The impact of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial: An institutional review

BackgroundAxillary dissection (AD) was historically recommended for all patients with breast tumor involvement discovered by sentinel lymph node biopsy (+SLNB). However, after the ACOSOG Z0011 trial, omission of AD became the recommendation for selected patients with a +SLNB. We report the impact of ACOSOG Z0011 on the completion AD rate in patients with +SLNB at our institution.MethodsWe retrospectively reviewed all patients diagnosed with breast cancer between March 2009 and February 2013 (n = 1781). This cohort was divided into two groups: 1) those diagnosed BEFORE Z0011 and 2) those diagnosed AFTER Z0011. We calculated both the percentage of patients with a +SNLB who underwent AD and, from those patients, the percentage who did and did not meet the Z0011 criteria.ResultsThe BEFORE group contained 849 patients; 144 had +SLNB and from those 113 underwent AD. The AFTER group contained 932 patients: 139 had +SLNB and from those 73 underwent AD. The completion AD rate in the BEFORE group was 78.5%, compared to 52.5% in the AFTER group (p < 0.001). From the patients who met the Z0011 criteria, 75.6% of the BEFORE patients underwent AD, compared to only 2.2%% in the AFTER group (p < 0.001). Among those who did not meet the Z0011 criteria, a similar percentage of patients underwent AD in each group (BEFORE 79.8%, AFTER 74.4%, p = 0.384).ConclusionFollowing the publication of the ACOSOG Z0011 trial, we experienced a significant decrease in the completion AD rate among patients with a +SLNB who met the Z0011 inclusion criteria.     

Preoperative assessment for patients with renal impairment

The kidneys play an essential role in homeostasis. They regulate crucial physiological variables including blood pressure, acid-base, fluid and electrolyte balance. With an ageing and increasingly diabetic population, the prevalence of chronic kidney disease is increasing. Acute kidney injury is also very common in hospitalized patients. It is therefore essential to identify patients with renal impairment and assess its impact on a patient's physiology, with aberrancies such as anuria, metabolic acidosis and hyperkalaemia all being potentially life-threatening if untreated. It is these physiological derangements that lead to the observed association of renal impairment with an increased perioperative morbidity and mortality. Prevention, identification and correction of the physiological consequences of renal impairment are vital in improving postoperative outcomes in these patients. This article aims to provide a context and structure for the preoperative assessment of patients with renal impairment irrespective of its cause.     

Impact of Simulation-Based Training on Radiology Trainee Education in Ultrasound-Guided Breast Biopsies

PurposeThe aim of this study is to determine the impact of a simulation-based ultrasound-guided (USG) breast biopsy training session on radiology trainee procedural knowledge, comfort levels, and overall procedural confidence and anxiety.MethodsTwenty-one diagnostic radiology residents from a single academic institution were recruited to participate in an USG breast biopsy training session. The residents filled out a questionnaire before and after the training session. Ten multiple-choice questions tested general knowledge in diagnostic breast ultrasound and USG breast biopsy concepts. Subjective comfort levels with ultrasound machine and biopsy device functionality, patient positioning, proper biopsy technique, image documentation, needle safety and overall procedural confidence and anxiety levels were reported on a 5-point Likert scale before and after training.ResultsParticipants demonstrated significant improvement in number of correctly answered general knowledge questions after training (P < .0001). Significant improvement was seen in resident comfort level in ultrasound machine functionality, patient positioning, biopsy device functionality, biopsy technique, image documentation, as well as overall confidence level (all P < .05). Participants indicated a slight but not significant reduction in anxiety levels (P = .27).ConclusionsA simulation-based USG breast biopsy training session may improve radiology trainee procedural knowledge, comfort levels, and overall procedural confidence.     

Phosphorylation of Ribosomal Protein S6 Mediates Mammalian Target of Rapamycin Complex 1–Induced Parathyroid Cell Proliferation in Secondary Hyperparathyroidism

Secondary hyperparathyroidism is characterized by increased serum parathyroid hormone (PTH) level and parathyroid cell proliferation. However, the molecular pathways mediating the increased parathyroid cell proliferation remain undefined. Here, we found that the mTOR pathway was activated in the parathyroid of rats with secondary hyperparathyroidism induced by either chronic hypocalcemia or uremia, which was measured by increased phosphorylation of ribosomal protein S6 (rpS6), a downstream target of the mTOR pathway. This activation correlated with increased parathyroid cell proliferation. Inhibition of mTOR complex 1 by rapamycin decreased or prevented parathyroid cell proliferation in secondary hyperparathyroidism rats and in vitro in uremic rat parathyroid glands in organ culture. Knockin rpS6^p−/− mice, in which rpS6 cannot be phosphorylated because of substitution of all five phosphorylatable serines with alanines, had impaired PTH secretion after experimental uremia- or folic acid–induced AKI. Uremic rpS6^p−/− mice had no increase in parathyroid cell proliferation compared with a marked increase in uremic wild–type mice. These results underscore the importance of mTOR activation and rpS6 phosphorylation for the pathogenesis of secondary hyperparathyroidism and indicate that mTORC1 is a significant regulator of parathyroid cell proliferation through rpS6.