Background Patients with stage II melanoma have a considerable risk for recurrence. Current guidelines are imprecise as to optimal follow-up. We hypothesized that by examining recurrence patterns, we ...could help to better inform guidelines. Study Design We queried IRB-approved melanoma databases of Thomas Jefferson University and University of North Carolina, identifying 581 patients with stage II melanoma between 1996 and 2015 with at least 1 year of follow-up. Data included location of first recurrence and how recurrence was detected (ie patient symptom, physician examination, or routine surveillance imaging). Cox regression with backward elimination was used for multivariable analysis. Results One hundred and seventy-one patients had a recurrence (29.4%), the incidence increased considerably by stage sub-group. Significant predictors of recurrence included male sex (p = 0.003), ulceration (p = 0.03), and stage (p < 0.001). On multivariable analysis, male sex and stage continued to be significant (p < 0.01). For overall survival, regression, ulceration, stage, and age were significant predictors of survival. Stage, regression, and age remained significant by multivariable analysis. Patient symptoms were the most frequent mode of detection (40%), followed by physician examination (30%) and surveillance imaging (26%)—this did not differ significantly by stage. Regional nodes were the most common site of recurrence (30%), followed by lung (27%) and in-transit (18%). Conclusions The majority of recurrences in stage II melanoma are detected by patients and their physicians and rarely by routine imaging. As such, clinical follow-up and patient education are critical factors in detection of recurrence. With the prevalence of regional nodal recurrences, ultrasound might prove to be an important strategy in early recurrence detection.
Abstract Introduction Learning procedural skills as a medical student has evolved, as task trainers and simulators are now ubiquitous. It is yet unclear whether they have supplanted bedside teaching ...or are adjuncts to it, and whether faculty or residents are responsible for student skills education in this era. In this study we sought to characterize the experience and opinions of both medical students and faculty on procedural skills training. Methods Surveys were sent to clinical medical students and faculty at UNC Chapel Hill. Opinions on the ideal learning environment for basic procedural skills, as well as who serves as primary teacher, were gathered using a 4-point Likert scale. Responses were compared via Fisher exact test. Results A total of 237 students and 279 faculty responded. Third-year students were more likely to report simulation as the primary method of education (64%), compared to either fourth-year students (35%; P < 0.0001) or faculty (43%; P = 0.0018). Third- and fourth-year students were also more likely to report interns as a primary teacher (15% and 10%, respectively) as opposed to faculty (2%), and less likely to suggest faculty were the primary teacher (30% and 21%, respectively, versus 35%), P < 0.0001. Residents were the primary teachers for all three groups (55%, 70%, and 63% respectively). Conclusions Our data suggest that both medical students and faculty recognize the utility of simulation in procedural skills training, but vary in the degree to which they think simulation is or should be the primary instructional tool. Both groups suggest residents are the primary teacher of these skills.
Background How to best risk-stratify patients with metastatic melanoma in the sentinel node (SN) is controversial. Not all node-positive disease is equivalent in terms of disease-free or overall ...survival, and some have suggested that submicrometastatic disease, characterized by <0.1 mm tumor burden, can represent a distinct classification not associated with a chance for recurrence or death. We hypothesize that all patients with metastatic melanoma cells in the sentinel node have potentially life-threatening disease. Study Design This is a retrospective review of an IRB-approved, prospectively maintained melanoma database of >1,100 patients. All invasive melanoma patients who had an SN biopsy and at least 1 year of followup were included. Patients with metastatic melanoma in the SN were divided into groups according to diameter of SN tumor burden: node-negative, <0.1 mm (submicrometastatic), 0.1 to 1.0 mm, and >1.0 mm. Statistical methods included the Jonckheere-Terpstra method, Fisher's exact tests, and Kaplan-Meier method. Results From July 1, 1998 to July 1, 2007, 578 patients with invasive melanoma underwent SN procedure. Median followup was 2.2 years. There was a statistically significant difference in the proportion of patients who experienced a recurrence between the node-negative group (11%) and the <0.1 mm group (24%) (p = 0.049). Patients in the submicrometastatic group have a statistically significant (p = 0.048) earlier recurrence than those in the node-negative group. Conclusions These results suggest that patients with submicrometastatic SN disease should not be treated as node-negative, as it appears to represent a more biologically aggressive melanoma, associated with a substantially faster time to recurrence. We cannot agree with recent proposals that patients with very small tumor burden in the SN can be treated as node-negative and be spared completion node dissection.
Background Atypical melanocytic neoplasms present a therapeutic dilemma. Current consensus is to perform a sentinel lymph node (SLN) biopsy as part of management. However, it is unclear whether this ...is required in all patients. We present our experience with sentinel lymphadenectomy in these patients and examine the clinical and pathologic variables associated with a positive SLN. Study Design A prospectively maintained melanoma database was queried for patients with controversial melanocytic lesions. All patients between January 1997 and January 2009 were included. Demographic and pathologic information was collected and correlated with results of SLN biopsy. Results Thirty-one patients underwent SLN biopsy. Median patient age was 19 years (range 5 to 59 years) and median tumor Breslow depth was 1.35 mm. Five patients (16%) had a positive SLN. Those with a positive SLN were younger (median 11 vs 23.5 years, p = 0.02) and had a greater Breslow depth (median 1.90 vs 1.09; p = 0.03) than those who were SLN negative. Median follow-up was16 months for patients with at least 6 months of follow-up time and there have been no recurrences identified. Conclusions We report an SLN positive rate of 16% in patients with atypical melanocytic tumors. Younger age and greater Breslow depth are associated with having a positive SLN. These results confirm earlier work demonstrating the importance of SLN biopsy in this disease and highlight the need to measure Breslow depth in these lesions so that they can be appropriately stratified as to the need for SLN biopsy.
