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This cohort study compares outcomes including hospital length of stay and 30-day rates of complications after nonelective subtotal cholecystectomy vs total cholecystectomy among patients with cholecystitis.

We propose a novel solid-fluid coupling method to capture the subtle hydrophobic and hydrophilic interactions between liquid, solid, and air at their multi-phase junctions. The key component of our approach is a Lagrangian model that tackles the coupling, evolution, and equilibrium of dynamic contact lines evolving on the interface between surface-tension fluid and deformable objects. This contact-line model captures an ensemble of small-scale geometric and physical processes, including dynamic waterfront tracking, local momentum transfer and force balance, and interfacial tension calculation. On top of this contact-line model, we further developed a mesh-based level set method to evolve the three-phase T-junction on a deformable solid surface. Our dynamic contact-line model, in conjunction with its monolithic coupling system, unifies the simulation of various hydrophobic and hydrophilic solid-fluid-interaction phenomena and enables a broad range of challenging small-scale elastocapillary phenomena that were previously difficult or impractical to solve, such as the elastocapillary origami and self-assembly, dynamic contact angles of drops, capillary adhesion, as well as wetting and splashing on vibrating surfaces.

Professional organizations recently set guidelines for avoiding surgeries of low utility and overutilization for the Choosing Wisely campaign. These include re-excision for invasive cancer close to margins, double mastectomy in patients with unilateral breast cancer, axillary lymph node dissection in patients with limited nodal disease, and sentinel lymph node biopsy (SLNB) in patients ≥70 years with early-stage breast cancer. Variable adherence to these recommendations led us to evaluate implementation rates of low-value surgical guidelines at a safety-net hospital.We retrospectively analyzed breast cancer patients who underwent surgery from 2015 to 2020. Each patient was assessed for eligibility for omission of the listed surgeries. Trends were evaluated by cohorts before and after a fellowship-trained breast surgeon joined the faculty in 2018. Outcomes were compared using Fisher's exact test.Among 195 patients, none underwent re-excision for close margins of invasive cancer. Only 6.7% of patients (3/45) received contralateral mastectomy and 1.8% of eligible patients (3/169) received axillary lymph node dissection. Overall, 60% of patients ≥ 70 years with stage 1 hormone-positive breast cancer (9/15) received SLNB. There was a downward trend from 71% of eligible patients receiving SLNB in 2015-2018 to 50% in 2019-2020.De-implementation of traditional surgical practices, deemed as low-value care, toward newer guidelines is achievable even at community hospitals serving a low socioeconomic community. By avoiding overtreatment, hospitals can achieve effective resource allocation which allow for social distributive justice among patients with breast cancer and ensure strategic use of scarce health economic resources while preserving patient outcomes.

Background In the age of COVID-19 and enforced social distancing, changes in patterns of trauma were observed but poorly understood. Our aim was to characterize traumatic injury mechanisms and acuities in 2020 and compare to years prior at our Level 1 trauma center. Materials and Methods Trauma patients triaged in 2016 through 2020 from January to May were reviewed. Patient demographics, level of activation (1 vs. 2), ISS, and mechanism of injury were collected. Data from 2016 through 2019 was combined, averaged by month, and compared to data from 2020 using Chi-squared analysis. Results During the months of interest, 992 trauma patients were triaged in 2020 and 4,311 in 2016-2019. The numbers of penetrating and Level 1 trauma activations in January – March of 2020 were similar to average numbers for the same months during 2016 through 2019. In April 2020, there was a significant increase in incidence of penetrating trauma compared to the prior four-year average (27% vs. 16%, p

Background: With TARGIT-R(Retrospective) showing a higher-than-expected ipsilateral breast tumor recurrence (IBTR) the community setting for intraoperative radiation therapy (IORT), we evaluated IORT outcomes in an integrated health care system.Methods: A retrospective review of early breast cancer patients who received IORT between February 2014-February 2020 was performed. IORT was offered at a single medical center within a large integrated healthcare system. Criteria for IORT included patients ≥50 years with T1, low to intermediate grade, endocrine-responsive HER2- invasive ductal carcinoma. All breast cancer patients were reviewed at weekly multidisciplinary breast conferences, and IORT was offered when patients met the eligibility criteria. Primary outcomes include IBTR, mortality, and complications. Results: Of 5,731 potentially eligible patients, 245 patients (4.3%) underwent IORT. Mean age was 65.4 ± 0.4 years with median follow-up 3.5 years ± 2.2 months. Based on American Society of Radiation Oncology guideline, 51% were suitable, 38.4% cautionary, and 10.6% unsuitable candidates based on the final pathology. The patients were reassigned to the cautionary group because of the margin width and/or extensive DCIS. Unintended boost (primary IORT followed by whole-breast radiation) was given in 6.5% of IORT patients. At median follow-up of 3.5 years, IBRT was 3.7% for all patients. There was one breast-cancer-related mortality (0.4%), and 7 mortality (2.9%) from other causes. Although not statistically significant, there was a trend towards higher recurrence in those not adherent with endocrine treatment than those who were (7.4% vs 1.9%, p=0.07). The overall complication rate was 14.7% with seroma as the most common.Conclusions: At 3.5-year follow-up, our IORT IBTR rate of 3.7%. Our protocol subsequently was modified to require all IORT patients to receive surgical shave margins, WBI for all cautionary patients on the final pathology, and requirement of endocrine treatment. Citation Format: Annie Tang, Jason Kelly, Elizabeth Cureton, Jonathan Svahn, Eva Thomas, Liisa Lyon, Veronica Shim. Intraoperative Radiation Therapy (IORT) : A large integrated healthcare system’s approach and outcomes [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-19-19.

