Robotic nipple-sparing mastectomy complication rate compared to traditional nipple-sparing mastectomy: a systematic review and meta-analysis.

Breast cancer is worldwide the most common cause of cancer in women and causes the second most common cancer-related death. Nipple-sparing mastectomy (NSM) is commonly used in therapeutic and prophylactic settings. Furthermore, (preventive) mastectomies are, besides complications, also associated with psychological and cosmetic consequences. Robotic NSM (RNSM) allows for better visualization of the planes and reducing the invasiveness. The aim of this study was to compare the postoperative complication rate of RNSM to NSM. A systematic search was performed on all (R)NSM articles. The primary outcome was determining the overall postoperative complication rate of traditional NSM and RNSM. Secondary outcomes were comparing the specific postoperative complication rates: implant loss, hematoma, (flap)necrosis, infection, and seroma. Forty-nine studies containing 13,886 cases of (R)NSM were included. No statistically significant differences were found regarding postoperative complications (RNSM 3.9%, NSM 7.0%, p = 0.070), postoperative implant loss (RNSM 4.1%, NSM 3.2%, p = 0.523), hematomas (RNSM 4.3%, NSM 2.0%, p = 0.059), necrosis (RNSM 4.3%, NSM 7.4%, p = 0.230), infection (RNSM 8.3%, NSM 4.0%, p = 0.054) or seromas (RNSM 3.0%, NSM 2.0%, p = 0.421). Overall, there are no statistically significant differences in complication rates between NSM and RNSM.

The potential of training specialist oncology nurses in real-life reporting of adverse drug reactions.

Specialist oncology nurses (SONs) have the potential to play a major role in monitoring and reporting adverse drug reactions (ADRs); and reduce the level of underreporting by current healthcare professionals. The aim of this study was to investigate the long term clinical and educational effects of real-life pharmacovigilance education intervention for SONs on ADR reporting. This prospective cohort study, with a 2-year follow-up, was carried out in the three postgraduate schools in the Netherlands. In one of the schools, the prescribing qualification course was expanded to include a lecture on pharmacovigilance, an ADR reporting assignment, and group discussion of self-reported ADRs (intervention). The clinical value of the intervention was assessed by analyzing the quantity and quality of ADR-reports sent to the Netherlands Pharmacovigilance Center Lareb, up to 2 years after the course and by evaluating the competences regarding pharmacovigilance of SONs annually. Eighty-eight SONs (78% of all SONs with a prescribing qualification in the Netherlands) were included. During the study, 82 ADRs were reported by the intervention group and 0 by the control group. This made the intervention group 105 times more likely to report an ADR after the course than an average nurse in the Netherlands. This is the first study to show a significant and relevant increase in the number of well-documented ADR reports after a single educational intervention. The real-life pharmacovigilance educational intervention also resulted in a long-term increase in pharmacovigilance competence. We recommend implementing real-life, context- and problem-based pharmacovigilance learning assignments in all healthcare curricula.

Medical students as adverse drug event managers, learning about side effects while improving their reporting in clinical practice.

Managing adverse drug reactions (ADRs) is a challenge, especially because most healthcare professionals are insufficiently trained for this task. Since context-based clinical pharmacovigilance training has proven effective, we assessed the feasibility and effect of a creating a team of Junior-Adverse Drug Event Managers (J-ADEMs). The J-ADEM team consisted of medical students (1st-6th year) tasked with managing and reporting ADRs in hospitalized patients. Feasibility was evaluated using questionnaires. Student competence in reporting ADRs was evaluated using a case-control design and questionnaires before and after J-ADEM program participation. From Augustus 2018 to Augustus 2019, 41 students participated in a J-ADEM team and screened 136 patients and submitted 65 ADRs reports to the Netherlands Pharmacovigilance Center Lareb. Almost all patients (n = 61) found it important that "their" ADR was reported, and all (n = 62) patients felt they were taken seriously by the J-ADEM team. Although attending physicians agreed that the ADRs should have been reported, they did not do so themselves mainly because of a "lack of knowledge and attitudes" (50%) and "excuses made by healthcare professionals" (49%). J-ADEM team students were significantly more competent than control students in managing ADRs and correctly applying all steps for diagnosing ADRs (control group 38.5% vs. intervention group 83.3%, p < 0.001). The J-ADEM team is a feasible approach for detecting and managing ADRs in hospital. Patients were satisfied with the care provided, physicians were supported in their ADR reporting obligations, and students acquired relevant basic and clinical pharmacovigilance skills and knowledge, making it a win-win-win intervention.

