A new angle on transcranial magnetic stimulation coil orientation: A targeted narrative review.

Transcranial magnetic stimulation (TMS) is used to treat several neuropsychiatric disorders including depression, where it is effective in approximately half of patients for whom pharmacological approaches have failed. Treatment response is related to stimulation parameters such as the stimulation frequency, pattern, intensity, location, total number of pulses and sessions applied, as well as target brain network engagement. One critical but underexplored component of the stimulation procedure is the orientation or yaw angle of the commonly used figure-of-eight TMS coil, which is known to impact neuronal response to TMS. However, coil orientation has remained largely unchanged since TMS was first used to treat depression and continues to be based on motor cortex anatomy which may not be optimal for the dorsolateral prefrontal cortex treatment site. This targeted narrative review evaluates experimental, clinical, and computational evidence indicating that optimizing coil orientation may potentially improve TMS treatment outcomes. The properties of the electric field induced by TMS, the changes to this field caused by the differing conductivities of head tissues, and the interaction between coil orientation and the underlying cortical anatomy are summarized. We describe evidence that the magnitude and site of cortical activation, surrogate markers of TMS dosing and brain network targeting considered central in clinical response to TMS, are influenced by coil orientation. We suggest that coil orientation should be considered when applying therapeutic TMS and propose several approaches to optimizing this potentially important treatment parameter.

Knowledge and attitudes towards eating disorders: A survey of psychiatrists and psychiatry trainees in New South Wales.

OBJECTIVE: To evaluate New South Wales (NSW) psychiatrists' and psychiatry trainees' knowledge and attitudes towards eating disorders (EDs). METHOD: A total of 1781 psychiatrists and trainees in NSW were invited to complete an anonymous questionnaire assessing ED confidence, knowledge and attitudes. RESULTS: A total of 51 doctors responded to the survey, with 38 completing all items. Significant knowledge gaps were revealed. Respondents expressed a desire for more ED training. CONCLUSION: Enhanced ED training in psychiatry education and incorporating the lived experience voice to improve attitudes appear necessary.

Defining a Childhood Type 1 Diabetes Cohort, Clinical Practice Measures, and Outcomes Within Administrative Data in British Columbia.

OBJECTIVE: We used administrative data to 1) establish a cohort of individuals with childhood-onset type 1 diabetes (T1D) in British Columbia (BC), and 2) define T1D-related clinical practice measures. METHODS: We applied a validated diabetes case-finding definition and differentiating algorithm to linked administrative data (1992-1993 to 2019-2020). Cases were removed when they did not meet inclusion criteria for childhood-onset T1D. Clinical practice measures were defined based on clinical practice guidelines. RESULTS: We developed an administrative cohort that included 5,901 individuals with childhood-diagnosed T1D between April 1, 1996, and March 31, 2020. The mean age was 22.31 (standard deviation 8.21) years. Clinical practice measures derived included diabetes outpatient visits (N=4,935) and glycated hemoglobin tests (N=4,935), and screening for thyroid function (N=4,457), retinopathy (N=1,602), and nephropathy (N=2,369). CONCLUSIONS: We established an administrative cohort of ∼6,000 individuals with childhood-onset T1D with 20+ years of follow-up data that can be used to describe the association between clinical practice measures and clinical outcomes.

Patient, operative and pain management factors influencing inpatient compared with surgical day care mastectomy procedures at a community hospital.