Despite advances in healthcare and improved chemotherapy, disparities in breast cancer outcomes continue to persist. Our aim was to evaluate socioeconomic factors that may impact timing of treatment for patients receiving chemotherapy in underserved communities.A review of patients with breast cancer who received neoadjuvant or adjuvant chemotherapy from 2015-2019 was conducted at a safety-net hospital. The primary outcomes were times from diagnosis to chemotherapy and surgery. Clinicodemographic factors including race, age, clinical stage, primary language, comorbidities, and median income by zip code were collected. Multivariable regression analysis was performed to evaluate for factors associated with the primary outcomes.One hundred patients were identified. For the neoadjuvant group, median time from diagnosis to chemotherapy and surgery was 52 ± 34 days and 256 ± 59 days, respectively. For the adjuvant group, median time from diagnosis to surgery and chemotherapy was 24.5 ± 18 days and 94.5 ± 53 days, respectively. Non-English language and older age were associated with increased time to chemotherapy in the adjuvant group (p 0.05). Language and age were not associated with increased time to surgery in both groups. Race, age, comorbidities, and income were not associated with delay in treatment in either groups.Older age and non-English language were associated with prolonged time from surgery to adjuvant chemotherapy. Targeted interventions directed at patient education and decreasing language barriers especially post-operatively may decrease delays in treatment and subsequently reduce disparities seen in the breast cancer population.

Background: Dysregulation of the inflammatory and immune response to injury may increase susceptibility to secondary infections after trauma. It is unknown whether cytokines involved in this respon...

Background Intraoperative ultrasound (IUS) localization for breast cancer is a noninvasive localization technique. In 2015, an IUS program for breast-conserving surgery (BCS) was initiated in a large, integrated health care system. This study evaluated the clinical results of IUS implementation. Methods The study identified breast cancer patients with BCS from 1 January to 31 October 2015 and from 1 January to 31 October 2019. Clinicopathologic characteristics were collected, and localization types were categorized. Clinical outcomes were analyzed, including localization use, surgeon adoption of IUS, day-of-surgery intervals, and re-excision rates. Multivariate logistic regression analysis was performed to evaluate predictors of re-excision. Results The number of BCS procedures increased 23%, from 1815 procedures in 2015 to 2226 procedures in 2019. The IUS rate increased from 4% of lumpectomies (n = 79) in 2015 to 28% of lumpectomies (n = 632) in 2019 (p p p = 0.006), and IUS predicted lower re-excision rates in a multivariable model (odds ratio [OR], 0.59). Conclusions In a high-volume integrated health system, IUS was adopted for BCS by a majority of surgeons. The use of IUS decreased the time from admission to incision compared with wire localization, and decreased re-excision rates compared with other localization techniques.

To determine the positive predictive value (PPV) of magnetic resonance imaging (MRI)-guided breast biopsy stratified by body mass index (BMI). Secondary endpoints include evaluation of indications for breast MRI and identification of factors associated with malignant biopsy. We retrospectively analyzed results of MRI-guided breast biopsies in a consecutive cohort of women at a single institution between 2014 and 2019. The PPV was compared between BMI subgroups and the overall group by the one-sample z-test. Factors associated with malignant biopsy were analyzed using multivariate regression analysis. Among 427 MRI-guided breast biopsies, the PPV was significantly higher in patients with a BMI ≥ 35 compared to BMI

Patients 65 years old or older with early endocrine-responsive breast cancer have many treatment options, including no radiation. This study aimed to evaluate treatment preference when intraoperative radiation therapy (IORT) is offered in this population. The study reviewed patients 65 years old or older with a diagnosis of early-stage endocrine-responsive breast cancer in 2016–2019 at a single hospital in a large integrated health care system. Electronic medical records of multidisciplinary breast tumor board discussion, treatment options documented by the treatment team, and final treatment offered were reviewed. Variables including age at biopsy, language, endocrine treatment, and comorbidities were collected. Regression analysis was used to evaluate for variables associated with patients’ choice regarding radiation treatment. The institutional IORT guidelines were met by 63 patients in the described age group who had a documented offer of all radiation treatment options. The median age of the patients was 70 years (interquartile range 63–77 years). Overall, 74.6% of the patients chose IORT, and 14.3% opted for whole-breast irradiation. Only 4.8% chose to omit radiation after breast-conserving surgery, and 6.3% chose mastectomy. The patients who chose IORT were more likely to receive endocrine treatment (odds ratio 3.70; p = 0.03). Age, race, language, and comorbidities were not associated with preference for IORT (p