WHO guide to good prescribing is 25 years old: quo vadis?

INTRODUCTION: Twenty-five years ago, the World Health Organization (WHO) published the Guide to Good Prescribing (GGP), followed by the accompanying Teacher's Guide to Good Prescribing (TGGP). The GGP is based on a normative 6-step model for therapeutic reasoning and prescribing, and provides a six-step guide for students to the process of rational prescribing. METHOD: We reviewed the need to update both WHO publications by evaluating their use and impact, including new (theoretical) insights and demands. Based on information from literature, Internet, and other (personal) sources, we draw the following conclusions. RESULTS: 1. An update of the GGP and TGGP, both in terms of content and form, is necessary because of the current need for these tools (irrational medicine use and unavailability of medicines), the lack of similar documents, and the lack of connection with recent developments, such as Internet and modern education; 2. The basic (6-step) model of the GGP is effective in terms of rational prescribing in the undergraduate situation and is still consistent with current theories about (context) learning, clinical decision-making, and clinical practice; 3. The dissemination and introduction of the GGP and TGGP in education has been successful so far, but is still not optimal because of lack of support and cooperation. CONCLUSIONS: On the basis of the evaluation results, a plan for the revision of the GGP and TGGP is presented.

Acute gastric necrosis caused by a ß-hemolytic streptococcus infection: a case report and review of the literature.

Acute necrotizing gastritis, which appears to be a variant of phlegmonous gastritis is the rarest cause of gastric necrosis. We report a case of a 57-year-old female patient with an acute necrotizing gastritis caused by a Group A ß-hemolytic streptococcus. The case presented herein is of unusual interest because only a limited number of case reports on this etiology have been published. Diagnosing infectious necrotizing gastritis remains complex because of its rarity and nonspecific clinical presentation. Nevertheless, prompt diagnosis is of high importance because necrotizing gastritis can progress rapidly into a more advanced stage causing septic shock or even death. In our opinion, early resection of necrotic gastric wall combined with adequate antimicrobial therapy is the cornerstone in treatment of necrotizing gastritis. We will present a case in which adequate medical treatment was not successful.

Essential diseases in prescribing: A national Delphi study towards a core curriculum in pharmacotherapy education.

AIMS: Prescribing is a core skill for junior doctors, yet 8-10% of their prescriptions contain errors. To ensure adequate training in prescribing, it is important to define the diseases for which junior doctors should be competent to prescribe. The aim of the present study was therefore to identify the essential diseases in prescribing for junior doctors. METHODS: A two-round Delphi consensus study was conducted among medical specialists, general practitioners, junior doctors, pharmacists and pharmacotherapy teachers from all eight academic hospitals in the Netherlands. Using a five-point Likert scale, the participants indicated for each item on an initial questionnaire whether it should be considered an essential disease for junior doctors. The items for which ≥80% of all respondents agreed or strongly agreed were accepted as essential diseases. RESULTS: Sixty-two participants completed the Delphi survey. In total, 63 of 220 items were considered to be essential diseases. CONCLUSION: This is the first Delphi consensus study identifying exact conditions that junior doctors must be able to prescribe for. The essential diseases can be used for training in prescribing and assessment of junior doctors' prescribing competence.

Urgent need to modernize pharmacovigilance education in healthcare curricula: review of the literature.