Background Medical student knowledge is assessed during surgical clerkships subjectively and objectively. Subjective evaluation depends on faculty assessment during clinical and didactic ...interactions. Objective measurement derives from standardized tools, such as the National Board of Medical Examiners Surgery Subject test (shelf). Few efforts have been made to characterize the correlation between subjective and objective measures of medical knowledge. Study Design All 308 third-year medical students who completed the 8-week surgery clerkship at the University of North Carolina at Chapel Hill between July 2005 and June 2007 received subjective assessment of knowledge on 3 clinical rotations (one 4-week core and two 2-week elective rotations) and a longitudinal small-group tutorial. Faculty evaluators assigned percentile scores to rate students' knowledge base relative to their peers. In addition, students took the shelf test the last day of clerkship, and percentile scores were assigned based on National Board of Medical Examiners−supplied normative data from first-time test-takers within the same academic quarter. Subjective versus objective knowledge scores were plotted overall, and Pearson product-moment correlation coefficients were generated for core, elective, and tutorial assessments. Results There were only weak linear relationships noted between subjective faculty-assigned knowledge scores and objective shelf scores. Pearson correlations were 0.24 for core rotations (4 weeks exposure), 0.14 for elective rotations (2 weeks exposure), and 0.22 for tutorials (1-hour exposure/week during 8 weeks), with p values <0.0001. Conclusions Faculty assessment of knowledge is only weakly correlated with shelf performance. Faculty evaluations after 4-week rotations or longitudinal small-group interactions are better correlated with shelf scores than after 2-week electives.
Centralization trends in thyroid cancer surgery Baker, Justin J., MD; Meyers, Michael O., MD, FACS; Calvo, Benjamin F., MD, FACS ...
Journal of the American College of Surgeons,
2011, Letnik:
213, Številka:
3
Journal Article
Recenzirano
Introduction Recent guidelines recommend considering central lymph node dissection (CLND) in patients with papillary thyroid cancer. We set out to examine trends in regionalization of thyroidectomy ...and utilization of lymphadenectomy (LND). Methods The Nationwide Inpatient Sample database was used to examine trends in thyroid cancer surgery. All patients undergoing thyroidectomy for cancer from 1999-2008 were included. Hospitals were defined as Rural(R), Urban Non-Teaching (UNT), or Urban Teaching (UT). Results Thyroidectomy for cancer increased from 13,940 in 1999 to 23,814 in 2008. The proportion of thyroidectomies at each hospital type has not changed. Utilization of LND has increased as a proportion of all thyroidectomies from 8% in 1999 to 13% in 2008 (p<0.001). In 1999 the proportion undergoing LND was equal between the three hospital types (p=0.26). However, by 2008 an LND was most likely to be performed at an UT compared to either an UNT (Odds Ratio (OR) 1.47 (95% CI 1.31-1.56; p<0.001)) or R (OR 4.20 (95% CI 3.14-5.63; p<0.001)). Length of stay (LOS) and hypocalcaemia rates were higher when a lymphadenectomy was performed, (OR 1.64 (95% CI 1.45-1.86; p<0.001) and 1.30 (95% CI 1.18-1.43;p<0.001)) respectively, although other complications were not increased. Conclusions Thyroidectomy for cancer has increased significantly in the past decade. Although no change was observed in the proportion of cases performed by hospital type, patients at an UT hospital were more likely to undergo a lymphadenectomy than at other hospital types. LOS and hypocalcemia are inversely proportional to the rates of lymphadenectomy
Abstract Introduction Professionalism is now recognized as a core competency for graduate medical education and maintenance of certification. However, few models exist in plastic surgery that define, ...teach, and assess professionalism as a competency. The purpose of this project was to evaluate the effectiveness of a professionalism curriculum in an academic plastic surgery practice. Methods We created and conducted a 6-wk, 12-h course for health care professionals in plastic surgery (faculty, residents, nurses, medical students). Teaching methods included didactic lectures, journal club, small group discussions, and book review. Topics included: (1) Professionalism in Our Culture, (2) Leadership Styles, (3) Modeling Professional Behavior, (4) Leading Your Team, (5) Managing Oneself, and (6) Leading While You Work. Using Kirkpatrick methodology to assess perception of the course (level 1 data), learning of the material (level 2 data), effect on behavior (level 3 data), and impact on the organization (level 4 data), we compiled participant questionnaires, scores from pre- and post-tests, and such metrics as incidence of sentinel events (defined as infractions requiring involvement by senior administrators), number of patient complaints reported to Patient Relations, and patient satisfaction (Press Ganey surveys), for the 6 mo before and after the course. Results Thirty health care professionals participated in a 6-wk course, designed to improve professionalism in plastic surgery. Level 1 data: Although only 56.5% of respondents felt that the course was a “good use of my time,” 73.9% agreed that the course “will help me become a better professional” and 82.6% “would recommend the course to others.” Level 2 data: Post-test scores increased from 48% to 70% ( P < 0.05), and the ability to recall all six competencies increased from 22% to 73% ( P < 0.01). Level 3 data: The number of sentinel events in our division decreased from 13 to three. After the course, one resident was placed on probation and resigned, and two other employees left the division after being counseled on issues of professionalism. Interestingly, these participants did very well on the post-test but were not considered to be “team players.” Level 4 data: Patient complaints decreased from 14 to eight, and patient satisfaction increased from 85.5% to 90.5%. Conclusions A focused curriculum in professionalism may improve the knowledge of participants and overall behavior of the group, but may not affect individual attitudes. Nevertheless, efforts toward assessing, teaching, and influencing professionalism in plastic surgery are very valuable and should be pursued by educators to help satisfy Graduate Medical Education/Maintenance of Certification requirements and to improve the performance of the organization.
