Intraoperative Radiation for Breast Cancer with Intrabeam™: Factors Associated with Decreased Operative Times in Patients Having IORT for Breast Cancer.

INTRODUCTION: Intraoperative radiation with Intrabeam™ (IORT) for breast cancer is a newer technology recently implemented into the operating room (OR). This procedure requires time and coordination between the surgeon and radiation oncologist, who both perform their treatments in a single operative setting. We evaluated the surgeons at our center, who perform IORT and their OR times to examine changes in OR times following implementation of this new surgical procedure. We hypothesized that IORT is a technique for which timing could be improved with the increasing number of cases performed. METHODS: A prospectively maintained IRB approved database was queried for OR times (incision and close) in patients who underwent breast conserving surgery (BCS), sentinel lymph node biopsy with and without IORT using the Intrabeam™ system at our institution from 2011 to 2015. The total OR times were compared for each surgeon individually and over time. Next, the OR times of each surgeon were compared to each other. Continuous variables were summarized and then a prediction model was created using IORT time, OR time, surgeon, and number of cases performed. RESULTS: There were five surgeons performing IORT at our institution during this time period with a total of 96 cases performed. There was a significant difference observed in baseline surgeon-specific OR time for BSC (p = 0.03) as well as for BCS with IORT (p < 0.05), attributable to surgeon experience. The average BCS times were faster than the BCS plus IORT procedure times for all surgeons. The overall mean OR time for the entire combined surgical and radiation procedure was 135.5 min. The most common applicator sizes used were the 3.5 and 4 cm, yielding an average 21 min IORT time. Applicator choice did not differ over time (p = 0.189). After adjusting for IORT time and surgeon, the prediction model estimated that surgeons decreased the total BCS plus IORT OR time at a rate of -4.5 min per each additional 10 cases performed. CONCLUSION: Surgeon experience and applicator size are related to OR times for performing IORT for breast cancer. OR time for IORT in breast cancer treatment can be improved over time, even among experienced surgeons.

Medical student documentation in electronic health records: a collaborative statement from the Alliance for Clinical Education.

PURPOSE: The electronic health record (EHR) is an important advancement in health care. It facilitates improvement of health care delivery and coordination of care, but it creates special challenges for student education. This article represents a collaborative effort of the Alliance for Clinical Education (ACE), a multidisciplinary group formed in 1992. ACE recognizes the importance of medical student participation in patient care including the ability of documentation. This article proposes guidelines that can be used by educators to establish expectations on medical student documentation in EHRs. SUMMARY: To provide the best education for medical students in the electronic era, ACE proposes to use the following as practice guidelines for medical student documentation in the EHR: (a) Students must document in the patient's chart and their notes should be reviewed for content and format, (b) students must have the opportunity to practice order entry in an EHR--in actual or simulated patient cases--prior to graduation, (c) students should be exposed to the utilization of the decision aids that typically accompany EHRs, and (d) schools must develop a set of medical student competencies related to charting in the EHR and state how they would evaluate it. This should include specific competencies to be documented at each stage, and by time of graduation. In addition, ACE recommends that accreditation bodies such as the Liaison Committee for Medical Education utilize stronger language in their educational directives standards to ensure compliance with educational principles. This will guarantee that the necessary training and resources are available to ensure that medical students have the fundamental skills for lifelong clinical practice. CONCLUSIONS: ACE recommends that medical schools develop a clear set of competencies related to student in the EHR which medical students must achieve prior to graduation in order to ensure they are ready for clinical practice.

Low correlation between subjective and objective measures of knowledge on surgery clerkships.

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.

A CRASH course in procedural skills improves medical students' self-assessment of proficiency, confidence, and anxiety.

BACKGROUND: Medical students enter the clinical education years with minimal exposure to procedural skills. This study aims to determine the effect of a pre-clinical skills course on students' ratings of proficiency, confidence, and anxiety levels. METHODS: An elective pre-clinical course in procedural skills was given to medical students prior to clinical rotations. Self-assessment of proficiency, confidence, and anxiety in performing these skills was made prior to and on completion of the course. RESULTS: Course participants reported low proficiency and confidence, and high anxiety regarding performing procedural skills. Following the course, there was significant improvement in self-assessed proficiency, confidence, and anxiety. There were no gender differences in responses. CONCLUSIONS: Medical students entering clinical rotations have poor self-assessment of proficiency, low confidence, and high anxiety regarding procedural skills. A concentrated course in procedural skills significantly improved students' assessment of their proficiency, confidence, and anxiety levels.

Ductal carcinoma in situ of the breast and heparanase-1 expression: a molecular explanation for more aggressive subtypes.

BACKGROUND: Ductal carcinoma in situ of the breast (DCIS) forms a heterogeneous group of lesions with varying invasive potential. This study tested whether heparanase-1 (HPR1), an endoglycosidase that specifically degrades the heparan sulfate (HS) proteoglycans in the breast extracellular matrix, was associated with the most aggressive DCIS subtypes. STUDY DESIGN: Fifty-seven DCIS specimens and 10 normal breast specimens were examined for HPR1 expression using immunohistochemical staining. Twenty-seven arbitrarily selected specimens were also examined for HS deposition by immunofluorescence staining, confirming HPR1 activity. Patient medical records were obtained to explore a possible association between biologic potential using Van Nuys Prognostic Index (VNPI) and HPR1 expression. RESULTS: Twenty-one (75%) of 28 comedo and microinvasive DCIS specimens stained HPR1 positive; 4 (14%) of 29 other subtypes (papillary, cribriform, and solid subtypes) stained HPR1 positive on immunohistochemistry (p = 0.003). Among 27 DCIS stained for HS, we found that 8 (67%) of 12 HPR1-negative DCIS had intact HS deposition in the extracellular basement membrane; none of the 15 HPR1-positive DCIS stained HS positive. Six (86%) of seven DCIS with VNPI scores 8 to 9 and 14 (50%) of 28 DCIS with VNPI scores 5 to 7 were HPR1 positive; only 3 (17%) of 18 DCIS with VNPI scores 3 to 4 were HPR1 positive. Median VNPI score in patients with HPR1-positive DCIS was 7 (range 3 to 9), compared with 4.5 (range 3 to 7) in patients with HPR1-negative DCIS (p < 0.001). CONCLUSIONS: HPR1 was expressed at a significantly higher frequency in the invasive comedo and DCIS with microinvasion subtypes than in the noninvasive subtypes. HPR1 expression was inversely associated with HS deposition in the extracellular basement membrane of the DCIS. HPR1 expression was associated with a higher VNPI score. These observations suggest that HPR1 expression in DCIS can play an important role in development of DCIS into an invasive breast cancer.