Background: The COVID 19 pandemic has disrupted all aspects of healthcare, including the diagnosis and treatment of breast cancer. In March 2020, the Society of Surgical Oncology, the American College of Surgeons, and the American Society of Breast Surgeons issued guidelines regarding the timing of surgery for cancer patients to preserve hospital resources and minimize exposure of patients and staff to COVID 19. Recommendations included delaying breast cancer surgery if possible, and using neoadjuvant chemotherapy or neoadjuvant endocrine therapy to treat selected patients while waiting for definitive surgery. In California, the “shelter in place” (SiP) order began March 17, 2020, and both screening mammography and elective surgeries were stopped in a large, integrated health care system. We evaluated the impact of these operational changes on the presentation and treatment of breast cancer patients in our system.Methods:We performed a retrospective review of patients newly diagnosed between 3/17/20, the starting date of SiP, and 5/18/20, when elective operations resumed in our system. We compared this cohort to patients who were diagnosed between 3/17/19 and 5/18/19. Age, histology, anatomic staging features, grade, receptor status, and initial treatment were compared between the cohorts. For the patients who underwent surgery, we compared the time from biopsy to time to surgery (TTS) and the type of operation. Comparisons involving categorical variables were performed using the chi-square test. Normally-distributed continuous variables were compared using two sample-t-tests. P-values of Citation Format: Sharon B. Chang, Alison C. Savitz, Brooke Vuong, Annie Tang, Margaret Mentakis, Amy M. Miller, Veronica C. Shim, Gillian E. Kuehner. Characterization of breast cancer management during the COVID 19 pandemic in a large integrated healthcare delivery system: Stage at diagnosis and timing/modality of first treatment [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr SS2-06.

The Choosing Wisely campaign has emerged recently in setting guidelines for surgical procedures of low utility and cost-ineffectiveness. Hospitals caring for underserved medical populations represent a unique opportunity to assess for quality of care and adherence to these guidelines. The Choosing Wisely campaign for breast surgery has highlighted: avoiding surgical re-excision for invasive cancer close to margins of excised breast tissue, avoiding double mastectomy in patients who have a single breast with cancer, avoidance of axillary lymph node dissection in women undergoing lumpectomy with limited nodal disease, and avoiding sentinel lymph node biopsy in patients ≥ 70 years of age with early stage breast cancer. Recent studies have shown variable adherence to these recommendations. In order to evaluate cost-effective surgery at our hospital serving a poorer patient population, we retrospectively analyzed patients who underwent surgery for breast cancer from 2015-2020. A total of 231 patients were identified. There were no patients who underwent re-excision for close margins of invasive cancer. Only 0.9% of patients (2/231) received contralateral mastectomy and only 1.6% of eligible patients (3/191) received axillary lymph node dissection instead of sentinel lymph node biopsy. Although 77.7% of patients ≥ 70 years of age with stage 1 hormone positive breast cancer (14/18) received sentinel lymph node biopsy, there was a downward trend during 2015 to 2020 from 100% to 50% of eligible patients receiving sentinel lymph node biopsy. De-implementation of traditional surgical practices, deemed as low-value care, towards newer cost-effective guidelines are achievable even at community hospitals serving a low socioeconomic community while preserving patient outcome and avoiding overtreatment. By avoiding overtreatment, cost savings can be achieved which allow for social distributive justice amongst breast cancer patients by ensuring careful utilization of scarce health economic resources. Citation Format: Annie Tang, Colin Mooney, Shannon Ugarte, Kevin Knopf, Amal Khoury. High compliance with choosing wisely breast procedures at a safety net hospital [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS9-56.

Background Subtotal cholecystectomy is a “damage control” or “bailout procedure” that is used in difficult gallbladder cases when severe inflammation distorts the local anatomy resulting in increased risk in damage to surrounding structures. Subtotal cholecystectomy rates increased nationally over the past decade. We aimed to determine provider experience and patient factors associated with the performance of subtotal cholecystectomies. Methods All cholecystectomies from 2016 to 2019 were reviewed. Patient demographics, laboratory values, imaging, preoperative diagnosis, surgical technique (fenestrating vs. reconstituting), and years of attending and resident experience were collected. Multivariable regression analysis was performed to evaluate for factors that increase the likelihood of subtotal cholecystectomy. Results Of 916 cholecystectomies, 86 were subtotal. The likelihood of subtotal cholecystectomy did not increase based on attending experience of ≤5 vs. > 5 years (odds ratio (OR) .66, P = .09). Older age (adjusted odds ratio (aOR) 1.23, P = .03), male sex (aOR 2.59, P < .01), white blood cells (WBC) above 10.3 (aOR 2.02, P = .02), and preoperative diagnosis of acute on chronic cholecystitis (aOR 5.47, P < .01) were associated with increased likelihood of subtotal cholecystectomy. Discussion Older age, male sex, WBC above 10.3, and preoperative diagnosis of acute on chronic cholecystitis were associated with the increased likelihood of subtotal cholecystectomies. The performance of subtotal cholecystectomy was not impacted by attending years of experience. In cases of severe gallbladder pathology, this technique is being used as an operative strategy among all surgeon levels.