BACKGROUND: The COVID-19 pandemic highlighted the importance of maximizing same-day discharge after surgery to mitigate potential patient harms associated with inpatient admission and conserve valuable hospital resources. Adoption of same-day discharge after breast surgery, particularly mastectomy, has been slow despite recent research suggesting the physical and psychological benefits of same-day discharge after surgery. We sought to identify factors associated with inpatient compared with surgical day care mastectomy procedures at a community hospital in Vernon, British Columbia. METHODS: We conducted a retrospective chart review of all patients who underwent a total mastectomy without reconstruction at Vernon Jubilee Hospital, a 196-bed community hospital, between April 2016 and March 2019. Patient characteristics, operative variables and pain management were compared between inpatient and surgical day care mastectomy procedures. We also compared 7-day readmission, reoperation and complications. RESULTS: A total of 187 mastectomy patients were analyzed with 72 (38.5%) surgical day care procedures. Factors associated with inpatient procedures included longer operative time (66.1 min v. 53.5 min, p = 0.001), bilateral mastectomy (91% v. 9%, p = 0.01) and suspected or confirmed obstructive sleep apnea (32% v. 17%, p = 0.04). Preoperative acetaminophen (83% v. 17%, p < 0.001), multilevel intercostal block (83% v. 17%, p < 0.001) and a prescription for acetaminophen plus tramadol (58% v. 42%, p < 0.001) were associated with day care surgeries. There were no significant differences between the inpatient and surgical day care groups with respect to 7-day readmission, reoperation or postoperative complications. CONCLUSION: We found no significant differences in surgical outcomes between inpatients and those with same-day discharge after mastectomy procedures. These findings add to the growing body of evidence that surgical day care mastectomy procedures are safe in the community setting.

Accelerated Repetitive Transcranial Magnetic Stimulation to Treat Major Depression: The Past, Present, and Future.

Repetitive transcranial magnetic stimulation (rTMS) is an effective and evidence-based therapy for treatment-resistant major depressive disorder. A conventional course of rTMS applies 20-30 daily sessions over 4-6 weeks. The schedule of rTMS delivery can be accelerated by applying multiple stimulation sessions per day, which reduces the duration of a treatment course with a predefined number of sessions. Accelerated rTMS reduces time demands, improves clinical efficiency, and potentially induces faster onset of antidepressant effects. However, considerable heterogeneity exists across study designs. Stimulation protocols vary in parameters such as the stimulation target, frequency, intensity, number of pulses applied per session or over a course of treatment, and duration of intersession intervals. In this article, clinician-researchers and neuroscientists who have extensive research experience in accelerated rTMS synthesize a consensus based on two decades of investigation and development, from early studies ("Past") to contemporaneous theta burst stimulation, a time-efficient form of rTMS gaining acceptance in clinical settings ("Present"). We propose descriptive nomenclature for accelerated rTMS, recommend avenues to optimize therapeutic and efficiency potential, and suggest using neuroimaging and electrophysiological biomarkers to individualize treatment protocols ("Future"). Overall, empirical studies show that accelerated rTMS protocols are well tolerated and not associated with serious adverse effects. Importantly, the antidepressant efficacy of accelerated rTMS appears comparable to conventional, once daily rTMS protocols. Whether accelerated rTMS induces antidepressant effects more quickly remains uncertain. On present evidence, treatment protocols incorporating high pulse dose and multiple treatments per day show promise and improved efficacy.

Privacy-preserving cancer type prediction with homomorphic encryption.

Cancer genomics tailors diagnosis and treatment based on an individual's genetic information and is the crux of precision medicine. However, analysis and maintenance of high volume of genetic mutation data to build a machine learning (ML) model to predict the cancer type is a computationally expensive task and is often outsourced to powerful cloud servers, raising critical privacy concerns for patients' data. Homomorphic encryption (HE) enables computation on encrypted data, thus, providing cryptographic guarantees to protect privacy. But restrictive overheads of encrypted computation deter its usage. In this work, we explore the challenges of privacy preserving cancer type prediction using a dataset consisting of more than 2 million genetic mutations from 2713 patients for several cancer types by building a highly accurate ML model and then implementing its privacy preserving version in HE. Our solution for cancer type inference encodes somatic mutations based on their impact on the cancer genomes into the feature space and then uses statistical tests for feature selection. We propose a fast matrix multiplication algorithm for HE-based model. Our final model achieves 0.98 micro-average area under curve improving accuracy from 70.08 to 83.61% , being 550 times faster than the standard matrix multiplication-based privacy-preserving models. Our tool can be found at https://github.com/momalab/octal-candet .

