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 Whiteboard Time Out: A Novel Tool to Improve Resident Learning in the Operating Room.

OBJECTIVE: "Flipping the classroom" is a strategy that has been implemented in various educational environments to create a student-centered learning environment. Within this model of teaching, "first exposure" occurs prior to the classroom in a lower form of cognitive demand, allowing students to employ higher forms of cognition within the classroom. Surgical education has evolved over recent years to incorporate different modalities of learning; however, optimal educational approaches within the operating room (OR) have not been clearly defined. The Whiteboard Time Out (WBTO) utilizes the idea of "flipping the classroom" to make learning within the OR more resident centered. Residents complete most of the preoperative work prior to the case with a focus on the indications, steps of the procedure, and potential complications associated with the procedure. Residents then utilize a whiteboard located in the OR to outline, diagram, and discuss this information with the attending. Aims of the study are to enhance higher level intraoperative resident learning and attending teaching and improve resident knowledge and the ability to communicate surgical steps. DESIGN: Faculty and residents completed a preimplementation questionnaire aligned to the Student Evaluation of Educational Quality (SEEQ) in July 2021. Participants were assigned 3 digit codes to ensure anonymity. The questionnaire was composed of 6 questions with a 5-point Likert scale. Whiteboards were mounted in every operating room, 19 total, in both the general OR and an ambulatory surgical center. The residents were expected to go to the OR, prior to scrubbing the case, and use the whiteboard to outline the indications, key steps and potential complications. After the resident completed the white board, the resident and attending reviewed the white board together prior to the start of the case. After the procedure, residents uploaded a picture of the whiteboard with a self-evaluation and faculty provided resident feedback via an online Wufoo Survey link. The start of the utilization of the whiteboards occurred after the initial survey in July 2021. The SEEQ questionnaire was again administered in October 2021, 3 months post-WBTO implementation, to assess resident and attending satisfaction. SEEQ questionnaire results were compared using a t-test. PARTICIPANTS: Participants included surgical residents and attendings at Maimonides Medical Center (MMC). MMC is a 700-bed university-affiliated, academic, tertiary medical center in Brooklyn, New York. The General Surgery Residency is approved for up to 5 graduates annually. RESULTS: A total of 17 attendings and 17 residents filled out the questionnaire. The average number of whiteboards completed was highest amongst the PGY1 class with an average of 18 whiteboards per resident. However, the average number of whiteboards completed declined amongst more senior residents. There was a statistically significant increase in overall SEEQ survey score amongst residents and attendings after implementation of the WBTO suggesting that whiteboards were useful (p < 0.03 and p < 0.02, respectively). Residents found that the whiteboard was an effective means of teaching surgical education compared to the current curriculum (p < 0.04). CONCLUSIONS: The whiteboard timeout is a tool created to enhance resident education in the OR. This idea is centered on a "flipped classroom," an educational strategy to increase student engagement. Our data demonstrates that the whiteboard timeout is an effective method of intraoperative teaching.

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.

The Attending Meritocracy: Implementation of a Novel Team-Based Approach to Provide Effective Resident Feedback.

OBJECTIVE: Providing timely quality feedback is an essential responsibility of teaching faculty and is critical for resident assessment and development throughout training. Numerous evaluation platforms have been created to provide immediate and big picture end-of-rotation feedback. Faculty suffer burnout from electronic documentation demands and workload and as a result, evaluation activity is relegated to a lower priority leading to poor compliance. We implemented a novel team-based Attending Meritocracy (AM)1 program that encompasses monetary, automated reminder, and punitive components, while adding a competition element to further engage faculty. The aim of this study is to determine effectiveness of AM in increasing compliance with resident feedback. DESIGN, SETTING AND PARTICIPANTS: Surgical faculty (n = 36) were divided into 5 teams according to service and subspecialty. Points could be earned by completing surgical (Firefly, MiniCEX) or rotation (New Innovations) evaluations, leaving comments, and other educational tasks. A prize for the highest scoring team was identified as a dinner financed by the non-winning teams. Data from evaluation platforms was extracted. Continuous variables were compared using Mann-Whitney-U test, and categorical variables using chi-squared test. RESULTS: When comparing July 2019 to February 2020 (control period) with July 2020 to February 2021(initial implementation period), we found a 237% increase in submitted NI evaluations (n = 111-374) and a 42.5% decrease in median time to completion from 60.4 (33.2-106.9) days to 34.7 (24.0-64.5) days, (p = 0.001).2 We observed an increase in operative evaluations completed (Mini CEX n = 4-97, Firefly n = 150-1284). CONCLUSIONS: Implementation of a team-based attending meritocracy program is an effective budget neutral method to increase completion of resident evaluations. Further investigation is needed to assess improvement in quality of feedback as well as to explore it's impact on progression of resident autonomy.

Rapid Adoption of an Interdisciplinary Care Team Model for Surgical Residents Managing Coronavirus Disease-19.

Introduction: Patients infected with SARS-Cov-2, the causative virus behind the coronavirus disease-19 (COVID-19) pandemic, have been increasing rapidly in New York City. New York City has the highest incidence in the United States and fully 45% of all deaths from COVID-19. Our medical center is located within a high-density region of cases in south Brooklyn and, in fact, three of our neighborhood zip codes are in the top seven in New York in incidence. As a result, our center has experienced a dramatic increase in hospitalizations, particularly respiratory distress secondary to COVID-19, which rapidly exceeded the capacity of our internal medicine service. This necessitated the formation of new COVID-19 units throughout the hospital, replacing all former service lines. These units employed management teams composed of residents from many medical and surgical disciplines, including general surgery residents. Methods: Our general surgery residency program established a surgical COVID-19 (SCOVID) management team. Initially, 4 surgical residents (2 senior and 2 junior), 1 attending surgeon, and 1 attending internal medicine physician were allocated to the initial SCOVID team. On day 3 of implementation, to achieve more rapid competence in the complex management of these patients, a senior medicine resident with direct experience in the care of COVID-19 patients was added in an advisory capacity. Results: The addition of an experienced senior medical resident and attending allowed for the quick adoption of uniform management protocols by surgical residents and attendings. Discussion: We describe a protocol for the establishment of COVID-19 management teams staffed with general surgical residents, as well as a strategy for the achievement of rapid increases in competency. The addition of a senior internal medicine resident and attending to our SCOVID team allowed for rapid achievement of competency in the care of COVID-19 patients in our large institution at the epicenter of the COVID-19 pandemic.

Schizophrenia in DiGeorge Syndrome: A Unique Case Report.

Herein we present the unique case of a 21-year-old African American woman who presented with psychotic features and the incidental finding of basal ganglia calcifications on computed tomography (CT) scan of the head. She was initially presumed to have Fahr's syndrome in the context of idiopathic bilateral basal ganglia calcifications and psychotic features. Genetic testing performed revealed the deletion of 22q11.2, thus establishing the diagnosis of DiGeorge syndrome. This case highlights the importance of noticing subtle physical exam findings along with laboratory findings as this led to the diagnosis of DiGeorge syndrome for this patient. This case is unique in two aspects; first, the finding of basal ganglia calcification via CT of the brain in patients with DiGeorge syndrome has rarely been reported in the literature. Second, this case highlights the strong genetic predisposition for schizophrenia in patients with DiGeorge syndrome.