Reexcision after breast-conserving surgery (BCS) is costly for patients, but few studies have captured the economic burden to a healthcare system. We quantified operating room (OR) charges as well as OR time and then modeled expected savings of a reexcision reduction initiative.We performed a retrospective cohort review of all breast cancer patients with BCS between January 1, 2016 and December 31, 2020. Operating room charges of disposable supplies and implants as well as operative time were calculated.During the 5-year period, the 8804 patients who underwent BCS, 1628 (18.5%) required reexcision. The reexcision cohort was younger (61 vs. 64 years, p0.001), more likely to have ductal carcinoma in situ (DCIS) (23.7% vs. 15.2%, p0.001), and had larger tumors (T1+T2 73.2% vs. 83.1%, p0.001). Reexcision costs represented 39% of total costs, the cost per patient for surgery was fourfold higher for reexcision patients. Reexcision operations comprised 14% of total operating room (OR) time (1848 of 13,030 hours). The reexcision rate for 54 surgeons varied from 7.2-39.0% with 46% (n = 25) having a reexcision rate20%. A model simulating reducing reexcision rates to 20% or below for all surgeons reduced the reexcision rate to 16.2% overall. Using per procedure data, the model predicted a decrease in reexcision operations by 18% (327 operations), OR costs by 14% ($287,534), and OR time by 11% (204 hours).Reexcision after BCS represents 39% of direct OR costs and 14% of OR time in our healthcare system. Modest improvements in surgeon reexcision rates may lead to significant economic and OR time savings.

Background Granulomatous mastitis (GM) is a rare entity of benign origin. Multiple treatment strategies, including surgical procedures, can have sequelae of recurrence, nonhealing wounds, and protracted pain. Even after GM is diagnosed, the best management strategy remains controversial. We sought to evaluate intralesional steroid injection as a potential treatment for GM. Materials and methods Electronic medical records from 2003 to 2017 of patients diagnosed with benign breast lesions were retrospectively reviewed. Patients with pathologically confirmed GM were identified. All treatment methods were documented, which included observation, oral steroids, methotrexate, steroid injection, and surgical excision. Primary outcome was time to resolution. Effectiveness was based on relief of symptoms along with duration of symptoms from initial time of diagnosis to full relief. Analysis of variance was used to compare outcomes between groups. Results Of the 49 patients with confirmed GM diagnoses, 57% had observation only, 24% had steroid injection, and 19% had surgical resection. The average time to resolution differed significantly among the three groups (11.5 mo from the start of observation, 2.0 mo from the time of steroid injection, and 0.5 mo from the time of surgical excision, P Conclusions Intralesional steroid injection is an effective treatment of GM. Selective management is appropriate for patients with GM, and surgical resection is not required for most patients.

Evidence-based treatments for posttraumatic stress disorder (PTSD) are available for veterans, but many do not benefit due to low treatment engagement. This may be partially due to avoidance behaviors characteristic of individuals with PTSD. Acceptance and Commitment Therapy (ACT) is a transdiagnostic treatment approach that aims to reduce avoidance. The authors propose the use of adjunctive ACT techniques to enhance engagement with treatment for PTSD. ACT techniques such as cognitive defusion and values clarification have been shown to promote engagement with other cognitive-behavioral treatments, but no studies to date have examined these techniques as adjuncts to treatment for PTSD. Because of its focus on reducing avoidance, ACT is uniquely suited for promoting treatment engagement with the “gold standard” treatments for PTSD. The authors review the existing research on ACT as an adjunctive intervention, discuss specific concepts and techniques from ACT that are relevant to PTSD, and provide recommendations for future research.

Conscientious use of scarce health economic resources allows for social distributive justice by avoiding over-treatment of patients to allow for appropriate treatment for a broader patient population. Lower socioeconomic status patients with breast cancer have a worse outcome compared to higher socioeconomic status patients in the United States. In part, this is due to poor access to medical care and a failure of logistical care. We implemented a community based breast cancer multidisciplinary program with weekly meetings to discuss patients, coordinate care, and provide cost-effective care to a medically under-served and vulnerable patient population. Breast surgery and medical oncology providers saw patients together in a co-located space and expedited timely initiation of neoadjuvant and adjuvant chemotherapy / hormone therapy for appropriate patients. The conjoint clinic allowed for rapid temporal integration of care in our safety net hospital / community. A single breast cancer navigator provided rapid identification of patients, coordination through clinics, and assistance with social work and other needs. Weekly 30 minute discussion sessions reviewing all new and relevant follow up patient issues were implemented in lieu of a breast cancer tumor board for efficiency. The relevant published clinical literature was reviewed on an ongoing basis. Cost-effective care was obtained by implementing: 1) avoidance of post lumpectomy radiation for selected patients based on PRIME2 trial results, 2) judicious use of post-mastectomy radiation based on a careful re-analysis of the data, 3) avoidance of adjuvant/neoadjuvant Perjeta in HER2+ patients based on a lack of overall survival, 4) adoption of 6 month schedule of adjuvant Herceptin, 5) avoidance of excessive imaging by following NCCN guidelines and clinical judgment, 6) limiting dose dense chemotherapy to appropriate patients (ER- high risk node negative or node positive), and 7) No Nernyx. Using a cost-effectiveness analysis methodology, we are reviewing costs, effectiveness of interventions, and risks with outcomes measured from side effects, complications, recurrence, and mortality. The improvement in temporal parameters and economic endpoints are being currently monitored retrospectively and prospectively and will be presented. Citation Format: Annie Tang, Shannon Ugarte, Rohan John, Amal Khoury, Kevin Knopf. Cost-effective care for newly diagnosed breast cancer patients: Think globally, act locally [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-13-07.