Assurance of Timely Access to Breast Cancer Diagnosis and Treatment by a Regional Breast Health Clinic Serving Both Urban and Rural-Remote Communities.

In response to breast cancer diagnostic regional wait times exceeding both national and provincial standards and to symptomatic patient referrals for diagnostic mammography taking longer than abnormal screening mammography referrals, the Rae Fawcett Breast Health Clinic (RFBHC) was opened in 2017 in a mid-sized Canadian hospital serving both urban and rural-remote communities. We investigated whether the RFBHC improved wait times to breast cancer diagnosis, improved compliance with national and provincial breast cancer standards, and decreased the wait time disparity associated with referral source. Statistical analyses of wait time differences were conducted between patients who were diagnosed with breast cancer prior to and after the RFBHC establishment. Study group compliance with national and provincial standards and wait time differences by referral source were also analysed. A survey was administered to assess overall patient experience with the RFBHC and clinic wait times. RFBHC patients had a shorter mean wait to breast cancer diagnosis (24.4 vs. 45.7 days, p ≤ 0.001) and a shorter mean wait to initial breast cancer treatment (49.1 vs. 78.9 days, p ≤ 0.001) than pre-RFBHC patients. After the RFBHC establishment, patients who attended the RFBHC had a shorter mean wait time to breast cancer diagnosis (24.4 vs. 36.9 days, p = 0.005) and to initial treatment (49.1 vs. 73.1 days, p ≤ 0.001) than patients who did not attend the clinic. Compliance with national and provincial breast cancer standards improved after the RFBHC establishment and the wait time disparity between screening mammography referrals and symptomatic patient referrals decreased. Survey results indicate that the RFBHC is meeting patient expectations. We concluded that the establishment of a breast health clinic in a Canadian center serving urban and rural-remote communities improved breast diagnostic services.

Prediction of successful veno-venous extracorporeal life support liberation using the oxygen challenge test.

BACKGROUND: The oxygen challenge test (OCT) is an underutilized measure of lung recovery, easily performed prior to proceeding with a trial-off V-V ECLS as part of a weaning algorithm. Evidence-based thresholds for OCT results which support continuing with V-V ECLS weaning are lacking, making interpretation of these tests challenging in clinical practice. METHODS: We performed a retrospective review of patients commenced on V-V ECLS as a bridge-to-recovery at Vancouver General Hospital from 2015-2019. The absolute PaO2 post-OCT and change in PaO2 proportional to incremental FiO2 change on the ventilator (∆PaO2 ) were evaluated as predictive screening metrics for identifying conditions favorable for successful trial-off of V-V ECLS. RESULTS: An optimal cut-off of PaO2 ≥ 240 mm Hg post-OCT (AUC 0.77) and ∆PaO2 ≥ 250 mm Hg (AUC 0.76) was identified as a threshold for predicting successful trials-off. A total of 26 and 24 patients achieved post-OCT PaO2 and ∆PaO2 thresholds, and 100% of these patients were liberated successfully from ECLS during their admission. CONCLUSIONS: The OCT can serve as an effective screen of shunt reduction and native lung recovery which can be used alongside other measures of ventilation to assess for suitability of liberation from V-V ECLS prior to a trial-off. Achieving a PaO2 ≥ 240 mm Hg post-OCT is a strong prognostic indicator for successful liberation from V-V ECLS during ICU admission.

Population-based assessment of sentinel lymph node biopsy in the management of cutaneous melanoma.

