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Context: The long-term results of randomized trials have demonstrated equivalent survival rates for mastectomy and breast-conserving therapy for the treatment of early stage breast cancer. Consequently, the choice of treatment should be based on a patient's preferences.Objective: To evaluate the impact of a decision aid regarding the different surgical treatment options on patient decision making.Design and Setting: A cluster randomized trial for which general surgeons in the communities of central-west, and eastern Ontario, Canada, were randomly assigned to use the decision aid or not in the surgical consultation. Patients received the decision aid or not based on the surgeon seen.Participants: Twenty surgeons participated in the study. Of the 208 eligible women with newly diagnosed clinical stage I or II breast cancer seen by study surgeons, 201 agreed to be evaluated: 94 were assigned to the decision board and 107 to usual practice. Patients were recruited from November 1999 to April 2002.Intervention: The decision board is a decision aid designed to help physicians inform their patients about different treatment options and to enable patients to express a preference for treatment.Main Outcome Measures: Patient knowledge about the surgical treatment of breast cancer; decisional conflict; satisfaction with decision making; and the treatment decision following the consultation.Results: Patients in the decision board group had higher knowledge scores about their treatment options (66.9 vs 58.7; P<.001), had less decisional conflict (1.40 vs 1.62, P =.02), and were more satisfied with decision making (4.50 vs 4.32, P =.05) following the consultation. Patients who used the decision board were more likely to choose BCT (94% vs 76%, P =.03).Conclusions: The decision board was helpful in improving communication and enabling women to make a choice regarding treatment. Such instruments should be considered by surgeons when communicating the different surgical options to women with breast cancer. [ABSTRACT FROM AUTHOR]

BACKGROUND: The investigators designed a sustained, surgeon-directed, iterative project to improve the quality of breast cancer surgery in south central Ontario. METHODS: The strategy included audit and feedback of surgeon-selected quality indicators, workshops, and tailoring interviews. Workshops were held to discuss quality improvement strategies, select quality indicators, review audited results, and select interventions for subsequent implementation. Semistructured tailoring interviews were conducted to identify facilitators and barriers to improved quality. All presentations and results were disseminated to all surgeons performing breast surgery in the study region. RESULTS: Forty-four surgeons performing breast surgery across 12 hospitals are involved in the project. Five workshops have been held since 2005. Surgeons' enthusiasm and involvement in the project have been positive. Interim results demonstrated that over 4 audit cycles (2006-2010), the preoperative core biopsy rate increased from 73% to 92%. The tailoring interviews indicated that 18 of 21 surgeons performed preoperative core biopsies. CONCLUSIONS: This project highlights the feasibility of a surgeon-directed, iterative quality improvement strategy in breast cancer surgery. Interim results demonstrate consistent improvements in a key selected quality indicator. [ABSTRACT FROM AUTHOR]

Purpose: Traumatic diaphragmatic rupture (TDR) is an uncommon injury that can be associated with significant morbidity if not detected and treated in a timely manner. The purpose of our study was to evaluate the diagnostic accuracy of 64-slice multidetector computed tomography (64-MDCT) for the detection of TDR in patients at our level 1 trauma centre., Methods: We used our hospital's trauma registry to identify patients with a diagnosis of TDR from January 1, 2008, to December 31, 2012. Only patients with a 64-MDCT scan at presentation who subsequently underwent laparotomy/laparoscopy were included in the study cohort. Using surgical findings as the gold standard, the accuracy of the prospective radiology reports was analyzed., Results: Of the 3225 trauma patients who presented to our institution, 38 (1.2%) had a TDR. Fourteen of the 38 were excluded as they did not have MDCT before surgery. The study cohort consisted of 20 males and 4 females with a median age of 34.5 years and a median Injury Severity Score (ISS90) of 26. Fifteen had blunt trauma while 9 had a penetrating injury. The overall sensitivity of the radiology reports was 66.7% (95% confidence interval [CI]: 46.7%-82.0%), specificity was 100% (95% CI: 94.1%-100%), positive predictive value was 100% (95% CI: 80.6%-100%), negative predictive value was 88.4% (95% CI: 78.8%-94.0%), and accuracy was 90.6% (95% CI: 82.5%-95.2%). However, only 3 of 9 patients with penetrating injury had a correct preoperative diagnosis. Two of the 6 missed penetrating trauma cases had only indirect signs of injury., Conclusions: The detection of TDR in trauma patients on 64-MDCT can be improved, especially in patients presenting with penetrating injury. A careful search for subtle diaphragmatic defects and indirect evidence of injury is important to avoid missing the diagnosis., (Copyright © 2015 Canadian Association of Radiologists. Published by Elsevier Inc. All rights reserved.)

