What do breast surgeons do?

Background

There are an increasing number of fellowship-trained breast surgeons and surgical oncologists who dedicate their clinical practice exclusively to breast disease. However, there are little published data regarding characteristics of a breast surgical practice.

Methods

All patient visits at a university-based breast surgery practice were reviewed for calendar years 2006 and 2007.

Results

There were 10,381 patient visits, of which 2,334 (22%) represented new patients. Of these, 11% were referred with a diagnosis of cancer. Out of the remainder, 29% had a needle biopsy (8% by the surgeon and 21% by radiology), 29% underwent surgery, and 13% were ultimately diagnosed with cancer. After completion of initial therapy, 6 months or 1 year follow-up was recommended for 59% of the patients.

Conclusions

The specialty of breast surgery is unique in its nonoperative volume and extensive duration of follow-up. Strategies need to be designed to make this process more time-efficient for the surgeon.     

“Why do they do that?”

The problem of compliance or adherence with medical advice is complex in every aspect. Frequently compliance definitions vary, measurements are not well quantified, interventions are uncontrolled or not fully elaborated. Nevertheless the importance of facilitating and maximizing compliance is undeniable. As the medications available become more potent and effective, the challenge of achieving optimal medication compliance comes into sharper focus and becomes a concern for everyone involved in health care. Here some of the recent clinical research on compliance is presented together with strategies intended to improve medication compliance by pediatric patients.     

How much colorectal surgery do general surgeons do?

BACKGROUND: Surgical subspecialization has croded the traditional domain of the general surgeon. The purpose of this study was to assess the volume and distribution of colon and rectal cases performed by general surgeons. STUDY DESIGN: The American Board of Surgery database was queried to identify and categorize the number of colorectal cases performed yearly by "generalists" (general surgeons) recertified between 1995-1997. RESULTS: There were 2,434 general surgeons (those with a basic certificate only) recertified. The mean number of large bowel cases was 33 (range 0-243). Thirty-one cases represented the 70th percentile and 60 cases represented the 90th percentile. The mean number of anorectal cases was 12.3 (range 0-185). The 70th percentile was 15 cases, and the 90th percentile was 26 cases. Seventy-five percent of general surgeons perform > or = 17 large intestine cases each year, whereas, only 25% perform > 16 total anorectal cases. CONCLUSION: General surgeons perform a substantial number of colon resections and relatively few anorectal cases. It is unclear whether this is an issue of anorectal training in general surgery programs or referral patterns.     

What do surgery residents do on their call nights?

BACKGROUND: Surgical resident education is entering a critical era of achieving core competencies despite work hour restrictions. An assessment of on-call activity is needed to maximize educational merit. METHODS: A time-motion study of resident on-call activity was performed at a university medical center and an urban affiliate hospital. Residents were followed by "shadow" residents who concurrently recorded resident activity. RESULTS: Activities of daily living and patient evaluation comprised the majority of on-call activity. Residents slept a median of 200 minutes per night. Cross-coverage activities accounted for 41% of pages and 19% of patient evaluation. Direct patient contact comprised only 7% of call night duties. Communication activity occupied 15% of total minutes, and a mean of 16 pages were received nightly. Significant differences in activities existed between resident levels and hospitals. CONCLUSIONS: Call activity consists primarily of activities of daily living, patient evaluation, and communication. Sleep accounts for nearly one third of all on-call activity. These data may be useful in improving both patient care and resident call experience.     

Femoral neck non-unions: how do I do it?

Femoral head necrosis and non-union are frequent complications after femoral neck fracture. The main reason for failure leading to non-union is an inadequate osteosynthesis and/or poor mechanical conditions, leading to instability. Criteria for optima reduction and fixation techniques, which can prevent non-union in the majority of cases, are described. This knowledge is mandatory for each surgeon as in the non-expert situation up to 30% inadequacy of the "simple" procedure occurs! Although in the elderly endoprosthetic replacement is the treatment of first choice, in the younger and active patients the treatment should be directed towards salvage of the own hip. In non-complex cases a valgisation osteotomy according to Pauwels will lead to very good results. The technique of this secondary procedure is demonstrated by a case report. In case of combined pathology with (complete) a vascular necrosis of the femoral head, the age threshold for endoprosthetic replacement will be far lower nowadays, but even in those cases, especially below the age of 50, salvage procedures with free fibular grafting lead to a good outcome and form a useful alternative.     

What do they do with their metalwork? What patients do with orthopaedic implants given to them after surgery

Removal of metalwork is one of the commonest orthopaedic elective procedures with patients often requesting to keep their implants. Five hundred consecutive patients who had removal of their orthopaedic implant between April 1994 and March 2000 were contacted by post. Three hundred and seventy-two responded (response rate 74%). Two hundred and thirty-nine patients (64%) had metalwork extracted from their lower limb, whilst one hundred and thirty-three (36%) had metalwork extracted from their upper limb. Sixty-one patients (17%) had kept their metalwork upon being contacted. Of the sixty-one patients, 10 (16%) had used their implant for functional use, 22 (36%) had stored theirs and 29 (48%) did not know what had happened to theirs.     

Neuropathic pain: what do we do with all these theories?

Only a generation ago there were few ideas as to what might cause neuropathic pain, and even fewer relevant data. In contrast, we can currently point to hundreds of distinct cellular changes that are triggered by nerve injury and that might be relevant to the emergence of pain symptomatology. The number may soon increase to thousands. It is essential, therefore, to redirect efforts towards the development of experimental strategies for testing which of these are essential parts of the pain process and which are tangential. In this paper I point out four such strategies: timing, deletion, prevention and genetic heterogeneity, and summarize how one neuropathic pain theory, the ectopic pacemaker hypothesis, holds up to scrutiny.     

Periprosthetic femoral fractures: What to do,what to do?

Post-operative periprosthetic fractures have an incidence of 1.1% (Berry, 1999 [1]). The periprosthetic fracture is commonly classified by the location of the fracture. The most frequently utilized fracture classification categorizes patients by the location of the fracture including: peritrochanteric, around the stem, or distal to the femoral implant. Additional considerations incorporated in this classification include femoral implant stability and host bone status. We will review the different treatment modalities for each fracture type with consideration given to stem stability and host bone status.     

Breast tomosynthesis: What do we know and where do we stand?

Digital breast tomosynthesis (DBT) is a new imaging technology that addresses the limitation caused by overlapping structures in conventional two-dimensional digital mammography owing to the acquisition of a series of low-dose projection images. This unique technique provides a dual benefit to patients screened for breast cancer. First, DBT increases the cancer detection rate mostly by highlighting architectural distortions and allowing better assessment of masses shape and margins. Second, DBT helps reduce recall rate by discarding asymmetries related to overlapping tissue. However, DBT is not included in the majority of cancer screening programs worldwide. Several issues still need to be addressed such as over-diagnosis and over-treatment, lack of reduction of interval breast cancer, quality control and storage, and radiation dose. In the diagnostic setting, DBT increases the diagnostic accuracy and reduces the number of indeterminate lesions in symptomatic women. Its aforementioned performances regarding asymmetries, masses and architectural distortions allow reducing the number of additional views while working-up a screening-detected lesion. Tumor size is also better assessed at DBT as well as multicentricity, two significant benefits in the staging of breast cancer. Finally, DBT allows a better analysis of scars and helps reduce the rate of indeterminate findings after surgery. Although somewhat limited by high breast density, DBT globally outperforms digital mammography in both screening and diagnostic breast imaging. Additional research is however needed, particularly on relevant screening outcomes. This review describes the main performances of breast DBT in breast cancer screening and diagnosis and the resulting consequences in both settings.