Purpose We assessed the efficacy of a multidisciplinary, patient-focused approach emphasizing appropriate use of medical resources among a population of breast cancer patients at our safety-net hospital. Methods A multidisciplinary program coordinated and provided value-based care. Surgery, oncology, and navigation were physically co-located. Real time decisions were made by medical and surgical oncologists. Focused institution-specific protocols initiated in 2018, advised against four specific cancer resources that our team had determined as lower-value: imaging tests for indications not recommended in NCCN guidelines, inappropriate Oncotype Dx testing, radiation for patients ≥65 years with stage I hormone-positive disease, and administration of pertuzumab and neratinib as adjuvant therapy in HER2+ breast cancer patients. Time to treatment and rates of use of these resources were monitored. Results Newly diagnosed breast cancer patients from 2015-2019 were compared to the pre-protocol era (2015-2017). Time from first breast clinic visit to oncology appointment decreased 39 days (60% decrease, median of 63.0 vs 22.5 days, p Conclusions After initiating a breast cancer program focused on reducing rates of use of four commonly excessively ordered breast cancer resources our team identified as lower-value, care at our safety-net hospital achieved high compliance with NCCN maging guidelines and also reduced use of a low-value diagnostic test, and low-value radiation and chemotherapy.

Guidelines for penetrating occult pneumothoraces (OPTXs) are based on blunt injury. Further understanding of penetrating OPTX pathophysiology is needed. In observational management of penetrating OPTX, we hypothesized that specific clinical and radiographic features may be associated with interval tube thoracostomy (TT) placement. Our aims were to (1) describe OPTX occurrence in penetrating chest injury, (2) determine the rate of interval TT placement in observational management and clinical outcomes compared with immediate TT placement, and (3) describe risk factors associated with failure of observational management.Penetrating OPTX patients presenting to our level 1 trauma center from 2004 to 2019 were reviewed. Occult pneumothorax was defined as a pneumothorax on chest computed tomography but not on chest radiograph. Patient groups included immediate TT placement versus observation. Clinical outcomes compared were TT duration and complications, need for additional thoracic procedures, length of stay (LOS), and disposition. Clinical and radiographic factors associated with interval TT placement were determined by multivariable regression.Of 629 penetrating pneumothorax patients, 103 (16%) presented with OPTX. Thirty-eight patients underwent immediate TT placement, and 65 were observed. Twelve observed patients (18%) needed interval TT placement. Regardless of initial management strategy, TT placement was associated with longer LOS and more chest radiographs. Chest injury complications and outcomes were similar. Factors associated with increased odds of interval TT placement included Chest Abbreviated Injury Scale score of ≥4 (adjusted odds ratio [aOR], 7.38 [95% confidence interval, 1.43-37.95), positive pressure ventilation (aOR, 7.74 [1.07-56.06]), concurrent hemothorax (aOR, 6.17 [1.08-35.24]), and retained bullet fragment (aOR, 11.62 [1.40-96.62]) (all p0.05).The majority of patients with penetrating OPTX can be successfully observed with improved clinical outcomes (LOS, avoidance of TT complications, reduced radiation). Interval TT intervention was not associated with risk for adverse outcomes. In patients undergoing observation, specific clinical factors (chest injury severity, ventilation) and imaging features (hemothorax, retained bullet) are associated with increased odds for interval TT placement, suggesting need for heightened awareness in these patients.Prognostic, level IV.

Background/aim We evaluated timeliness of care at a safety-net hospital after implementation of a multidisciplinary breast program. Patients and methods A prospective database of patients with breast cancer was created after multidisciplinary breast program initiation in 2018. Patients were tracked to obtain time to completion of diagnostic imaging, biopsy, and treatment initiation. Patients with breast cancer diagnosed from 2015-2017 were reviewed for comparison. Results A total of 102 patients were identified. There was no statistical difference in time to completion of imaging, biopsy, and initial treatment between the 2018 and the 2015-2017 cohorts (p>0.05). No statistical difference was observed in time to completion of imaging, biopsy, and initial treatment between different races (p>0.05). Conclusion Within the same socioeconomic status, there was no differential delivery of screening, work-up, and treatment by race. Despite protocol implementations, efficiency of care remained limited in a safety-net hospital with lack of financial resources.

Background Obesity can often be a barrier to gender-affirming top surgery in transmasculine patients because of concern for increased surgical site complications. Study design All adult patients (N = 948) within an integrated health care system who underwent gender-affirming mastectomy from 2013 to 2018 were retrospectively reviewed to evaluate the relationship between obesity and surgical site complications or revisions. Results One third of patients (n = 295) had obese body mass index (BMI), and those patients were further stratified into obesity class I (BMI of 30-34.9 kg/m2, 9.4%), class II (BMI of 35-39.9 kg/m2, 8.9%), and class III (BMI of ≥40 kg/m2, 2.9%). A majority of patients across BMI categories underwent double incision surgery. There were no significant differences in complications or revisions between patients with obesity versus those with normal BMI, when BMI was treated as a categorical or continuous variable and when evaluating only patients who underwent double incision surgery. Conclusions Obesity alone should not be considered a contraindication for gender-affirming mastectomy. Attention should be given to several modifiable risk factors identified in this study, including lesser incision surgical techniques, tobacco use, and testosterone use. Further research is needed to understand risks associated with the highest BMI (≥40 kg/m2) patients and to assess patient satisfaction with surgical outcome.