BACKGROUND: Sentinel lymph node biopsy (SLNB) for melanoma plays a central role in determining prognosis and guiding treatment and surveillance strategies. Despite widely published guidelines for SLNB, variation exists in its use. We aimed to determine the frequency of and predictive factors for SLNB in patients with clinically node-negative melanoma in British Columbia. METHODS: A retrospective review was performed of patients with clinically node-negative melanoma diagnosed between January 2015 and December 2017. Patients included had a Breslow depth greater than 0.75 mm or a Breslow depth less than or equal to 0.75 mm with ulceration, or a mitotic rate greater than or equal to 1/mm2. SLNB was considered to be indicated for clinical stages IB to IIC (American Joint Committee on Cancer's AJCC Cancer Staging Manual, seventh edition). RESULTS: A total of 759 patients were included. SLNB was performed in 54.8% (363/662) of patients when indicated. SLNB was more likely to be performed for tumours with a Breslow depth greater than 1.0 mm or a mitotic rate greater than or equal to 1/mm2. SLNB was less likely to be performed in patients older than 75 years and with a nonextremity tumour location. Compliance with SLNB guidelines decreased distant recurrence but did not significantly affect regional recurrence, nor did it have a significant impact on overall survival among patients aged 75 years and younger. CONCLUSION: SLNB is being underutilized in British Columbia. These results are concerning and highly relevant given the rapidly evolving field of adjuvant systemic therapy for high-risk patients and the increased proportion of patients who should be considered for SLNB on the basis of the eighth edition of the AJCC Cancer Staging Manual and current guidelines. Efforts should be made to increase the use of SLNB in appropriate patients.

Excision of breast fibroepithelial lesions: when is it still necessary?-A 10-year review of a regional centre.

PURPOSE: Fibroepithelial lesions (FEL) range from benign fibroadenoma (FA) to malignant phyllodes tumor (PT), but can be difficult to diagnose on core needle biopsy (CNB). This study assesses risk factors for phyllodes tumor (PT) and recurrence and whether a policy to excise FELs over 3 cm in size is justified. METHODS: Patients having surgery for FELs from 2009 to 2018 were identified. The association of clinical, radiology and pathological features with PT and recurrence were evaluated. Trend analysis was used to assess risk of PT based on imaging size. RESULTS: Of the 616 patients with FELs, 400 were identified as having FA on CNB and 216 were identified as having FEL with a comment of concern for phyllodes tumor (query PT, QPT). PT was identified in 107 cases; 28 had CNB of FA (7.0%), while 79 had QPT (36.6%). Follow-up was available for 86 with a mean of 56 months; six patients had recurrence of PT, all of whom had QPT on CNB. The finding of PT was associated with CNB of QPT, increasing age and size on multivariate logistic regression. All patients diagnosed with PT following CNB of FA had enlarging lesions with a mean size of 38.3 mm. CONCLUSIONS: Our data does not support routine excision of FELs based on size alone. All patients with QPT on CNB, regardless of size should consider excision due to high risk of PT and recurrence, and the decision to excise FAs to rule out PT should also consider whether the lesion is enlarging.

Improved Electrophile Design for Exquisite Covalent Molecule Selectivity.

Covalent inhibitors are viable therapeutics. However, off-target reactivity challenges the field. Chemists have attempted to solve this issue by varying the reactivity attributes of electrophilic warheads. Here, we report the development of an approach to increase the selectivity of covalent molecules that is independent of warhead reactivity features and can be used in concert with existing methods. Using the scaffold of the Bruton's tyrosine kinase (BTK) inhibitor Ibrutinib for our proof-of-concept, we reasoned that increasing the steric bulk of fumarate-based electrophiles on Ibrutinib should improve selectivity via the steric exclusion of off-targets but retain rates of cysteine reactivity comparable to that of an acrylamide. Using chemical proteomic techniques, we demonstrate that elaboration of the electrophile to a tert-butyl (t-Bu) fumarate ester decreases time-dependent off-target reactivity and abolishes time-independent off-target reactivity. While an alkyne-bearing probe analogue of Ibrutinib has 247 protein targets, our t-Bu fumarate probe analogue has only 7. Of these 7 targets, BTK is the only time-independent target. The t-Bu inhibitor itself is also more selective for BTK, reducing off-targets by 70%. We investigated the consequences of treatment with Ibrutinib and our t-Bu analogue and discovered that only 8 proteins are downregulated in response to treatment with the t-Bu analogue compared to 107 with Ibrutinib. Of these 8 proteins, 7 are also downregulated by Ibrutinib and a majority of these targets are associated with BTK biology. Taken together, these findings reveal an opportunity to increase cysteine-reactive covalent inhibitor selectivity through electrophilic structure optimization.

