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This is a prospective, single-institution study to evaluate feasibility and accuracy of radar-localized reflector (RLR)-targeted axillary dissection (TAD) in node-positive breast cancer patients after neoadjuvant systemic therapy (NST).Patients with biopsy-proven T1-2, N1-3 disease were eligible. Before NST, a marker clip and/or RLR was placed into the positive node. After NST, RLR was inserted if not placed previously. All patients underwent RLR TAD followed by axillary lymph node dissection (ALND). Primary end points of the trial were feasibility of RLR TAD and false negative rate (FNR).Between 2017 and 2021, 101 patients with N1-3 disease underwent NST. Five patients withdrew from the study, 1 was ineligible, and there were 9 technical failures, thus our final study cohort comprised 86 patients. RLR TAD was performed with probe guidance and confirmed with intraoperative specimen radiograph. After RLR TAD, ALND was performed. Median number of RLR TAD nodes removed was 2 (range 1-10), and the RLR TAD nodes remained positive in 56 patients. Median number of ALND nodes removed was 18 (range 4-46). Accounting for 9 technical failures, feasibility was 90%. All technical failures occurred with attempted placement of RLR after NST. Feasibility rate was 100% when RLR placement occurred at diagnosis. Of the evaluable 86 patients, RLR TAD accurately predicted axillary status in 83 patients, with FNR of 5.1%.We demonstrate high accuracy of RLR TAD, especially when RLR is placed before NST. For patients who present with N1-3 disease, this is another step towards axillary surgery de-escalation strategies.

BACKGROUND Intracranial hemorrhage after liver transplantation is an infrequently reported complication but one which can have devastating consequences. METHODS We performed a retrospective cross-sectional analysis of all liver transplants performed between January 2010 and June 2015 at a single high-volume institution using a prospectively maintained electronic database and query of the electronic medical record. Cases of intracranial hemorrhage were adjudicated as either spontaneous intraparenchymal hemorrhage(IPH) or extra-axial hemorrhage (EAH). Patients with confirmed intracranial hemorrhage were compared with all other liver transplant recipients. Risk factors were identified by univariate analysis and logistic regression models for IPH and EAH. RESULTS Thirty-one (5.2%) of 595 liver transplant recipients developed an intracranial hemorrhage within 12 months of transplantation, 15 IPH and 16 EAH. The majority of intracranial hemorrhages were diagnosed within 1 month of transplantation. Eight (26%) intracranial hemorrhage patients died during hospitalization. Fourteen (45%) intracranial hemorrhage patients died within 1 year of transplantation and 1-year mortality was greater than in patients without intracranial hemorrhage (11.2%, P < 0.01). Female sex (adjusted odds ratio [OR], 3.291; 95% confidence interval [CI], 1.092-9.924; P = 0.034), higher pretransplant bilirubin (adjusted OR, 1.037; 95% CI, 1.006-1.070; P = 0.020), and greater increase in pretransplant to posttransplant systolic blood pressure (adjusted OR, 1.029; 95% CI, 1.006-1.052; P = 0.012) were associated with posttransplant IPH. Lower pretransplant serum fibrinogen level (adjusted OR, 0.988; 95% CI, 0.979-0.998; P = 0.017) was associated with posttransplant EAH. CONCLUSIONS Postoperative blood pressure control and pretransplant fibrinogen levels may be modifiable risk factors for preventing posttransplant intracranial hemorrhage.

Background Health care reform goals involve more cost-effective methods of delivering health care. The cost-effectiveness of axillary ultrasound-guided core needle biopsy (AUS-CNB) was compared with sentinel lymph node biopsy (SLNB) when evaluating the status of the axilla in operable invasive breast cancer. Study Design We performed an IRB-approved retrospective review of patients undergoing ultrasound of the axilla plus core needle biopsy at our institution from 2007 to 2012. An accuracy of technique and cost analysis (TreeAge Pro 2009) of AUS-CNB vs SLNB was conducted. Results The cohort of 95 patients was divided into 2 groups: clinically positive (CP) (32%) and negative (CN) (68%) axilla. In the CP group, 83% had a suspicious AUS, of which 90% were positive. In the CN group, AUS was suspicious in 70%, with a positive biopsy in 59%. The sensitivity and specificity of AUS-CNB were 90% (95% CI 84.8% to 98.8%) and 100% (95% CI 27% to 59.1%), respectively. Cost estimates comparing AUS-CNB with SLNB demonstrated a cost saving of $236,517 in the CP axilla and $248,490 in the CN axilla, for a total cost savings of $485,007. Conclusions Axillary ultrasound-guided core needle biopsy is a sensitive, diagnostic, surgeon-performed procedure. It is time-saving, cost-efficient, and less invasive, making it a viable option when evaluating the status of the axilla in invasive breast cancer or staging before neoadjuvant chemotherapy.