To determine the positive predictive value (PPV) of magnetic resonance imaging (MRI)-guided breast biopsy stratified by body mass index (BMI). Secondary endpoints include evaluation of indications for breast MRI and identification of factors associated with malignant biopsy.We retrospectively analyzed results of MRI-guided breast biopsies in a consecutive cohort of women at a single institution between 2014 and 2019. The PPV was compared between BMI subgroups and the overall group by the one-sample z-test. Factors associated with malignant biopsy were analyzed using multivariate regression analysis.Among 427 MRI-guided breast biopsies, the PPV was significantly higher in patients with a BMI ≥ 35 compared to BMI 35 (38.6% versus 24.5%, p = 0.043). This remained true in the 180 biopsies from high-risk screening studies, but there was no difference in PPV by BMI in the 205 biopsies performed to evaluate extent of known disease. Among this cohort who underwent MRI-guided breast biopsy, the underlying indication for MRI was less likely to be high-risk screening in those with a higher BMI or Black or Hispanic race (p = 0.015 and p 0.001, respectively). For high-risk screening studies, only BMI ≥ 35 was associated with malignant biopsies (OR 37.5, p = 0.003). For evaluation of extent of disease studies, only increased lesion size was a significant predictor of malignant result (OR 1.01, p = 0.04).Among women who underwent MRI-guided breast biopsy, elevated BMI was associated with increased PPV and malignant biopsies. Patients with a higher BMI or Black or Hispanic race who had MRI-guided biopsy were less likely to be undergoing high-risk screening and more likely to have breast MRI to evaluate extent of known disease.

Patients 65 years old or older with early endocrine-responsive breast cancer have many treatment options, including no radiation. This study aimed to evaluate treatment preference when intraoperative radiation therapy (IORT) is offered in this population.The study reviewed patients 65 years old or older with a diagnosis of early-stage endocrine-responsive breast cancer in 2016-2019 at a single hospital in a large integrated health care system. Electronic medical records of multidisciplinary breast tumor board discussion, treatment options documented by the treatment team, and final treatment offered were reviewed. Variables including age at biopsy, language, endocrine treatment, and comorbidities were collected. Regression analysis was used to evaluate for variables associated with patients' choice regarding radiation treatment.The institutional IORT guidelines were met by 63 patients in the described age group who had a documented offer of all radiation treatment options. The median age of the patients was 70 years (interquartile range 63-77 years). Overall, 74.6% of the patients chose IORT, and 14.3% opted for whole-breast irradiation. Only 4.8% chose to omit radiation after breast-conserving surgery, and 6.3% chose mastectomy. The patients who chose IORT were more likely to receive endocrine treatment (odds ratio 3.70; p = 0.03). Age, race, language, and comorbidities were not associated with preference for IORT (p 0.05).Patients 65 years old or older with early-stage endocrine-responsive breast cancer preferred to have IORT despite counsel about the lack of survival benefit. This study suggests that local cancer control with the convenient radiation delivery method is important to the described patient population.

Background Following placement of tube thoracostomy (TT) for evacuation of traumatic hemopneumothorax (HPTX), controversy persists over the need for routine post-TT removal chest radiograph (CXR). Current research demonstrates routine CXR may offer no advantage over clinical observation alone while simultaneously increasing hospital resource utilization. As such, we hypothesized that in resolved traumatic HPTXs routine post-TT removal CXR to assess recurrent PTX compared to clinical observation is not cost-effective. Methods We performed a decision-analytic model to evaluate the cost-effectiveness of routine CXR compared to clinical observation following TT removal. Our base case was a patient that sustained thoracic trauma with radiographic and clinical resolution of HPTX following TT evacuation. Cost, utility and probability estimates were generated from published literature, with costs represented in 2019 US dollars and utilities in Quality-Adjusted Life Years (QALYs). Deterministic and probabilistic sensitivity analyses were performed. Results Decision-analytic model identified that clinical observation after TT removal was the dominant strategy with increased benefit at less cost, when compared to routine CXR, with a net cost of $194.92, QALYs of 0.44. In comparison, routine CXR demonstrated an increase of $821.42 in cost with 0.43 QALYs. On probabilistic sensitivity analysis the clinical observation strategy was found cost-effective in 99.5% of 10,000 iterations. Conclusion In trauma patients with clinical and radiographic evidence of a resolved HPTX, the adoption of clinical observation in lieu of post-TT removal CXR is cost-effective. Routine CXR following TT removal accrues more cost without additional benefit. The practice of routinely obtaining a CXR following TT removal should be scrutinized.

