"The Uncertainty Principle"- studying immediate lymphatic reconstruction impacts the natural history of breast cancer related lymphedema.

Breast cancer-related lymphedema (BCRL) following axillary lymph node dissection (ALND) is a life-altering sequela for patients and a challenging problem for their surgeons. In order to prevent BCRL, immediate lymphatic reconstruction (ILR) is a surgical technique that has been devised to restore lymphatic drainage to the operative limb. Although ILR is becoming popular in the literature, we have identified several challenges within our own ILR research, including a lack of a clear definition of lymphedema, a lack of common outcome measures and possible alteration of the natural history of lymphedema through early compression therapy. Given these challenges, we must move forward with caution, while striving to develop clear and universally agreed upon definitions and outcomes, so that we can advance the body of evidence in support of ILR.

The clinico-pathological spectrum of plaque-type blue naevi and their potential for malignant transformation.

AIMS: Plaque-type blue naevi are rare melanocytic tumours presenting as large, pigmented plaques at birth or during childhood. There is a risk for malignant transformation, but no larger comprehensive studies exist and the diagnosis is challenging, especially on limited biopsy material. The aim is to describe the clinicopathological features and behaviour of the disease more comprehensively. METHODS AND RESULTS: We retrieved eight plaque-type blue naevi, presenting as large, pigmented plaques (median = 7 cm; range = 3-26) most frequently affecting the scalp (four) followed by the cheek, arm, abdominal wall and gluteal cleft (one each), with a slight female predilection. Median age at time of biopsy was 39.5 years (range = 15-90), but three tumours had been present at birth and one since childhood. Histopathologically, the tumours were poorly circumscribed and composed of cellular fascicles of uniform spindle cells in a background of variably prominent pigmented dendritic cells affecting dermis and subcutaneous tissues. The majority had mutations in GNAQ. One tumour showed malignant transformation, characterised by an expansile nodule of pleomorphic epithelioid melanocytes with rhabdoid morphology, high mitotic activity and areas of necrosis. This patient developed metastatic melanoma to lymph nodes. All patients are alive with a median follow-up of 60 months. CONCLUSION: Plaque-type blue naevi are diagnostically challenging tumours with risk for malignant transformation. Awareness and familiarity with the salient clinicopathological features are necessary for reliable diagnosis, and long-term clinical follow-up is required to monitor for malignant transformation.

Acceptance of outpatient enhanced recovery after surgery (ERAS©) protocols for implant-based breast reconstruction nudged on by the COVID-19 pandemic.

We retrospectively identified 295 women undergoing outpatient implant breast reconstruction (IBR) who received standardized ERAS care pre-pandemic (PP; April 2018-March 2020) and during the pandemic (DP; April 2020-March 2022). The majority of IBR was completed as outpatient surgeries DP versus PP (73% versus 38%, p < 0.001). Immediate IBR increased DP versus PP (p < 0.001). Preoperative ERAS© order sets were used 54% of the time. Lack of ERAS© order set use was associated with unplanned admissions (55.3% versus 44.7%, p = 0.02). COVID-19 changed health care and nudged IBR to outpatient procedures. With ERAS© recommendations, IBR can be safely and effectively transitioned to outpatient settings.

Questioning the Utility of Temporal Artery Biopsy in Giant Cell Arteritis: A Negative Biopsy May Facilitate Decision-making.

Plastic surgeons are frequently consulted to perform temporal artery biopsy (TAB), even though patients meet the American College of Rheumatology diagnostic criteria for giant cell arteritis (GCA) and are already treated. This study aimed to analyze the impact of TAB on steroid duration in patients undergoing TAB. Methods: We undertook a prospective study of adult patients undergoing TAB for GCA in Calgary. Consecutive, multicenter recruitment was performed over 2 years. Primary outcomes included initiation or discontinuation and duration of corticosteroids. Results: Twenty-one TABs were performed in 20 patients. Nineteen percent of TABs were positive, and 71.4%, negative. In 9.5% of patients, accidental sampling of a vessel other than the superficial temporal artery occurred. Fifty-two percent of patients received steroids before TAB, of which the mean duration was 8.0 days for TAB+ (postive temporal artery biopsy result) patients and 8.4 days for TAB- (negative temporal artery biopsy result; P = 0.22) patients. Before TAB, the American College of Rheumatology score was 2.5 for TAB+ patients and 2.4 for TAB- (P = 0.74). Postbiopsy, the American College of Rheumatology score was 3.5 for TAB+ patients (therefore reaching diagnostic threshold of 3) but remained 2.4 for TAB- (P = 0.02). TAB+ patients were treated for 352.3 days, whereas TAB- patients for 16.7 days (P = 0.29). Complications were more likely with long-term (>6 weeks) steroids (P = 0.17). Conclusion: In patients with a low suspicion of GCA, a negative TAB helps bolster physician confidence and leads to a shorter steroid duration.