Background: From 1998 to 2008, 1000 skeletally mature patients underwent autologous chondrocyte implantation for an osteochondral defect of the knee. We evaluated the functional outcomes in 827 of 869 patients who had undergone autologous chondrocyte implantation with Chondron or periosteum (ACI-C/ACI-P) or matrix-assisted chondrocyte implantation (MACI) and attempted to identify factors that influenced outcome. Methods: The age of the patient, the size and site of the osteochondral lesion, previous surgery, and the presence of early osteoarthritis were assessed for their influence on outcomes. Each factor was evaluated in a separate Cox proportional hazards model with use of hazard ratios (HRs), with 95% confidence intervals (CIs), describing the likelihood of failure for that particular factor. Outcomes were assessed with use of the modified Cincinnati score, visual analog scale pain score, and Stanmore functional score. Results: The mean duration of follow-up was 6.2 years (range, two to twelve years). The mean age was thirty-four years (range, fourteen to fifty-six years), with 493 males and 334 females. The average size of the defect was 409 mm2 (range, 64 to 2075 mm2). Four hundred and twenty-one procedures (51%) were performed on the medial femoral condyle; 109 (13%), on the lateral femoral condyle; 200 (24%), on the patella; and fifty (6%), on the trochlea. Kaplan-Meier survival analysis revealed that the unadjusted graft survival rate was 78.2% at five years and 50.7% and ten years for the entire cohort. No difference was found between the survival rates of the ACI-C/ACI-P and MACI techniques (HR = 0.948, 95% CI = 0.738 to 1.219, p = 0.678). There was a significant postoperative improvement in the function and pain scores of all three outcome measures (p < 0.002). Survivorship in the group with a previous cartilage regenerative procedure was inferior to that in patients with a previously untreated lesion, with failure five times more likely in the former group (HR = 4.718, standard error [SE] = 0.742, 95% CI = 3.466 to 6.420, p < 0.001). Degenerative change in any compartment had a significant detrimental effect on survivorship, with survivorship worsening as the osteoarthritis grade increased (Grade 1: HR = 2.077, 95% CI = 1.299 to 3.322, p = 0.002; Grade 2: HR = 3.450, 95% CI = 2.646 to 4.498, p < 0.001; and Grade 3: HR = 3.820, 95% CI = 2.185 to 6.677, p < 0.001). Conclusions: Our study demonstrated an overall graft survival of 78% at five years and 51% beyond ten years following both autologous chondrocyte implantation techniques. Despite study limitations, our results demonstrate that autologous chondrocyte implantation for the treatment of osteochondral defects of the knee can achieve good results. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The attainment of technical competence for surgical procedures is fundamental to a proficiency-based surgical training program. We hypothesized that aptitude may directly affect one's ability to successfully complete the learning curve for minimally invasive procedures. The aim was to assess whether aptitude has an impact on ability to achieve proficiency in completing a simulated minimally invasive surgical procedure. The index procedure chosen was a laparoscopic appendectomy.Two groups of medical students with disparate aptitude were selected. Aptitude (visual-spatial, depth perception, and psychomotor ability) was measured by previously validated tests. Indicators of technical proficiency for laparoscopic appendectomy were established by trained surgeons with an individual case volume of more than 150. All subjects were tested consecutively on the ProMIS III (Haptica) until they reached predefined proficiency in this procedure. Simulator metrics, critical error scores, and Objective Structured Assessment of Technical Skills (OSATS) scores were recorded.The mean numbers of attempts to achieve proficiency in performing a laparoscopic appendectomy for group A (high aptitude) and B (low aptitude) were 6 (range 4 to 7) and 14 (range 10 to 18), respectively (p0.0001). Significant differences were found between the 2 groups for path length (p = 0.014), error score (p = 0.021), and OSATS score (p0.0001) at the initial attempt.High aptitude is directly related to a rapid attainment of proficiency. These findings suggest that resource allocation for proficiency-based technical training in surgery may need to be tailored according to a trainee's natural ability.