OBJECTIVES: Pharmacovigilance education is essential since adverse drug reactions (ADRs) are a serious health problem and contribute to unnecessary patient burden and hospital admissions. Healthcare professionals have little awareness of pharmacovigilance and ADR reporting, and only few educational interventions had durable effects on this awareness. Our future healthcare providers should therefore acquire an adequate set of pharmacovigilance competencies to rationally prescribe, distribute, and monitor drugs. We investigated the pharmacovigilance and ADR-reporting competencies of healthcare students to identify educational interventions that are effective in promoting pharmacovigilance. METHODS: The PubMed, EMBASE, Cochrane, CINAHL, PsycINFO, and ERIC databases were searched using the terms "pharmacovigilance," "students," and "education.". RESULTS: Twenty-five cross-sectional and 14 intervention studies describing mostly medical and pharmacy students were included. Intentions and attitudes on ADR reporting were overall positive, although most students felt inadequately prepared, missed the training on this topic, and lacked basic knowledge. Although nearly all students observed ADRs during clinical rounds, only a few had actually been involved in reporting an ADR. Educational interventions were predominately lectures, sometimes accompanied by small interactive working groups. Most interventions resulted in a direct increase in knowledge with an unknown long-term effect. Real-life learning initiatives have shown that healthcare students are capable of contributing to patient care while increasing their ADR-reporting skills and knowledge. CONCLUSIONS: There is an urgent need to improve and innovate current pharmacovigilance education for undergraduate healthcare students. By offering real-life pharmacovigilance training, students will increase their knowledge and awareness but can also assist current healthcare professionals to meet their pharmacovigilance obligations.

Pharmacology and Therapeutics Education in the European Union Needs Harmonization and Modernization: A Cross-sectional Survey Among 185 Medical Schools in 27 Countries.

Effective teaching in pharmacology and clinical pharmacology and therapeutics (CPT) is necessary to make medical students competent prescribers. However, the current structure, delivery, and assessment of CPT education in the European Union (EU) is unknown. We sent an online questionnaire to teachers with overall responsibility for CPT education in EU medical schools. Questions focused on undergraduate teaching and assessment of CPT, and students' preparedness for prescribing. In all, 185 medical schools (64%) from 27 EU countries responded. Traditional learning methods were mainly used. The majority of respondents did not provide students with the opportunity to practice real-life prescribing and believed that their students were not well prepared for prescribing. There is a marked difference in the quality and quantity of CPT education within and between EU countries, suggesting that there is considerable scope for improvement. A collaborative approach should be adopted to harmonize and modernize the undergraduate CPT education across the EU.

Essential competencies in prescribing: A first european cross-sectional study among 895 final-year medical students.

European medical students should have acquired adequate prescribing competencies before graduation, but it is not known whether this is the case. In this international multicenter study, we evaluated the essential knowledge, skills, and attitudes in clinical pharmacology and therapeutics (CPT) of final-year medical students across Europe. In a cross-sectional design, 26 medical schools from 17 European countries were asked to administer a standardized assessment and questionnaire to 50 final-year students. Although there were differences between schools, our results show an overall lack of essential prescribing competencies among final-year students in Europe. Students had a poor knowledge of drug interactions and contraindications, and chose inappropriate therapies for common diseases or made prescribing errors. Our results suggest that undergraduate teaching in CPT is inadequate in many European schools, leading to incompetent prescribers and potentially unsafe patient care. A European core curriculum with clear learning outcomes and assessments should be urgently developed.

[An elderly, cachexic patient with a painful leg]. / Een oudere, magere vrouw met een pijnlijk been.

A 68-year-old female presented with acute abdominal discomfort in the left lower quadrant and a painful left leg. Her medical history only revealed an eating disorder. Physical examination was insignificant. Diagnostic imaging showed an obturator hernia; subsequently, a laparotomy was performed. An obturator hernia, also known as little old ladies' disease, is associated with abdominal pain and a painful leg.

The prescribing performance and confidence of final-year medical students.

It is widely believed that medical students are not as well prepared or as sufficiently skilled in prescribing as they should be at the outset of their careers. However, a preclinical context-learning pharmacotherapy program has been found to improve students' therapeutic skills during an ensuing clinical clerkship in internal medicine.(1) In this Commentary, we argue that a similar approach during a clinical clerkship may further enhance therapeutic skills at the end of the clerkship.

How to treat an appendiceal inflammatory mass: operatively or nonoperatively?