Background: Gaps in breast cancer (BC) surgical care have been identified. We have completed a surgeon-directed, iterative project to improve the quality of BC surgery in South-Central Ontario., Methods: Surgeons performing BC surgery in a single Ontario health region were invited to participate. Interventions included: audit and feedback (A&F) of surgeon-selected quality indicators (QIs), workshops, and tailoring interviews. Workshops and A&F occurred yearly from 2005-2012. QIs included: preoperative imaging; preoperative core biopsy; positive margin rates; specimen orientation labeling; intraoperative specimen radiography of nonpalpable lesions; T1/T2 mastectomy rates; reoperation for positive margins; sentinel lymph node biopsy (SLNB) rates, number of sentinel lymph nodes; and days to receive pathology report. Semistructured tailoring interviews were conducted to identify facilitators and barriers to improved quality. All results were disseminated to all surgeons performing breast surgery in the study region., Results: Over 6 time periods, 1,828 BC charts were reviewed from 12 hospitals (8 community and 4 academic). Twenty-two to 40 participants attended each workshop. Sustained improvement in rates of positive margins, preoperative core biopsies, specimen orientation labeling, and SLNB were seen. Mastectomy rates and overall axillary staging rates did not change, whereas time to receive pathology report increased. The tailoring interviews concerning positive margins, SLNB, and reoperation for positive margins identified facilitators and barriers relevant to surgeons., Conclusions: This surgeon-directed, regional project resulted in meaningful improvement in numerous QIs. There was consistent and sustained participation by surgeons, highlighting the importance of integrating the clinicians in a long-term, iterative quality improvement strategy in BC surgery.

Evidence suggests that early exposure to surgical techniques, surgical knowledge and mentors strongly correlates with students’ interest, knowledge and confidence in general surgery as a postgraduate career choice. Preclerkship exposure to surgery and implementation of a formal surgical curriculum is often restricted owing to attending surgeon time commitments and cost limitations. To promote earlier exposure to surgery, a group of senior medical students at McMaster University, Hamilton, Ont., developed and implemented a novel pilot program with a surgical lecture series and a surgical skills laboratory for preclerkship students. This commentary discusses the effectiveness of these initiatives.

Background: Literature suggests declining interest in General Surgery (GS) and other surgical specialties, with fewer Canadian medical residency applicants identifying a surgical specialty as their first choice. Although perceptions of surgical careers may begin before enrollment in clerkship, clerkship itself provides the most concentrated environment for perceptions to evolve. Most students develop perceptions about specialties during their clinical clerkships. This study examines the immediate impact of GS clerkship on student attitudes toward GS as a career, and on preferences towards GS compared with other specialties., Methods: A pre-post design involved 61 McMaster clinical clerks. Two instruments were used to collect data from students over the course of clerkship (2008-2009). Paired comparison (PC) compared ranking of career choices before and after clerkship. Semantic differential (SD) measured attitudes toward GS and variables that may have affected attitudes before and after clerkship. Analyses used SPSS 16.0 (SPSS Inc., Chicago, IL)., Results: Clerks ranked preferences for GS changed substantially after clerkship, moving from the 10th to the 5th position compared with other specialties. Ranks of surgical subspecialties also changed, though GS demonstrated the largest improvement. SD results were consistent with PC, showing improved attitudes after rotation, with differences both statistically and practically significant (t = 3.81, p < 0.000, effect size = 0.23). Results indicated that attitudes toward all areas related to GS clerkship (attending physicians, surgical residents, ward nurses, scrub nurses, workload, knowledge achieved, technical skills acquired) improved significantly except attitude toward technical skills acquired., Conclusions: Clinical clerkship at McMaster was a positive experience and significantly enhanced preferences towards GS and attitudes towards GS as a career. Medical schools should foster positive interaction between clinical clerks and staff (including attending surgeons and nurses), ensure that teaching hospital staff provide a positive experience for clerks, and should provide opportunities to learn basic technical skills during GS clerkship., (Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)