Socioeconomic status does not influence the presentation of patients with inguinal hernia at an urban Canadian teaching hospital.

BACKGROUND: Socioeconomic status (SES) has been shown to influence the outcomes of surgical pathologies in areas with unequal access to health care. The purpose of this study was to measure the effect of SES on the urgency for inguinal hernia repair in an area with purported equitable access to health care in the context of a universal health care system. METHODS: We included all adult patients who underwent surgical management of an inguinal hernia between 2012 and 2016 at 2 urban academic centres. We measured the SES using the Vancouver Area Neighbourhood Deprivation Index (VANDIX) score. RESULTS: We included 2336 patients: 98 emergency surgery and 294 elective surgery cases. We matched patients without replacement on age, sex and American Society of Anesthesiology score, using optimized propensity score matching at a ratio of 1 case to 3 controls. We found no significant correlation between lower SES and emergency surgical management (p = 0.122). Secondary analysis assessed the impact of SES on morbidity and length of stay. We found no significant difference in the rate of complications, length of stay and recurrence by SES category. Patients from lower SES brackets had increased odds for readmission (odds ratio 1.979; 95% confidence interval 1.111-4.318). CONCLUSION: We found no correlation between a low SES and the need for emergency inguinal hernia repair, but found an increased rate of readmission in patients from lower SES brackets. This finding should be further scrutinized through a deeper dive into the barriers to access to nonacute care settings, such as home care.

Accuracy of preoperative imaging estimates: Opportunities to de-escalate surgery for early invasive breast cancer.

BACKGROUND: There is current concern for overtreatment of breast cancer and rising mastectomy rates. This study compared preoperative imaging size (PIS) to postoperative pathology sizes (PPS) with a view to identifying opportunities to de-escalate surgery. METHODS: Patients having surgery from 2013 to 2017 for first invasive breast cancers were identified and PIS was compared to PPS looking at correlation and concordance. Associated clinical features were evaluated by regression models stratified by clinical T stage. RESULTS: We identified 1512 tumors among 1502 patients. Ultrasound, mammogram, and MRI correlated to PPS with increasing discordance with increasing PIS. Ultrasound underestimated T1 and T2 tumors, and mammogram underestimated T1 tumors and overestimated T3 tumors. For T1 and T2 tumors ultrasound had the highest concordance with PPS. CONCLUSION: Patients can be reassured that imaging size can be used dependably by surgeons to plan lumpectomy for clinical T1 tumors. For larger tumors, overestimation by PIS should be considered in surgical planning.

Combinatorial Inactivation of Tumor Suppressors Efficiently Initiates Lung Adenocarcinoma with Therapeutic Vulnerabilities.

Lung cancer is the leading cause of cancer death worldwide, with lung adenocarcinoma being the most common subtype. Many oncogenes and tumor suppressor genes are altered in this cancer type, and the discovery of oncogene mutations has led to the development of targeted therapies that have improved clinical outcomes. However, a large fraction of lung adenocarcinomas lacks mutations in known oncogenes, and the genesis and treatment of these oncogene-negative tumors remain enigmatic. Here, we perform iterative in vivo functional screens using quantitative autochthonous mouse model systems to uncover the genetic and biochemical changes that enable efficient lung tumor initiation in the absence of oncogene alterations. Generation of hundreds of diverse combinations of tumor suppressor alterations demonstrates that inactivation of suppressors of the RAS and PI3K pathways drives the development of oncogene-negative lung adenocarcinoma. Human genomic data and histology identified RAS/MAPK and PI3K pathway activation as a common feature of an event in oncogene-negative human lung adenocarcinomas. These Onc-negativeRAS/PI3K tumors and related cell lines are vulnerable to pharmacologic inhibition of these signaling axes. These results transform our understanding of this prevalent yet understudied subtype of lung adenocarcinoma. SIGNIFICANCE: To address the large fraction of lung adenocarcinomas lacking mutations in proto-oncogenes for which targeted therapies are unavailable, this work uncovers driver pathways of oncogene-negative lung adenocarcinomas and demonstrates their therapeutic vulnerabilities.