Traumatic pulmonary pseudocysts (TPPs) are under-reported in blunt trauma and rarely reported in penetrating trauma. Little is known about the impact of injury mechanism on the pathophysiology or the risk factors that predispose to worse patient outcomes. We hypothesized that blunt and penetrating TPPs have different clinical characteristics and outcomes.Computed tomography imaging was evaluated for patients presenting at a level 1 trauma center with confirmed TPP from 2011 to 2018. Diameter was determined by largest dimension of the dominant TPP. Clinical variables and TPP features were compared for blunt versus penetrating trauma by using comparative statistics and multivariable analysis.e RESULTS: A total of 101 TPP patients were identified (blunt = 64; penetrating = 37). In penetrating TPP, rates of concomitant pulmonary laceration, hemothorax, and pneumothorax, were, respectively, 4.5, 3.1, and 1.4 times higher than for blunt TPP. Concomitant rib fracture was twice as common in blunt TPP as in penetrating TPP (69% versus 32%). For penetrating injury, the risk of complications related to TPP was increased (aOR = 5.3), specifically persistent/recurrent pneumothorax (aOR = 10.4). All deaths resulted from pulmonary hemorrhage (blunt = 3, penetrating = 2). Regardless of mechanism, air-fluid level and hemoptysis correlated with death (p 0.02) and all patients with hemoptysis required pulmonary intervention (p = 0.0001).Penetrating TPPs demonstrate a unique pattern of concurrent lung injury and increased complication risk. Importantly, severe hemoptysis and air-fluid level may indicate risk of impending morbidity and mortality regardless of injury mechanism and should serve as an early warning sign for the trauma physician.

Background Rapid deceleration against a seat belt during a motor vehicle collision (MVC) may result in an abdominal seat belt sign (ASBS), which is associated with a higher risk of hollow viscus injury (HVI). After a negative abdominal CT scan, management of patients with ASBS is variable, but recent evidence suggests emergency department (ED) discharge may be safe. Therefore, we hypothesized that discharge from the ED is cost-effective compared with 23-h observation or hospital admission for patients with ASBS and a negative CT. Methods A cost-utility model was developed for an evaluable patient with ASBS and negative CT scan using TreeAge software. ED discharge was compared with 23-h observation and admission. Analysis was from a health care–based third-party payer perspective. Quality-adjusted life years (QALYs) were based on 3-y expected outcomes. Probability and costs were estimated from published literature and the Healthcare Cost and Utilization Project. Results In our base case, ED discharge was the most cost-effective strategy, yielding a cost of $706 with 2.86 QALYs. The average costs of 23-h observation and hospital admission were $2600 and $8,827, respectively, with 2.87 QALYs gained each. The strategy of ED observation becomes cost-effective when the rate of HVI after ED discharge exceeds 2.3%. In a Monte Carlo simulation, ED discharge was the optimal strategy in 91% of 1000 trials of the model. Conclusions ED discharge is a cost-effective strategy for evaluable patients with ASBS and a negative abdominal CT and remains so when the risk of HVI after ED discharge is higher than currently assumed.

The conventional D-dimer cut-off value of at least 500 μg FEU/l has good sensitivity but poor specificity for identifying pulmonary embolism. An elevated age-adjusted D-dimer value (age in years × 10 μg FEU/l) for patients at least 50 years old has been recommended as a better cut-off with adequate sensitivity and improved specificity for identifying pulmonary embolism compared with the conventional value. We retrospectively reviewed 3117 patient encounters in which a D-dimer was ordered. The D-dimer value, age of the patient, and the computed tomography radiology report was evaluated. The sensitivity and specificity of the age-adjusted D-dimer was calculated using bootstrapping. With an assumed 99% sensitivity for the conventional D-dimer cut-off the specificity was 39.2% [95% confidence interval (CI): 37.5-41.0%]. The sensitivity of the age-adjusted D-dimer was 91.8% (95% CI: 83.8-97.2%) with a specificity of 51.0% (95% CI: 49.1-53.1%). The sensitivity of the age-adjusted D-dimer was unacceptably low compared with the conventional D-dimer cut-off.

e12612 Background: Patients over 65 years of age with early-stage hormone receptor (HR)-positive breast cancer have many radiation treatment options based on the PRIME II and CALGB 9343. Our study aims to evaluate treatment preference of patients over 65 years of age when intraoperative radiation therapy (IORT) is offered. Methods: A retrospective chart review was conducted among patients over 65 years old diagnosed with early-stage HR-positive breast cancer during 2016-2019 in a single breast program in a large integrated healthcare system. At our institution, every breast cancer patient is reviewed at a weekly multi-disciplinary breast conference for IORT eligibility and tracked prospectively. All patients in this study met with breast surgeons and radiation oncologists prior to their locoregional treatment decisions. We identified patients who were offered IORT as an option. The tumor board discussion, treatment team recommendation, and the final patient decision for radiation were obtained from the chart review. Demographics including age, race, hormone therapy, and co-morbidities (Charlson Comorbidity Index) were collected. Logistic regression analysis was used to evaluate if any factors were associated with patients’ radiation treatment choice. Results: Among 225 patients who were over 65 with early endocrine responsive breast cancer, 63 patients met the IORT guideline (28%). Their ages ranged from 65-86 with a mean of 70.4 years. 74.6% of patients chose IORT compared with 14.3% who opted for whole breast radiation. Only 4.8% of patients chose to omit radiation after breast-conserving surgery, and 6.3% chose mastectomy. Patients who chose IORT was also more likely to take endocrine treatment (OR 4.76 CI 1.42-16.0, p = 0.01). Age, race, and co-morbidities were not associated with preference for IORT (OR 0.95 p = 0.34, OR 1.09 p 0.92, and OR 1.15 p = 0.53, respectively). Conclusions: Early-stage breast cancer patients over age 65 with HR-positive disease overwhelmingly desired radiation treatment even after being counseled that it does not confer an overall survival benefit. IORT was strongly preferred over whole breast radiation. This finding indicates that these women choose to maximize their local cancer control, regardless of its impact on overall survival, and prefer the convenience of single fraction, integrated radiation delivery. Further studies need to be completed on patient reported outcomes in this study population.