Not Waiting to Progress; How the COVID-19 Pandemic Nudged Neoadjuvant Therapy for Stage III Locally Advanced Melanoma Patients.

Background: Early-phase neoadjuvant trials have demonstrated promising results in the utility of upfront immunotherapy in locally advanced stage III melanoma and unresected nodal disease. Secondary to these results and the COVID-19 pandemic, this patient population, traditionally managed through surgical resection and adjuvant immunotherapy, received a novel treatment strategy of neoadjuvant therapy (NAT). Methods: Patients with node-positive disease, who faced surgical delays secondary to COVID-19, were treated with NAT, followed by surgery. Demographic, tumour, treatment and response data were collected through a retrospective chart review. Biopsy specimens were analysed prior to the initiation of NAT, and therapy response was analysed following surgical resection. NAT tolerability was recorded. Results: Six patients were included in this case series; four were treated with nivolumab alone, one with ipilimumab and nivolumab and one with dabrafenib and trametinib. Twenty-two incidents of adverse events were reported, with the majority (90.9%) being classified as grade one or two. All patients underwent surgical resection: three out of six patients following two NAT cycles, two following three cycles and one following six cycles. Surgically resected samples were histopathologically evaluated for the presence of disease. Five out of six patients (83%) had ≤1 positive lymph node. One patient showed extracapsular extension. Four patients demonstrated complete pathological response; two had persisting viable tumour cells. Conclusions: In this case series, we outlined how in response to surgical delays secondary to the COVID-19 pandemic, NAT was successfully applied to achieve promising treatment response in patients with locally advanced stage III melanoma.

Incorporating Lymphovenous Anastomosis in Clinically Node-Positive Women Receiving Neoadjuvant Chemotherapy: A Shared Decision-Making Model and Nuanced Approached to the Axilla.

INTRODUCTION: Lymphedema remains a risk for 13-34% of breast cancer patients who require an axillary dissection (ALND) and radiation. Immediate lymphovenous anastomosis (LVA) may mitigate lymphedema by up to 30% by restoring the physiologic lymphatic drainage immediately after ALND. Currently, completion of ALND (cALND) versus radiation after neoadjuvant therapy (NAC) is being addressed by the Alliance A11202 trial, leaving a paucity of data to guide practice. Our study describes the implementation process of LVA into clinical practice after NAC for node-positive breast cancer in the current clinical context. METHODS: We reviewed a prospective database of LVA in node-positive patients (cT1-4,Nany) who received NAC followed by axillary surgery ± immediate LVA from October 2021 to 2022. The evolution of the surgical approach is described. Specifically, patients who downstaged to clinically negative nodes post-NAC were offered targeted SLNB with dual-tracer and intraoperative frozen section (FS). Patients were reminded that the standard of care for any node positive is cALND. Immediate cALND with LVA was performed for grossly positive nodes or all positive SLNs; cALND was omitted for those with negative SLNs. For a microscopic disease on a frozen section, a shared decision was made pre-operatively, given each patient's differing valuations of the benefit and risks of cALND ± LVA versus no cALND with planned regional radiation postoperatively. LVA was offered as an option as part of our institutional evaluation of the procedure. RESULTS: A total of 15 patients were included; the mean age was 49.9 (range 32-75) with stage IIA to IIIB breast cancer. Of these, 6 (40%) were triple negative, 5 (33.3%) HER-2 positive, and 4 (26.7%) ER/PR+ HER-2 negative. There were 13 women (86.7%) who had persistent axillary adenopathy based on clinical and/or ultrasound assessment, with 8 patients proceeding directly to ALND with LVA. Among these patients, 3 (37.5%) had pathologic nodal disease, and 5 (62.5%) were node negative, confirming the limitations of pre-operative imaging. As a result, the subsequent 7 (46.7%) underwent targeted SLNB with FS, with 3 patients (42.9%) avoiding an ALND as a result of a negative FS. A total of 4 patients (57.1%) had 1 or more positive lymph nodes on FS: 3 proceeded with a cALND and LVA, and 1 patient (14.2%) opted for no cALND based on a pre-operative discussion and received adjuvant radiation and chemotherapy. Of the 11 patients who underwent ALND and LVA, 1 patient (9.1%) developed lymphedema at 6.9 months following their surgery. The accuracy, sensitivity, and specificity of pre-operative US were 46.7%, 85.7%, and 12.5% and intraoperative FS were 88.0%, 72.7%, and 100%, respectively. CONCLUSIONS: As adjuvant nodal radiation and systemic therapy continue to improve, the benefit of a cALND in patients with the limited residual disease remains unclear as we await the outcomes from clinical trials. In the era of clinical uncertainty, we propose a nuanced approach to the axilla by utilizing a shared decision model with patients, incorporating targeted SLNB with FS and completion node dissection when required and desired by the patient, coupled with LVA in a simple stepwise treatment pathway.