Revisiting the effectiveness of repetitive transcranial magnetic stimulation treatment in depression, again.

Following on from the publication of the Royal Australian and New Zealand Journal of Psychiatry Mood Disorder Clinical Practice Guidelines (2020) and criticisms of how these aberrantly addressed repetitive transcranial magnetic stimulation treatment of depression, questions have continued to be raised in the journal about this treatment by a small group of authors, whose views we contend do not reflect the broad acceptance of this treatment nationally and internationally. In fact, the evidence supporting the use of repetitive transcranial magnetic stimulation treatment in depression is unambiguous and substantial, consisting of an extensive series of clinical trials supported by multiple meta-analyses, network meta-analysis and umbrella reviews. Importantly, the use of repetitive transcranial magnetic stimulation treatment in depression has also been subject to a series of health economic analyses. These indicate that repetitive transcranial magnetic stimulation is a cost-effective therapy and have been used in some jurisdictions, including Australia, in support of public funding. An argument has been made that offering repetitive transcranial magnetic stimulation treatment may delay potentially effective pharmacotherapy. In fact, there is considerably greater danger of the opposite happening. Repetitive transcranial magnetic stimulation is as, if not more effective, than antidepressant medication after two unsuccessful medication trials and should be a consideration for all patients under these circumstances where available. There is no meaningful ongoing debate about the use of repetitive transcranial magnetic stimulation treatment in depression - it is a safe, effective and cost-effective treatment.

Impact of new cancer therapies on outpatient treatment delivery for colorectal cancer: A population-based study.

We investigated the impact of new systemic therapies approved in Canada for colorectal cancer on the frequency, intensity and duration of oncology clinic and infusion visits over five treatment phases from diagnosis (P1, P3) to treatment (P2, P4) of primary and metastatic disease, respectively, and during the last 6 months of life (P5). In total, 15,157 adult patients with newly diagnosed colorectal cancer and referred between 2000 and 2012 to any cancer clinic in British Columbia, Canada, were included. Frequency, intensity and duration of medical oncology clinic visits (CVs), oncology infusions (OIs) and oncology prescriptions (OPs) were measured by treatment phase. Mean, total and adjusted total duration for CVs increased for P1-5. CVs increased in P1-5, and in P1-4 when adjusted by treatment length. Adjusted and unadjusted OIs decreased in P1 coinciding with the introduction of an oral treatment option, but increased in P2-5. Mean OI duration increased in P1-5, while total and adjusted total decreased in P1 and increased in P2-5. OPs increased in P2-4, but were unchanged in P1 and P5. Multi-fold increases in resources and time required per patient were also observed, which have significant implications for demand projections in cancer care planning and delivery. In conclusion, patients required more visits in almost all treatment phases, visits on average took longer and patients were in treatment for longer periods of time.

Selective identification and localization of indolent and aggressive prostate cancers via CorrSigNIA: an MRI-pathology correlation and deep learning framework.

