsit form completion. High completion rates were found for all visit types (74%, 67%, and 64% for new, return, and postoperative visits, respectively). Women had a higher completion rate than men (71% versus 64%; P = 0.031). White patients (72%; P = 0.001) and patients in the third median household income quartile ($53,725 to $83,088; 72%; P = 0.008) had higher completion rates than their respective counterparts. CONCLUSION: Most patients remotely completed PROMIS forms. The efficiency and accessibility of PROMIS forms may help improve ease of collection of patient-reported outcomes.

Using Patient-Reported Outcome Measurement Information System Computer Adaptive Testing Domains to Investigate the Impact of Obesity on Physical Function, Pain Interference, and Mental Health in Sports Medicine Patients.

BACKGROUND: While obesity has become an increasingly prevalent health concern in the United States, little emphasis has been placed on utilizing patient reported outcome measures (PROM) to investigate its impact on life from the patients' perspective. The purpose of the study was to determine the association between patients' body mass index (BMI) and three Patient-Reported Outcome Measurement Information System (PROMIS) computer adaptive test scores: upper extremity physical function (UE) or lower extremity physical function (PF), pain interference (PI), and depression (D). METHODS: Patients were recruited from two sports medicine orthopedic surgery clinics. PROMIS questionnaires were administered to patients arriving for their first visit. Patients were stratified into BMI groupings according to the National Institute of Health standards. Patients' BMI, sex, race, ethnicity, and injury were determined retroactively. Data were analyzed using a Pearson correlation and a least significant difference post hoc test. RESULTS: A total of 833 patients completed the set of PROMIS questionnaires that were retrospectively analyzed. BMI was found to have a correlation with PROMIS-UE (R=-0.111, P<0.05), PROMIS-PF (R=-0.174, P<0.01), PROMIS-PI (R=0.224, P<0.01), and PROMIS-D (R=0.092, P<0.05). Obese patients also portrayed the worst PROMIS-UE, PROMIS-PI, and PROMIS-PF. CONCLUSION: We found BMI to correlate with each PROMIS domain: negatively with PROMIS-UE, PROMIS-PF, PROMIS-D, and positively with PROMIS-PI. Additionally, overweight and obese BMI patients portrayed worse physical function and pain interference scores than their healthy group counterparts.