The mandible is often included in the radiation field during treatment of head and neck cancers.1,2 Osteoradionecrosis affects approximately 5 percent of patients and is a debilitating complication for these patients treated with radiation therapy for head and neck cancers.3 Those stricken with osteoradionecrosis often have severe limitations in mandibular function and are at heightened risk for pathologic fracture. Quality of life is often affected in patients with osteoradionecrosis, including limitations related to loss of dentition and altered aesthetics, all of which result in limitation of social interaction. Clearly, a management strategy that avoids this condition and ensures that patients have the ability to remain as productive members of society is both desirable and warranted. For grade IV osteoradionecrosis that does not respond to medical treatment options, a segmental I mandibulectomy is typically indicated. Currently, there are not many reconstructive options for these patients—the criterion standard for reconstruction following a segmental mandibulectomy after irradiation is osseous free tissue transfer or soft tissue in combination with a reconstruction bar/plate. Studies have shown that free tissue transfer procedures have superior efficacy in preventing plate exposure and wound infection, leading to the increased use of these procedures.4,5 However, free tissue transfer requires the harvest of bony and soft-tissue substrate from a distant donor site, and these procedures are characterized by longer operative times, multiple comorbidities, and increased complication rates. Distraction osteogenesis, the gradual separation of two osteogenic fronts to stimulate new bone formation, presents an alternative to free tissue transfer. One of the limitations to the immediate translation of distraction osteogenesis to surgical practice for the purpose of oncologic reconstruction is the immense difficulty in healing previously radiated tissue.6 The effects of ionizing radiation on the regeneration of bone within a fracture site include decreased osteocyte number, suppressed osteoblast activity, and diminished vascularity in murine models of distraction osteogenesis.7 As the success of distraction osteogenesis (and in general, bone healing) is predicated on resident vascularity and cellularity, the direct cellular impairment and vascular injury caused by adjuvant radiation therapy are potential obstacles to successful distraction osteogenesis reconstruction following segmental mandibulectomy. Parathyroid hormone is a major regulator of Ca2+ homeostasis and exerts both anabolic and catabolic effects on bone homeostasis, and is currently used clinically for the treatment of osteoporosis. Continuous infusions of the hormone (or its active portion, amino acids 1 to 34) lead to greater bone resorption, whereas intermittent daily dosing has an anabolic effect and leads to increased bone mass, osteoblast generation and mobilization, and improved fracture healing.8 Our goal is to investigate the effects of parathyroid hormone and radiotherapy in murine models of distraction osteogenesis by using metrics of biomechanical response. Our previous research indicates significant improvement of union quality and radiomorphometric parameters given an anabolic dosing regimen of parathyroid hormone following irradiation and mandibular osteogenesis. Our hypothesis is that intermittent systemic administration of parathyroid hormone will serve as a stimulant to cellular function that will act to reverse a human-equivalent dose of radiation–induced damage and enhance bone regeneration. Specific quantitative analysis of bone will allow us to compare outcomes of irradiated animals and tissues that have been treated with those that have not been treated with parathyroid hormone. In addition, we will gauge the efficacy of parathyroid hormone to remediate radiation damage by comparing our results to those of nonirradiated animals who underwent distraction osteogenesis without irradiation.

METHODS: Samples of histologically normal small bowel were obtained from obese patients undergoing laparoscopic Roux-en-Y gastric bypass. Control specimens were from non-obese patients undergoing resection for benign disease. No patient had diabetes or known motility disorder. The samples were transported in pre-oxygenated Krebs solution and experiments were performed within 1hour. Circular smooth muscle strips were microdissected and suspended under 1g of tension in organ baths containing oxygenated Krebs solution at 37°C. Contractile activity was recorded using isometric transducers at baseline and in response to receptor-mediated contractility using prostaglandin F2a, adenosine triphosphate, nitric oxide, and substanceP under both equivocal and NANC conditions (using guanethidine and atropine). The University hospital’s ethics committee approved this study and the use of human tissue.

A recently developed system for measuring antiepileptic drug concentrations was evaluated for phenytoin and phenobarbital. The apoenzyme reactive immunoassay system was compared with gas-liquid chromatography, EMIT, and TDX systems. Comparisons were performed with control specimens and with sera obtained from patients at three facilities. Precision for all methods was similar, with within-run and between-run coefficients of variation generally 5%. The accuracy of all methods was acceptable, but bias was present in some. However, measurements obtained by a nontechnical person (physician) in a clinical setting were sometimes inaccurate.