INTRODUCTION: While there is consensus on how to treat acute appendicitis, the most suitable treatment for an appendiceal inflammatory mass is still debated. This study compares the outcomes of operative and nonoperative management. MATERIAL AND METHODS: We retrospectively evaluated 119 patients (2007-2011) with an appendiceal inflammatory mass, 85 of whom were treated nonoperatively and 34 operatively. Of the nonoperative patients, 69 did not receive interventional treatment and 16 underwent percutaneous drainage of an accompanying abscess; the data for these patients were analyzed separately. RESULTS: Of the noninterventional managed patients, 49 (71.0%) experienced at least one recurrence and 37 (53.6%) ultimately needed an acute surgical or radiological intervention. Of the 16 patients who underwent percutaneous drainage, 7 (43.8%) experienced at least one recurrence and 6 (37.5%) underwent an acute surgical or (second) percutaneous intervention. None of the operated patients had a recurrence and the incidence of complications was 17.6%. The incidence of underlying malignant tumor in our study population was 5.9%. In 35 patients, the definitive diagnosis remained unclear because the patients did not undergo surgery or follow-up colonoscopy after nonoperative treatment. The rate of extensive (ileocecal + hemicolonic) resection in all operated patients was 30.8%. CONCLUSION: We conclude that the high rate of recurrence and intervention in the nonoperative group and the high proportion of these patients who did not receive adequate follow-up despite the relatively high rate (5.9%) of bowel malignancy support the operative management of an appendiceal inflammatory mass. Noninterventional management or a percutaneous intervention should be reserved as a bridge to surgery for patients with a large accompanying abscess or as treatment for patients with significant comorbidity. If nonoperative treatment is chosen, follow-up colonoscopy is mandatory to exclude malignancy.

The limited role of ultrasound in the diagnostic process of colonic diverticulitis.

BACKGROUND: Diverticulitis is commonly diagnosed using ultrasound (US), followed by computed tomography (CT). Our aim was to determine the diagnostic accuracy of US compared with CT for patients with uncomplicated and complicated diverticulitis. METHODS: We reviewed medical records of 232 patients admitted with diverticulitis via the emergency department between January 2009 and January 2011. Patients who had undergone US and a CT scan were identified and further analyzed. RESULTS: A total of 123 patients underwent an US and a CT scan. In 78/94 patients with uncomplicated diverticulitis, results of US and CT scan were compatible (83 %); in 6 of the remaining 29 patients both modalities showed a complicated diverticulitis (21 %). US misdiagnosed 17 % of patients with uncomplicated diverticulitis and 79 % with complicated diverticulitis. CONCLUSIONS: US is insufficient for diagnosing a complicated diverticulitis. Missing a complicated diverticulitis can have important clinical implications, and if diverticulitis is suspected, we suggest obtaining a CT scan to confirm diagnosis and to exclude complications.

Contralateral axillary lymph node metastases at the time of primary breast cancer diagnosis: curative or palliative intent?

Contralateral axillary lymph node metastases (CAMs) in breast cancer patients are uncommon. CAM can be found at the time of primary breast cancer diagnosis or following prior treatment of breast cancer as a recurrence. This distinction may have important implications for disease staging and treatment selection. We report the case of a premenopausal woman with synchronous CAM. Despite extensive multimodality treatment, a recurrence was found 27 months after primary surgery. We reviewed the literature on histopathological tumor characteristics associated with CAM, lymphatic drainage of the breast to other sites than the ipsilateral axilla, and outcome of cases with CAM. This case contradicts current conceptions that CAM only develops from tumors with poor histopathological features. Emerging evidence shows that altered lymphatics play a central role in development of synchronous CAM. It is precisely this etiology that supports the concept that synchronous CAM occurs by lymphatic spread and not by hematogenous spread. Although controversial, treatment of synchronous CAM (without evidence of distant metastases) should therefore be of curative intent.

The feasibility of incorporating structured therapeutic consultations with real patients into the clinical clerkship internal medicine.