Automated methods for detecting prostate cancer and distinguishing indolent from aggressive disease on Magnetic Resonance Imaging (MRI) could assist in early diagnosis and treatment planning. Existing automated methods of prostate cancer detection mostly rely on ground truth labels with limited accuracy, ignore disease pathology characteristics observed on resected tissue, and cannot selectively identify aggressive (Gleason Pattern≥4) and indolent (Gleason Pattern=3) cancers when they co-exist in mixed lesions. In this paper, we present a radiology-pathology fusion approach, CorrSigNIA, for the selective identification and localization of indolent and aggressive prostate cancer on MRI. CorrSigNIA uses registered MRI and whole-mount histopathology images from radical prostatectomy patients to derive accurate ground truth labels and learn correlated features between radiology and pathology images. These correlated features are then used in a convolutional neural network architecture to detect and localize normal tissue, indolent cancer, and aggressive cancer on prostate MRI. CorrSigNIA was trained and validated on a dataset of 98 men, including 74 men that underwent radical prostatectomy and 24 men with normal prostate MRI. CorrSigNIA was tested on three independent test sets including 55 men that underwent radical prostatectomy, 275 men that underwent targeted biopsies, and 15 men with normal prostate MRI. CorrSigNIA achieved an accuracy of 80% in distinguishing between men with and without cancer, a lesion-level ROC-AUC of 0.81±0.31 in detecting cancers in both radical prostatectomy and biopsy cohort patients, and lesion-levels ROC-AUCs of 0.82±0.31 and 0.86±0.26 in detecting clinically significant cancers in radical prostatectomy and biopsy cohort patients respectively. CorrSigNIA consistently outperformed other methods across different evaluation metrics and cohorts. In clinical settings, CorrSigNIA may be used in prostate cancer detection as well as in selective identification of indolent and aggressive components of prostate cancer, thereby improving prostate cancer care by helping guide targeted biopsies, reducing unnecessary biopsies, and selecting and planning treatment.

The Breast Cancer Patient Experience of Telemedicine During COVID-19.

BACKGROUND: The COVID-19 pandemic has seen major shifts in the delivery of health care across the world, including adoption of telemedicine. We present a survey of patient experience with telemedicine for the treatment of breast cancer. METHODS: A questionnaire designed to assess patient satisfaction with telemedicine was distributed to all patients who underwent surgery at the Providence Breast Centre (PBC) for breast cancer or benign/high-risk lesions with surgery follow-up dates between October 13 and December 31, 2020. Surveys were conducted via phone or at in-person follow-ups. RESULTS: A total of 123 of 172 (72%) eligible patients completed the survey; 85% of these patients enjoyed their telemedicine consultation, 93% found there was enough time for dialogue, 66% would choose to have a telemedicine consultation again, 79% would recommend telemedicine at PBC to a friend or family member, and 92% found Zoom© easy to use. When asked whether they prefer a telemedicine initial consultation over an in-person, 28% of patients agreed. When patients are analyzed according to their home address, those more than 10-km away from PBC prefer telemedicine over in-person appointments (37%) more often than those who live less than 10-km away (23%) (p = 0.045). CONCLUSIONS: Patients report a high level of satisfaction with telemedicine. It may be worthwhile to continue telemedicine beyond the pandemic era, due to its convenience, efficiency, and low-cost while keeping patients, physicians, and office staff safe. It also may be more useful in large geographic areas, such as British Columbia to increase access to care.

Introducing oncoplastic breast surgery in a community hospital.

Oncoplastic breast surgery (OPBS) has been shown to increase breast-conserving surgery with improved oncologic and cosmetic outcomes, but access to OPBS in Canada varies greatly. This article summarizes the impact of introducing OPBS in a community hospital. All breast oncology surgery cases performed before and after the introduction of OPBS by a single surgeon were reviewed. After implementing OPBS in our centre, breast conservation increased from 30% to 50%, and the positive margin rate decreased from 25% to 10%. The completion mastectomy rate was lower in patients who received OPBS, and this group had a slightly higher readmission rate for postoperative hematoma. This review suggests OPBS can be performed safely in the community setting with appropriate training and improve outcomes in breast surgery for patients in smaller centres.