Rates of Burnout in Female Orthopaedic Surgeons Correlate with Barriers to Gender Equity.

BACKGROUND: The primary purpose of this study was to investigate the relationships between career burnout and the barriers to gender equity identified by Canadian female orthopaedic surgeons. A secondary purpose was to assess relationships between the demographic characteristics of the female surgeons and career burnout and job satisfaction. METHODS: An electronic survey was distributed to 330 Canadian female orthopaedic surgeons. Demographic variables including age, stage and years in practice, practice setting, and marital status were collated. The survey included the Gender Bias Scale (GBS) questionnaire and 2 questions each about career burnout and job satisfaction. The Pearson r correlation coefficient evaluated the relationships among the higher- and lower-order factors of the GBS, burnout, and job satisfaction. Spearman rank correlation coefficient assessed relationships among burnout, job satisfaction, and demographic variables. RESULTS: Survey responses were received from 218 (66.1%) of the 330 surgeons. A total of 110 surgeons (50.5%) agreed or strongly agreed that they felt career burnout (median score = 4). Burnout was positively correlated with the GBS higher-order factors of Male Privilege (r = 0.215, p < 0.01), Devaluation (r = 0.166, p < 0.05), and Disproportionate Constraints (r = 0.152, p < 0.05). Job satisfaction (median = 4) was reported by 168 surgeons (77.1%), and 66.1% were also satisfied or very satisfied with their role in the workplace (median = 4). Burnout was significantly negatively correlated with surgeon age and job satisfaction. CONCLUSIONS: Half of the female orthopaedic surgeons reported symptoms of career burnout. Significant relationships were evident between burnout and barriers to gender equity. Identification of the relationships between gender-equity barriers and burnout presents an opportunity to modify organizational systems to dismantle barriers and reduce this occupational syndrome. CLINICAL RELEVANCE: Given the relationships between gender inequity and career burnout in this study of female orthopaedic surgeons, actions to dismantle gender barriers and address systemic biases are necessary at all career stages to reduce burnout.

Effect of Smartphone App Postoperative Home Monitoring After Oncologic Surgery on Quality of Recovery: A Randomized Clinical Trial.