This study aims to determine the feasibility of incorporating structured therapeutic consultations (TCs) into the clinical clerkship internal medicine. TCs were considered feasible if students were able to draw up a therapeutic plan and carry out a TC, and if students and their supervisors considered TCs workable and useful. From March 2008 to October 2009, medical students carried out a "diagnostic" and subsequent "therapeutic" consultation with the same patient during their clinical clerkship internal medicine at the VU University Medical Center. After the diagnosis was established, the student had to formulate a therapeutic plan and then carry out a TC with the patient, supervised by a clinician. The supervisor assessed the therapeutic plan and how the student conducted the TC. Both the student and the supervisor received a questionnaire about the workability and usefulness of the TC. On average, students' performance in drawing up a therapeutic plan was awarded a score of 4.4 on a five-point scale, and the TC performance of 96 % of the students was considered amply sufficient or better. Eighty-three percent of the supervisors agreed or strongly agreed with the statement that the TC is a worthwhile addition to the clerkship, and 67 % of the students indicated that they would like to perform more TCs. This study shows that incorporating a structured TC with a real patient into the clinical clerkship internal medicine is both feasible and worthwhile. This may be an important step to improving the prescribing skills and attitudes of junior doctors and residents and to reducing their prescribing errors after graduation.

Ultrasound and fine needle aspiration cytology of axillary lymph nodes in breast cancer. To do or not to do?

AIM: The purpose of our study was to evaluate the accuracy of axillary ultrasound and ultrasound-guided fine needle aspiration cytology (FNAC) in the preoperative diagnosis of axillary metastases. METHODS: Between 2004 and 2009, 1132 female patients were evaluated and treated in our clinic for histologically proven breast carcinoma. Preoperative axillary ultrasound with subsequent FNAC in case of suspicious lymph nodes was performed in 1150 axillae (18 bilateral breast carcinomas). We analyzed the results of axillary ultrasound and FNAC retrospectively. Pathological node status was used as the reference standard (based on axillary dissection or sentinel node biopsy). RESULTS: Axillary ultrasound showed suspicious lymph nodes in 327 axillae (28.4%). FNAC showed axillary metastases in 107 of these 327 axillae. Final histological analysis confirmed 106 metastases (one false positive). Histological analysis showed metastatic disease in 429 of 1150 axillae (37.3%). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of axillary ultrasound alone were 43.8% (188/429), 80.7% (582/721), 57.5% (188/327) and 70.7% (582/823), respectively. When combining axillary ultrasound with FNAC of suspicious lymph nodes, sensitivity was 24.7% (106/429), specificity was 99.9% (720/721), PPV was 99.1% (106/107) and NPV was 69.0% (720/1043). CONCLUSIONS: 106/429 (24.7%) Node-positive axillae were identified by ultrasound-guided FNAC and spared unnecessary sentinel node biopsy. Unfortunately, the percentage of false negative results of ultrasound-guided FNAC (28.1%, 323/1150) was very high.

Do medical students copy the drug treatment choices of their teachers or do they think for themselves?

PURPOSE: Although the importance of rational prescribing is generally accepted, the teaching of pharmacotherapy to undergraduate medical students is still unsatisfactory. Because clinical teachers are an important role model for medical students, it is of interest to know whether this extends to therapeutic decision-making. The aim of this study was to find out which factors contribute to the drug choices made by medical students and their teachers (general practitioners and clinical specialists). METHODS: Final-year medical students (n = 32), and general practitioners (n = 29), lung specialists (n = 26), orthopaedic surgeons (n = 24), and internists (n = 24) serving as medical teachers from all eight medical schools in the Netherlands participated in the study. They were asked to prescribe treatment (drug or otherwise) for uncomplicated (A) and complicated (B) written patient cases and to indicate which factors influenced their choice of treatment, using a list of factors reported in the literature to influence drug prescribing. RESULTS: Final-year medical students primarily based their drug choice on the factors 'effectiveness of the drugs' and 'examples from medical teachers'. In contrast, clinical teachers primarily based their drug choice on the factors 'clinical experience', 'effectiveness of the drugs', 'side effects of the drugs', 'standard treatment guidelines', and 'scientific literature'. CONCLUSIONS: Medical teachers would appear to base their drug choice mainly on clinical experience and drug-related factors, whereas final-year medical students base their drug choice mainly on examples provided by their medical teachers. It is essential that medical teachers clearly explain to their students how they arrive at a specific choice of medication since medical students tend to copy the therapeutic drug choices from their teachers, mainly because of a lack of experience. Presenting students with clinical therapeutic problems early during undergraduate training will not only give them a chance to gain experience in solving medical problems but will also give meaning to what they are studying as opposed to merely reproducing what they learn or copying what they are told.

