Breast conserving surgery combined with radiation therapy offers improved survival over mastectomy in early-stage breast cancer.

INTRODUCTION: Landmark trials established equivalent survival regardless of extent of breast surgery in early-stage breast cancer. However, recent studies suggest a survival advantage for breast conserving surgery (BCS) with radiotherapy (BCT). This study assesses the impact of type of surgery on overall survival (OS), breast cancer specific survival (BCSS) and local recurrence (LR) in a modern population-based cohort. METHODS: Female patients aged ≥18, pT1-2pN0, who had surgery between 2006 and 2016 were identified from Breast Cancer Outcome Unit prospective database. Neoadjuvant chemotherapy patients were excluded. Multivariable Cox regression was used to assess the effect of surgical procedure on OS, BCSS, and LR on cohort with complete data. RESULTS: BCT was performed in 8422 patients and TM in 4034 patients. The baseline characteristics differed between the groups. Mean follow up was 8.3 years. BCT was associated with increased OS HR 1.37, p < 0.001, BCSS survival HR 1.49, p < 0.001, and similar LR HR 1.00, p > 0.90. CONCLUSION: This study supports that in early-stage breast cancer, BCT has improved BCSS compared to TM without an increased risk of LR.

Benign spindle cell lesions of the breast: a diagnostic approach to solitary fibrous tumour, nodular pseudoangiomatous stromal hyperplasia and nodular fasciitis.

Benign spindle cell lesions of the breast include neoplastic and reactive entities that are diagnostically challenging given their rarity and similar histomorphology. Accurate diagnosis on percutaneous core biopsy within this category is essential as some lesions require excision and surveillance, whereas others may be observed. We present three cases of rare benign spindle cell lesions of the breast that reflect the diversity of this group: solitary fibrous tumour, nodular pseudoangiomatous stromal hyperplasia and nodular fasciitis. Through these cases, we discuss the associated differential diagnosis and demonstrate how emerging ancillary studies can be integrated into a diagnostic approach. We highlight distinctive clinical and histopathological features and summarise recent updates to the clinical management of these lesions. An organised approach to the broad differential of spindle cell lesions is essential for appropriate diagnosis and treatment.

Using CanMEDS to guide international health electives: an enriching experience in Uganda defined for a Canadian surgery resident.

BACKGROUND: Surgery residents who wish to travel during their residency will often seek an elective experience in a low-or middle-income country. Objectives for international health electives (IHEs) are often vague and poorly defined. Further, feedback to, and evaluation of, the resident after the IHE are often not specific because international preceptors are not familiar with the desired educational outcomes of Canadian residency programs. Residents who choose an elective in a low-income country usually anticipate that they will contribute some medical service to an existing impoverished health care system, and in this setting, they hope to gain exposure to a high operative volume with potentially fewer institutional and administrative obstacles. METHODS: In this paper, we describe one resident's elective experience in Mbarara, Uganda. In addition to her clinical experience, the resident performed a retrospective audit of surgical admissions. After her elective, we asked the resident to reflect on her experience and to use the Canadian Medical Education Directives for Specialists (CanMEDS) framework to describe the challenges she encountered and to define the learning outcomes gained with respect to each CanMEDS role. RESULTS: We discovered that the resident had a rich and insightful educational experience when discussed in this context. As a result, we have created a guide for structuring postgraduate IHEs around the CanMEDS roles, using them to ask pre-and postelective questions to develop relevant and practical IHE objectives. CONCLUSION: We propose that this guide has the potential to improve both resident preparation before international experience and also subsequent evaluation of resident performance in this ill-defined area. More important, we found that IHEs are a useful vehicle to evaluate resident achievement of the CanMEDS competencies in a way that is reflective, realistic and representative of the multiple challenges involved when working in international health.

Characteristics and conviction rates of injured alcohol-impaired drivers admitted to a tertiary care Canadian Trauma Centre.

PURPOSE: Alcohol intoxication is an important factor in motor vehicle crash (MVC) related morbidity and mortality. Despite greater societal attention, medical admission after MVC results in avoidance of legal consequences. We sought to determine characteristics of, and consequences to, injured alcohol-impaired drivers (IAIDs). METHODS: All injured adults [Injury Severity Score (ISS) >12, age>18] entered in a Trauma Centre registry between April 1 1995 to March 31 2003 were reviewed. Legally intoxicated patients who had been drivers involved in a MVC and who had a blood alcohol content (BAC) > or =80 mg/dl were cross-referenced to municipal and federal databases to identify investigations, charges, and legal outcomes. RESULTS: Of BACs obtained from 1933 (41%) of 4727 patients; 39% (757) were legally intoxicated (BAC > or =80 mg/dl); 185 (24%) were IAIDs. The IAIDs were generally very intoxicated (mean BAC 190 mg/dl); seriously injured (median ISS 22); often in ICU (47%), and had 8% mortality. Charges were laid against 69 (37%) of IAIDs, only 58 (31%) suffered legal consequences; 27 (15%) of impaired driving, and 31 (17%) of other convictions. All IAIDs who caused a fatal injury to another were convicted. A lower severity of injury of the IAIDs, non-fatal injury to another, and occurrence in the more recent years of the study were independently associated with a conviction in multivariable analysis. CONCLUSION: Despite increasing convictions over time and among most of those charged, the majority of injured drivers escape legal consequences. Increased BAC testing and reporting of this phenomenon could address this.

Long-term outcomes after injury in the elderly.

BACKGROUND: The lasting impact of injury on lifestyle in the elderly remains poorly defined. The purpose of this study was to determine the long-term quality-of-life outcomes in elderly trauma patients. METHODS: The trauma registry at a regional trauma center was used to identify hospital survivors of injury > or = 65 years old discharged from April 1996 to March 1999. The 36-Item Short Form (SF-36) Health Survey was administered to this group by telephone interview and the scores compared with age-adjusted Canadian norms. Comparisons with test were made for continuous data. RESULTS: Complete data collection was achieved in 128 of 171 (75%) study patients. The mean Injury Severity Score was 21, the mean initial Glasgow Coma Scale score was 13, and the mean age was 74. Most (97%) were victims of blunt trauma. Compared with Canadian age-adjusted norms, there was a significant (p < 0.05) decrease in seven of eight SF-36 domains: Physical Functioning, Role-Physical and Role-Emotional (limitations secondary to physical and emotional health), Social Functioning, Mental Health, Vitality, and General Health. Before injury, most (98%) were living independently at home. However, at long-term follow-up (mean, 2.8 years; range, 1.5-4.5 years), only 63% were living independently and 20% still required home care. CONCLUSION: Although the majority of elderly injury survivors achieve independent living, long-term follow-up indicates significant residual disability in quality of life as measured by the SF-36.