Health literacy assessment and patient satisfaction in surgical practice.

BACKGROUND: Individuals with limited health literacy have barriers to patient-physician communication. Problems in communication are known to contribute to malpractice litigation. Concern exists, however, about the feasibility and patient acceptance of a health literacy assessment. This study was performed to determine the feasibility of health literacy assessment in surgical practice and its effect on patient satisfaction. STUDY DESIGN: Every patient seen in a Breast Surgery Clinic during a 2-year period was asked to undergo a health literacy assessment with the Newest Vital Sign (NVS) as part of the routine history and physical examination. During the year before routine NVS assessments and during the 2-year study period, all patients were asked to rate their "overall satisfaction with clinic visit" on a 5-point scale. RESULTS: A total of 2,026 of 2,097 patients (96.6%) seen during the study were eligible for the health literacy assessment. Of those, no patients refused assessment, and only one patient was missed. Therefore, 2,025 of 2,026 eligible patients (99.9%) underwent the assessment. The average time for NVS assessment was 2:02 minutes. Only 19% of patients had adequate health literacy. Patient satisfaction ratings were slightly greater during the first year of the health literacy assessment (3.8 vs 3.7, P = .049) compared with the year prior to health literacy assessment and greater during the second year of health literacy assessment (4.1 vs 3.7, P < .0001). CONCLUSION: Routine health literacy assessment is feasible in surgical practice and results in no decrease in patient satisfaction. In fact, satisfaction was greater during the years when health literacy assessments were performed.

Intraoperative ultrasound can facilitate the wire guided breast procedure for mammographic abnormalities.

Wire guided breast procedures are the most commonly used breast conserving operation for nonpalpable cancers. We did a retrospective review of all patients who underwent the wire guided breast procedure at a county hospital with an associated surgical residency program. Twenty-eight patients underwent the procedure with intraoperative ultrasound from June 2009 to March 2010. Breast cancer patients who underwent a wire-guided lumpectomy with intraoperative ultrasound had a lower rate of positive margins (9% vs. 26%, P = 0.28) and a smaller volume of tissue removed (126 cm3 vs. 146 cm3, P = 0.57). For wire guided excisional biopsy, the volume of tissue removed was smaller in the intraoperative ultrasound group (30 cm3 vs. 44 cm3, P = 0.17) and the targeted area was more likely to be removed in one specimen (1.1 vs. 1.5, P = 0.03). Intraoperative ultrasound can improve surgical outcomes of the wire guided breast procedure.

Intraoperative ultrasound can decrease the re-excision lumpectomy rate in patients with palpable breast cancers.

Positive margins occur in 15 to 69 per cent of patients undergoing lumpectomy. The current study was performed to evaluate intraoperative ultrasound in patients undergoing lumpectomy for palpable breast cancer. A retrospective chart review was performed of patients with palpable cancer who underwent lumpectomy with intraoperative ultrasound from 2004 to 2009. Each patient was matched with two patients who underwent lumpectomy alone over the same time period. Matching criteria included tumor size, clinical stage, body mass index, age at diagnosis, and lymphovascular invasion or extensive intraductal component. Twenty-two consecutive patients who underwent lumpectomy with intraoperative ultrasound were matched with 44 patients who underwent lumpectomy without intraoperative ultrasound. In addition to matching criteria, the patients were similar with respect to ethnicity, insurance status, weight, predominant histology, estrogen receptor, progesterone receptor, and Her2 status. Patients who underwent lumpectomy with intraoperative ultrasound were significantly less likely to have an involved margin (41 vs 9%, P = 0.01) and less likely to require a re-excision (34 vs 9%, P = 0.04). The lumpectomy volumes in the intraoperative ultrasound group were smaller than the volumes in the lumpectomy alone group. Intraoperative ultrasound can decrease the rate of positive margins and re-excision lumpectomy in patients with palpable breast cancers.

Cell surface chondroitin sulfate glycosaminoglycan in melanoma: role in the activation of pro-MMP-2 (pro-gelatinase A).

We previously reported that CS (chondroitin sulfate) GAG (glycosaminoglycan), expressed on MCSP (melanoma-specific CS proteoglycan), is important for regulating MT3-MMP [membrane-type 3 MMP (matrix metalloproteinase)]-mediated human melanoma invasion and gelatinolytic activity in vitro. In the present study, we sought to determine if CS can directly enhance MT3-MMP-mediated activation of pro-MMP-2. Co-immunoprecipitation studies suggest that MCSP forms a complex with MT3-MMP and MMP-2 on melanoma cell surface. When melanoma cells were treated with betaDX (p-nitro-beta-D-xylopyranoside) to inhibit coupling of CS on the core protein, both active form and proform of MMP-2 were no longer co-immunoprecipitated with either MCSP or MT3-MMP, suggesting a model in which CS directly binds to MMP-2 and presents the gelatinase to MT3-MMP to be activated. By using recombinant proteins, we determined that MT3-MMP directly activates pro-MMP-2 and that this activation requires the interaction of the C-terminal domain of pro-MMP-2 with MT3-MMP. Activation of pro-MMP-2 by suboptimal concentrations of MT3-MMP is also significantly enhanced in the presence of excess C4S (chondroitin 4-sulfate), whereas C6S (chondroitin 6-sulfate) or low-molecular-mass hyaluronan was ineffective. Affinity chromatography studies using CS isolated from aggrecan indicate that the catalytic domain of MT3-MMP and the C-terminal domain of MMP-2 directly bind to the GAG. Thus the direct binding of pro-MMP-2 with CS through the C-domain would present the catalytic domain of pro-MMP-2 to MT3-MMP, which facilitates the generation of the active form of MMP-2. These results suggest that C4S, which is expressed on tumour cell surface, can function to bind to pro-MMP-2 and facilitate its activation by MT3-MMP-expressing tumour cells to enhance invasion and metastasis.

Membrane type-1 matrix metalloproteinase promotes human melanoma invasion and growth.

Membrane type-I metalloproteinase (MT1-MMP) is a transmembrane metalloproteinase that is critical for tumor cell invasion. MT1-MMP can degrade extracellular matrix (ECM) proteins directly and/or indirectly by activating soluble MMPs such as pro-MMP-2. Although MT1-MMP is upregulated in malignant melanoma, the biological consequences of elevated MT1-MMP expression for tumor progression are not entirely understood. In the current study, we have utilized the Bowes melanoma line for evaluating MT1-MMP in invasion and growth. Our studies extend the earlier observations to demonstrate that MT1-MMP expression in Bowes melanoma cells promotes selective invasion into matrigel but not matrices consisting of type-I collagen. Furthermore, MT1-MMP expressing melanoma cells exhibit increased migration in response to laminin 1 but not to type-I or type-IV collagen. MT1-MMP expression results in enhanced 3 dimensional growth in agarose gels and in long-term cultures within matrigel. The hydroxymate inhibitor BB94 inhibits MT1-MMP enhanced invasion and growth in 3 dimensional culture systems, but had no effect on increased motility. We demonstrated that MT1-MMP expression significantly facilitated tumorigenicity and growth by intradermal injection. The results suggest a more general role for elevated MT1-MMP in promoting both the selective invasion and increased growth of malignant melanoma in vivo.