Importance: There has been an increase in health care-focused smartphone apps, including those for encouraging healthy behaviors and managing chronic conditions, but app-assisted postsurgical care has yet to be fully explored. Objective: To compare quality of recovery and patient satisfaction between conventional in-person follow-up and smartphone app-assisted follow-up for patients following Enhanced Recovery After Surgery Society (ERAS) protocols. Design, Setting, and Participants: This randomized clinical trial, conducted from June 2019 to April 2021, included women older than 18 years undergoing oncologic breast reconstruction or major gynecologic oncology surgery following ERAS protocols with the care of 2 surgeons at an academic tertiary care center. Interventions: Patients were randomized 1:1 to receive smartphone app-assisted follow-up or conventional in-person follow-up. The smartphone group used a surgeon-monitored app to record Quality of Recovery 15 (QoR15) scores, European Organisation for Research and Treatment of Cancer-selected adverse events, drain outputs, and surgical site photographs over 6 weeks. Patient satisfaction scores were assessed using validated Patient Satisfaction Questionnaire III (PSQ-III) subscales at 2 and 6 weeks postoperatively. The conventional follow-up group also completed the QoR15 and PSQ-III questionnaires at these intervals. Main Outcomes and Measures: The primary outcomes were quality of recovery and patient satisfaction, as measured by the QoR15 and PSQ-III, respectively. Secondary outcomes were costs of follow-up; the number of contacts with the medical system, complications, and surgeons' contacts with patients; and surgeons' perceptions of app-assisted care. Results: Of 72 patients included in the trial, 36 underwent breast reconstruction (mean [SD] age, 45.30 [9.13] years) and 36 underwent gynecologic oncology surgery (mean [SD] age, 54.90 [11.18] years). Three patients dropped out (2 who underwent breast reconstruction [1 in the app group, 1 in the control group], 1 who underwent gynecologic oncology surgery [control group]). The app group had significantly higher mean (SD) QoR15 scores than the control group (2 weeks: 127.58 [22.03] vs 117.68 [17.52], P = .02; 6 weeks: 136.64 [17.53] vs 129.76 [16.42], P = .03). Patients were equally satisfied between groups in all subsets of the PSQ-III at these intervals. The mean (SD) number of complications was similar in both groups, and a similar number of surgeon contacts per patient occurred (1.6 [1.2] vs 2.1 [2.0], P = .16). Surgeons appreciated early identification of complications with the app. Conclusions and Relevance: In this randomized clinical trial, postoperative follow-up for patients undergoing breast reconstruction and gynecologic oncology surgery using smartphone app-assisted monitoring led to improved quality of recovery and equal satisfaction with care compared with conventional in-person follow-up. Trial Registration: ClinicalTrials.gov Identifier: NCT03456167.

Mitigating Breast-Cancer-Related Lymphedema-A Calgary Program for Immediate Lymphatic Reconstruction (ILR).

With increasing breast cancer survival rates, one of our contemporary challenges is to improve the quality of life of survivors. Lymphedema affects quality of life on physical, psychological, social and economic levels; however, prevention of lymphedema lags behind the progress seen in other areas of survivorship such as breast reconstruction and fertility preservation. Immediate lymphatic reconstruction (ILR) is a proactive approach to try to prevent lymphedema. We describe in this article essential aspects of the elaboration of an ILR program. The Calgary experience is reviewed with specific focus on team building, technique, operating room logistics and patient follow-up, all viewed through research and education lenses.

Current Controversies in Melanoma Treatment.

LEARNING OBJECTIVES: After reading this article and viewing the videos, the participant should be able to: 1. Discuss margins for in situ and invasive disease and describe reconstructive options for wide excision defects, including the keystone flap. 2. Describe a digit-sparing alternative for subungual melanoma. 3. Calculate personalized risk estimates for sentinel node biopsy using predictive nomograms. 4. Describe the indications for lymphadenectomy and describe a technique intended to reduce the risk of lymphedema following lymphadenectomy. 5. Offer options for in-transit melanoma management. SUMMARY: Melanoma management continues to evolve, and plastic surgeons need to stay at the forefront of advances and controversies. Appropriate margins for in situ and invasive disease require consideration of the trials on which they are based. A workhorse reconstruction option for wide excision defects, particularly in extremities, is the keystone flap. There are alternative surgical approaches to subungual tumors besides amputation. It is now possible to personalize a risk estimate for sentinel node positivity beyond what is available for groups of patients with a given stage of disease. Sentinel node biopsy can be made more accurate and less morbid with novel adjuncts. Positive sentinel node biopsies are now rarely managed with completion lymphadenectomy. Should a patient require lymphadenectomy, immediate lymphatic reconstruction may mitigate the lymphedema risk. Finally, there are minimally invasive modalities for effective control of in-transit recurrences.