The effect of rosiglitazone on asymmetric dimethylarginine (ADMA) in critically ill patients.

Asymmetric dimethylarginine (ADMA) plays a crucial role in the arginine-nitric oxide pathway. Critically ill patients have elevated levels of ADMA which proved to be a strong and independent risk factor for ICU mortality. The aim of this study was to investigate the effect of the peroxisome proliferator-activated receptor (PPAR)-gamma agonist rosiglitazone on ADMA plasma levels in critically ill patients. In a randomized controlled pilot study, ADMA, arginine and symmetric dimethylarginine (SDMA) were measured in 21 critically ill patients on the intensive care unit (ICU). Twelve patients received 4mg rosiglitazone once a day for a maximum of 6 weeks or until discharge or death. Nine patients served as control patients. In addition, total sequential organ failure assessment (SOFA score), kidney function and liver function were determined. Compared to the ADMA levels of healthy individuals as specified in earlier studies, ADMA plasma levels of critically ill patients were significantly higher (0.42+/-0.06 versus 0.73+/-0.2micromol/L, respectively; p<0.001). Both ADMA (B=3.5; 95% CI: 0.5-6.5; p=0.023) and SDMA (B=1.7; 95% CI: 0.7-2.7; p=0.001) were independently related to SOFA scores. Overall, rosiglitazone treatment had no effect on ADMA levels, which only significantly differed between the rosiglitazone and control groups at day 7 (p=0.028). The SOFA score in the rosiglitazone group was lower compared to the control group but the difference was only statistically significant at day 10 (p=0.01). In conclusion, in critically ill patients plasma ADMA levels were elevated and associated with the extent of multiple organ failure, but no significant ADMA-lowering effect of the PPAR-gamma agonist rosiglitazone was observed.

Should medical students learn to develop a personal formulary? An international, multicentre, randomised controlled study.

OBJECTIVE: This study was performed to determine whether students who are trained in developing a personal formulary become more competent in rational prescribing than students who have only learned to use existing formularies. METHODS: This was a multicentre, randomised, controlled study conducted in eight universities in India, Indonesia, the Netherlands, the Russian Federation, Slovakia, South Africa, Spain and Yemen. Five hundred and eighty-three medical students were randomised into three groups: the personal formulary group (PF; 94), the existing formulary group (EF; 98) and the control group (C; 191). The PF group was taught how to develop and use a personal formulary, whereas e the EF group was taught how to review and use an existing formulary. The C group received no additional training and participated only in the tests. Student's prescribing skills were measured by scoring their treatment plans for written patient cases. RESULTS: The mean PF group score increased by 23% compared with 19% for the EF group (p < 0.05) and 6% for controls (p < 0.05). The positive effect of PF training was only significant in universities that had a mainly classic curriculum. CONCLUSION: Training in development and use of a personal formulary was particularly effective in universities with a classic curriculum and with traditional pharmacology teaching. In universities with a general problem-based curriculum, pharmacotherapy teaching can be based on either existing or personal formularies.

A context-learning pharmacotherapy program for preclinical medical students leads to more rational drug prescribing during their clinical clerkship in internal medicine.

The irrational prescribing of drugs seems to be a general problem in medical practice, occasionally leading to serious consequences. In order to improve the drug prescribing performance of medical students, a compulsory context-learning pharmacotherapy module was implemented in 1998 in the medical curriculum of 2nd-4th-year medical students at theVU University Medical Center (VUmc), Amsterdam, The Netherlands. As part of this program, preclinical medical students are taught how to select, prescribe, and evaluate a drug regimen rationally. The aim of this study was to investigate the effect of this preclinical pharmacotherapy program on the quality of rational prescribing during the ensuing clinical clerkship of these students in internal medicine. The results of this study indicate that preclinical context-learning in pharmacotherapy leads to the use of more rational prescribing modalities by medical students during their ensuing clinical clerkship in internal medicine. This effect was obtained not only with respect to the clinical topics in which training had been given as part of the pharmacotherapy curriculum, but also for other disease situations that the students dealt with. This implies that students not only remember the specific information they have learned during the training, but are also able to apply the acquired skills in new situations (transfer effect).