Perfusion is an important biomarker of tissue function and has been associated with tumor pathophysiology such as angiogenesis and hypoxia. Arterial spin labeling (ASL) MRI allows noninvasive and quantitative imaging of perfusion; however, the application in mouse xenograft tumor models has been challenging due to the low sensitivity and high perfusion heterogeneity. In this study, flow-sensitive alternating inversion recovery (FAIR) ASL was optimized for a mouse xenograft tumor. To assess the sensitivity and reliability for measuring low perfusion, the lumbar muscle was used as a reference region. By optimizing the number of averages and inversion times, muscle perfusion as low as 32.4 ± 4.8 (mean ± standard deviation) ml/100 g/min could be measured in 20 min at 7 T with a quantification error of 14.4 ± 9.1%. Applying the optimized protocol, heterogeneous perfusion ranging from 49.5 to 211.2 ml/100 g/min in a renal carcinoma was observed. To understand the relationship with tumor pathology, global and regional tumor perfusion was compared with histological staining of blood vessels (CD34), hypoxia (CAIX) and apoptosis (TUNEL). No correlation was observed when the global tumor perfusion was compared with these pathological parameters. Regional analysis shows that areas of high perfusion had low microvessel density, which was due to larger vessel area compared with areas of low perfusion. Nonetheless, these were not correlated with hypoxia or apoptosis. The results suggest that tumor perfusion may reflect certain aspect of angiogenesis, but its relationship with other pathologies needs further investigation.

A capillary electrophoresis-based method for quantitation of total salicylic acid levels in Arabidopsis leaves was developed. Direct comparison to previous high-performance liquid chromatography (HPLC)-based measurements showed similar levels of salicylic acid. Simultaneous quantitation of trans-cinnamic acid, benzoic acid, sinapic acid, and an internal recovery standard was achieved. A rapid, streamlined protocol with requirements for plant tissue reduced relative to those of HPLC-based protocols is presented. Complicated, multiparameter experiments were thus possible despite the labor-intensive nature of inoculating plants with bacterial pathogens. As an example of this sort of experiment, detailed time course studies of total salicylic acid accumulation by wild-type Arabidopsis and two lines with mutations affecting salicylic acid accumulation in response to either of two avirulent bacterial strains were performed. Accumulation in the first 12 h was biphasic. The first phase was partially SID2 and NDR1 dependent with both bacterial strains. The second phase was largely independent of both genes with bacteria carrying avrB, but dependent upon both genes with bacteria carrying avrRpt2. Virulent bacteria did not elicit salicylic acid accumulation at these time points. Application of this method to various Arabidopsis pathosystems and the wealth of available disease resistance signaling mutants will refine knowledge of disease resistance and associated signal transduction.

Perfusion is an important biomarker of tissue function and has been associated with tumor pathophysiology such as angiogenesis and hypoxia. Arterial spin labeling (ASL) MRI allows noninvasive and quantitative imaging of perfusion; however, the application in mouse xenograft tumor models has been challenging due to the low sensitivity and high perfusion heterogeneity. In this study, flow-sensitive alternating inversion recovery (FAIR) ASL was optimized for a mouse xenograft tumor. To assess the sensitivity and reliability for measuring low perfusion, the lumbar muscle was used as a reference region. By optimizing the number of averages and inversion times, muscle perfusion as low as 32.4 ± 4.8 (mean ± standard deviation) ml/100 g/min could be measured in 20 min at 7 T with a quantification error of 14.4 ± 9.1%. Applying the optimized protocol, heterogeneous perfusion ranging from 49.5 to 211.2 ml/100 g/min in a renal carcinoma was observed. To understand the relationship with tumor pathology, global and regional tumor perfusion was compared with histological staining of blood vessels (CD34), hypoxia (CAIX) and apoptosis (TUNEL). No correlation was observed when the global tumor perfusion was compared with these pathological parameters. Regional analysis shows that areas of high perfusion had low microvessel density, which was due to larger vessel area compared with areas of low perfusion. Nonetheless, these were not correlated with hypoxia or apoptosis. The results suggest that tumor perfusion may reflect certain aspect of angiogenesis, but its relationship with other pathologies needs further investigation.

Hepatocytes isolated from male Fisher 344VF rats were cultured on two substrates, collagen I and a lactose-derivatized polystyrene (PS-lactose), to compare morphological and functional differences. Hepatocyte morphology changed dramatically depending upon the substrate, shown through actin cytoskeletal staining and scanning electron microscopy. Functional assays performed included albumin secretion, reduced glutathione content, UDP-glucuronosyl transferase, and cytochrome P4501A1 activity. The presence of dexamethasone and dimethylsulfoxide (DMSO) in the media was required for the maintenance of several differentiated functions for cells cultured on collagen. In general, cells cultured on the PS-lactose substrate showed a much slower loss of function over the same period of time. The maintenance of differentiated function of cells on PS-lactose was enhanced with the addition of dexamethasone and DMSO. This is the first report of a culture system in which hepatocytes, cultured on a polymer substrate without additional protein coatings or media additives, have been able to maintain differentiated functions for up to 1 week. (c) 1996 John Wiley & Sons, Inc.