Breast Reconstruction Decision Aids Decrease Decisional Conflict and Improve Decisional Satisfaction: A Randomized Controlled Trial.

BACKGROUND: Decision aids are useful adjuncts to clinical consultations for women considering breast reconstruction. This study compared the impact of two online decision aids, the Breast RECONstruction Decision Aid (BRECONDA) and the Alberta Health Services (AHS) decision aid, on decisional conflict, decisional satisfaction, and decisional regret. METHODS: This randomized controlled trial included 60 women considering whether or not to undergo breast reconstruction. Two online decision aids, the AHS and the BRECONDA, were compared using randomized two-arm equal allocation. Participants responded to questionnaires at baseline, after the first and second consultations, and at 6 weeks and 6 months after deciding to, or not to, undergo reconstruction. Change in decisional conflict scores was compared between the BRECONDA and the AHS decision aid. Secondary outcomes included decisional regret and decisional satisfaction. RESULTS: Both groups were similar in demographic, clinical, and behavioral characteristics. Women spent more time consulting the BRECONDA in comparison to women using the AHS decision aid (56.7 ± 53.8 minutes versus 28.4 ± 27.2 minutes; P < 0.05). Decisional conflict decreased (P < 0.05), and decisional satisfaction improved over time in both groups (P < 0.05). However, there were no differences based on the type of decision aid used (P > 0.05). Both decision aids had a similar reduction in decisional regret (P > 0.05). CONCLUSIONS: Decision aids decrease decisional conflict and improve decisional satisfaction among women considering breast reconstruction. Physicians should therefore offer patients access to decision aids as an adjunct to breast reconstruction consultations to help patients make an informed decision. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Management of Uveal Melanoma: Updated Cancer Care Alberta Clinical Practice Guideline.

OBJECTIVE: The purpose of this guideline update is to reassess and update recommendations in the prior guideline from 2016 on the appropriate management of patients with uveal melanoma. METHODS: In 2021, a multidisciplinary working group from the Provincial Cutaneous Tumour Team, Cancer Care Alberta, Alberta Health Services was convened to update the guideline. A comprehensive review of new research evidence in PubMed as well as new clinical practice guidelines from prominent oncology groups informed the update. An enhancement in methodology included adding levels of evidence and strength of recommendations. The updated guideline was circulated to all members of the Provincial Cutaneous Tumour Team for review and endorsement. RESULTS: New and modified recommendations address provider training requirements, diagnostic imaging for the detection of metastases, neo-adjuvant pre-enucleation radiotherapy, intravitreal anti-vascular endothelial growth factor agents for radiation retinopathy, genetic prognostic testing, surveillance following definitive local therapy, and systemic therapy for patients with metastatic uveal melanoma. DISCUSSION: The recommendations represent evidence-based standards of care agreed to by a large multidisciplinary group of healthcare professionals.

Temporal Artery Biopsy Debate: Positive TAB Result Prolongs Steroid Use in Giant Cell Arteritis.

Temporal artery biopsy (TAB) in diagnosing giant cell arteritis has been criticized due to surgical risks, a high false negative rate, and redundant information when patients already met American College of Rheumatology criteria. The objective of this study was to investigate TAB's impact on steroid treatment duration. Methods: A retrospective chart review garnered patient demographics, symptoms, comorbidities, and steroid treatment duration in patients undergoing TAB at a single center. Steroid treatment was compared between TAB+ and TAB - patients. Results: One hundred seven patients undergoing TAB were included. Patients were predominantly women (70.1%) with a median age of 74 years (46 -91). Of 107 TAB results, 74 (69.2%) were negative, 23 (21.5%) were positive, and 10 (9.3%) were found to be indeterminate. In TAB+ patients, the mean erythrocyte sedimentation rate was not significantly different than TAB - patients (60.2 versus 43.7, P = 0.45), nor was the median C-reactive protein (38.8 versus 18.1, P = 0.17). Regarding steroid use, both TAB+ and TAB - patients had a similarly high rate of prebiopsy steroid initiation (82.6% versus 70.3%, P = 0.32). More TAB+ patients remained on steroids at 6 weeks (95.0% versus 57.4%, P = 0.004), 6 months (95% versus 37.7%, P < 0.001), 1 year (65.0% versus 31.1%, P = 0.024), and 18 months (50.0% versus 19.7%, P = 0.045). By 2 years, the difference no longer met significance (35.0% versus 14.8%, P = 0.12). P = 0.12). Conclusion: TAB positivity does seem to influence maintenance of steroids up to 18 months after biopsy.

Higher Rate of Lymphedema with Inguinal versus Axillary Complete Lymph Node Dissection for Melanoma: A Potential Target for Immediate Lymphatic Reconstruction?

BACKGROUND: The present study was conducted to define the lymphedema rate at our institution in patients undergoing axillary (ALND) or inguinal (ILND) lymph node dissection (LND) for melanoma. It aimed to examine risk factors predisposing patients to a higher rate of lymphedema, highlighting which patients could be targeted for immediate lymphatic reconstruction (ILR). METHODS: A retrospective chart review was conducted between October 2015 and July 2020 to identify patients who had undergone ALND or ILND for melanoma. The main outcome measures were rates of transient and permanent lymphedema. Univariate and multivariate analyses were performed to assess the relationship between lymphedema rate and factors related to patient characteristics, surgical procedure, pathology findings, and adjuvant treatment. RESULTS: Between October 2015 and July 2020, 66 patients underwent LND for melanoma: 34 patients underwent ALND and 32 patients underwent ILND. At a median follow-up of 29 months, 85.3% (n = 29) of patients having had an ALND did not experience lymphedema, versus 50.0% (n = 16) of ILND (p = 0.0019). The rates of permanent lymphedema for patients having undergone ALND and ILND were 11.8% (n = 4) and 37.5% (n = 12) respectively (p = 0.016, NS). The rate of transient lymphedema was 2.9% (n = 1) for ALND and 12.5% (n = 4) for ILND (p = 0.13, NS). On univariate analysis, the location of LND and wound infection were found to be significant factors for lymphedema. On multivariate analysis, only the location of LND remained a significant predictor, with the inguinal location predisposing to lymphedema. CONCLUSION: This study highlights the high rate of lymphedema following ILND for melanoma and is a potential target for future patients to be considered for ILR.

Immediate Lymphatic Reconstruction during Axillary Node Dissection for Breast Cancer: A Systematic Review and Meta-analysis.

The objective of this study is to summarize the current body of evidence detailing the impact of immediate lymphatic reconstruction (ILR) on the incidence of breast cancer-related lymphedema (BCRL) following axillary node dissection (ALND). Methods: Medline and Embase databases were queried for publications, where ILR was performed at the time of ALND for breast cancer. Exclusion criteria included lymphaticovenous anastomosis for established BCRL, animal studies, non-breast cancer patient population studies, and descriptive studies detailing surgical technique. Meta-analysis was performed with a forest plot generated using a Mantel -Haenszel statistical method, with a random-effect analysis model. Effect measure was reported as risk ratios with associated 95% confidence intervals. The risk of bias within studies was assessed by the Cochrane Collaboration tool. Results: This systematic review yielded data from 11 studies and 417 breast cancer patients who underwent ILR surgery at the time of ALND. There were 24 of 417 (5.7%) patients who developed BCRL following ILR. Meta-analysis revealed that in the ILR group, 6 of 90 patients (6.7%) developed lymphedema, whereas in the control group, 17 of 50 patients (34%) developed lymphedema. Patients in the ILR group had a risk ratio of 0.22 (CI, 0.09 -0.52) of lymphedema with a number needed to treat of four. Conclusions: There is a clear signal indicating the benefit of ILR in preventing BCRL. Randomized control trials are underway to validate these findings. ILR may prove to be a beneficial intervention for improving the quality of life of breast cancer survivors.

Necessity of Temporal Artery Biopsy for Giant Cell Arteritis: A Systematic Review.

Temporal artery biopsy (TAB) is currently the gold standard procedure to diagnose giant cell arteritis. Despite low sensitivity, TAB is routinely performed even if a clinical diagnosis has already been made. The objective of this study was to determine the usefulness of TAB for giant cell arteritis management. Methods: We performed a systematic review to identify studies that compared steroid treatment between TAB+ and TAB- patients. EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials were searched from inception until April 4, 2020. Titles, abstracts, and full texts were reviewed by two independent reviewers and conflicts resolved by consensus. Studies reporting TAB result and steroid treatment were included. Information pertaining to steroid treatment was compared between TAB+ and TAB- groups. Steroid duration was compared by grouping patients in a less than 6 month group, a 6-24 month group, and a more than 24 month group. Results: An estimated 5288 abstracts were screened and 13 studies involving 1355 patients were included. Rate of prebiopsy steroid treatment was higher in TAB+ patients compared with TAB- patients [93% versus 63% (P < 0.001)]. The TAB+ group was more likely to be started on steroids prebiopsy [28% versus 8% (P < 0.001)]. TAB+ and TAB- patients had similar steroid duration for all groups [<6-month group 17% versus 19% (P-0.596), the 6-24-month group 16% versus 19% (P-0.596), and the >24-month group 66% versus 63% (P-0.642)]. Conclusion: TAB results have minimal impact on treatment, and the utility should be reconsidered when a clinical diagnosis of giant cell arteritis is possible.

Experiences of Canadian Female Orthopaedic Surgeons in the Workplace: Defining the Barriers to Gender Equity.

BACKGROUND: Only 13.6% of orthopaedic surgeons in Canada are women, even though there is nothing inherent to the practice of orthopaedic surgery that favors men over women. Clearly, there is a need to identify, define, and measure the barriers faced by women in orthopaedic surgery. METHODS: An electronic survey was distributed to 330 female-identifying Canadian orthopaedic surgeons and trainees and included the validated Gender Bias Scale (GBS) and questions about career burnout. The barriers for women in Canadian orthopaedics were identified using the GBS. The relationships between the GBS and burnout were investigated. Open-text questions explored the barriers perceived by female orthopaedic surgeons. RESULTS: The survey was completed by 220 female orthopaedic surgeons and trainees (66.7%). Five barriers to gender equity were identified from the GBS: Constrained Communication, Unequal Standards, Male Culture, Lack of Mentoring, and Workplace Harassment. Career burnout correlated with the GBS domains of Male Privilege (r = 0.215; p < 0.01), Disproportionate Constraints (r = 0.152; p < 0.05), and Devaluation (r = 0.166; p < 0.05). Five main themes emerged from the open-text responses, of which 4 linked closely to the barriers identified in the GBS. Work-life integration was also identified qualitatively as a theme, most notably the difficulty of balancing disproportionate parental and childcare responsibilities alongside career aspirations. CONCLUSIONS: In this study, 5 barriers to workplace equity for Canadian female orthopaedic surgeons were identified using the validated GBS and substantiated with qualitative assessment using a mixed-methods approach. Awareness of these barriers is a necessary step toward dismantling them and changing the prevailing culture to be fair and equitable for all. CLINICAL RELEVANCE: A just and equitable orthopaedic profession is imperative to have healthy and thriving surgeons who are able to provide optimal patient care.

Canadian Expert Opinion on Breast Reconstruction Access: Strategies to Optimize Care during COVID-19.

BACKGROUND: Breast reconstructive services are medically necessary, time-sensitive procedures with meaningful health-related quality of life benefits for breast cancer survivors. The COVID-19 global pandemic has resulted in unprecedented restrictions in surgical access, including access to breast reconstructive services. A national approach is needed to guide the strategic use of resources during times of fluctuating restrictions on surgical access due to COVID-19 demands on hospital capacity. METHODS: A national team of experts were convened for critical review of healthcare needs and development of recommendations and strategies for patients seeking breast reconstruction during the pandemic. Following critical review of literature, expert discussion by teleconference meetings, and evidenced-based consensus, best practice recommendations were developed to guide national provision of breast reconstructive services. RESULTS: Recommendations include strategic use of multidisciplinary teams for patient selection and triage with centralized coordinated use of alternate treatment plans during times of resource restrictions. With shared decision-making, patient-centered shifting and consolidation of resources facilitate efficient allocation. Targeted application of perioperative management strategies and surgical treatment plans maximize the provision of breast reconstructive services. CONCLUSIONS: A unified national approach to strategically reorganize healthcare delivery is feasible to uphold standards of patient-centered care for patients interested in breast reconstruction.