BACKGROUND:Pain management following mastectomy is a significant challenge often requiring opioids. Nonopioid pain management utilizing nerve blocks has been shown in other fields to reduce postoperative opioid use and may be effective for postoperative pain in mastectomy patients. The primary purpose of this study was to compare postoperative opioid use, measured in morphine milligram equivalents (MME), between mastectomy patients who underwent interpectoral nerve block (IPNB) and a historical control group. Secondary outcomes included length of stay (LOS) and postoperative pain scores. METHODS:This is a single-center, retrospective cohort study. The charts of women who underwent mastectomy for cancer without immediate reconstruction from 10/2017-12/2019 were reviewed. Wilcoxon rank sum test was used for unadjusted analysis and multiple linear regression for adjusted analysis. RESULTS:There were 105 patients included in this study, of which 37 (35%) underwent IPNB. In unadjusted analysis, median MME use was significantly lower in patients that received IPNB compared to the control group (IPNB = 5, controls = 17, p = 0.03). Patients that received IPNB had an observed reduction in LOS and postoperative pain, though these results failed to reach statistical significance. There were no IPNB-related complications. CONCLUSIONS:IPNB may be an effective strategy to decrease postoperative opioid use in mastectomy patients. Larger, prospective studies are needed to further investigate the effectiveness of IPNB.

BACKGROUND:Poor personal financial health has been linked to key components of health including burnout, substance abuse, and worsening personal relationships. Understanding the state of resident financial health is key to improving their overall well-being. STUDY DESIGN:A secondary analysis of a survey of New England general surgery residents was performed to understand their financial well-being. Questions from the National Financial Capability Study were used to compare to an age-matched and regionally matched cohort. RESULTS:Overall, 44% (250 of 570) of surveyed residents responded. Residents more frequently reported spending less than their income each year compared to the control cohort (54% vs 34%, p < 0.01). However, 17% (39 of 234) of residents reported spending more than their income each year. A total of 65% of residents (152 of 234), found it "not at all difficult" to pay monthly bills vs 17% (76 of 445) of the control cohort (p < 0.01). However, 32% (75 of 234) of residents reported it was "somewhat" or "very" difficult to pay monthly bills. Residents more frequently reported they "certainly" or "probably" could "come up with" $2,000 in a month compared to the control cohort (85% vs 62% p < 0.01), but 16% (37 of 234) of residents reported they could not. In this survey, 21% (50 of 234) of residents reported having a personal life insurance policy, 25% (59 of 234) had disability insurance, 6% (15 of 234) had a will, and 27% (63 of 234) had >$300,000 worth of student loans. CONCLUSIONS:Surgical residents have better financial well-being than an age-matched and regionally matched cohort, but there is still a large proportion who suffer from financial difficulties.

BACKGROUND:The COVID-19 pandemic altered access to healthcare by decreasing the number of patients able to receive preventative care and cancer screening. We hypothesized that, given these changes in access to care, radiologic screening for breast and lung cancer would be decreased, and patients with these cancers would consequently present at later stages of their disease.STUDY DESIGN:This is a retrospective cross-sectional study of 2017 to September 2021 UMass Memorial Tumor Registry data for adult breast and lung cancer patients. Changes in stage at presentation of breast and lung cancer during the COVID-19 pandemic were measured, defined as before and during COVID-19.RESULTS:There were no statistically significant changes in the overall stage of presentation before or during the COVID-19 pandemic for either breast or lung cancer patients. Analysis of case presentation and stage during periods of COVID-19 surges that occurred during the time of this study compared with prepandemic data demonstrated a statistically significant decrease in overall presentation of breast cancer patients in the first surge, with no other statistically significant changes in breast cancer presentation. A nonstatistically significant decrease in lung cancer presentation was seen during the initial surge of COVID-19. There was also a statistically significant increase in early-stage presentation of lung cancer during the second and third COVID-19 surges.CONCLUSIONS:In the 2 years after the COVID-19 pandemic, we were not able to demonstrate stage migration at presentation of breast and lung cancer patients to later stages despite decreases in overall presentation during the initial 2 years of the COVID pandemic. An increase in early-stage lung cancer during the second and third surges is interesting and could be related to increased chest imaging for COVID pneumonia.

BACKGROUND: Surgical culture has shifted to recognize the importance of resident well-being. This is the first study to longitudinally track regional surgical resident well-being over 5 years. STUDY DESIGN: An anonymous cross-sectional, multi-institutional survey of New England general surgery residents using novel and published instruments to create three domains: health maintenance, burnout, and work environment. RESULTS: Overall, 75% (15 of 20) of programs participated. The response rate was 44% (250 of 570), and 53% (133 of 250) were women, 94% (234 of 250) were 25 to 34 years old, and 71% (178 of 250) were in a relationship. For health maintenance, 57% (143 of 250) reported having a primary care provider, 26% (64 of 250) had not seen a primary care provider in 2 years, and 59% (147 of 250) endorsed being up to date with age-appropriate health screening, but only 44% (109 of 250) were found to actually be up to date. Only 14% (35 of 250) reported exercising more than 150 minutes/week. The burnout rate was 19% (47 of 250), with 32% (81 of 250) and 25% (63 of 250) reporting high levels of emotional exhaustion and depersonalization, respectively. For program directors and attendings, 90% of residents reported that they cared about resident well-being. Eighty-seven percent of residents believed that it was acceptable to take time off during the workday for a personal appointment, but only 49% reported that they would personally take the time. CONCLUSIONS: The personal health maintenance of general surgery residents has changed little over the past five years, despite an overwhelming majority of residents reporting that attendings and program directors care about their well-being. Further study is needed to understand the barriers to improvement of resident wellbeing.

We acknowledge the unfortunate consequences that U.K. medical students experienced due to COVID-19 pandemic–related early graduations. We believe that the structural differences in the U.S. medical education system may account for the contrasting U.K. experience. At the University of Massachusetts Medical School, fourth-year medical students rarely complete required clinical experiences in the 2 months before graduation. Most use this time for nonclinical requirements, electives that augment clinical exposure, or personal needs before beginning residency training. Our students front-load their fourth-year required clinical experiences from the prior May through October, completing a few final rotations January through March. Consequently, nearly all of our fourth-year medical students had completed traditional requirements at the time of their early graduation and seemed prepared to join frontline workers as limited-licensed physicians called surge contractors. To address concerns of early graduates having low confidence in entering the workforce, such as those expressed by Ramotshwana and colleagues, we solicited structured feedback after the 90-day term ended. The majority of both surge contractors and supervising physicians indicated surge contractors had the appropriate level of supervision, emotional support, and preparation to deal with the challenges of COVID-19 patients. Overall, both supervising physicians and early-graduate surge contractors found their experience positive, and the surge contractors practiced skills, particularly end-of-life discussions, that they will carry into future patient encounters. This experience highlighted the dedication, compassion, and commitment of the medical students in the class of 2020. The early graduates demonstrated readiness and a willingness to serve, with appropriate assignment and supervision, at a time when their contributions were both impactful and appreciated. Although we hope that this decision does not need to be made in the future, we are confident that our curriculum and training structure will prepare our student doctors well should the need for an early graduation arise again.

The Breast JournalVolume 27, Issue 9 p. 737-738 COMMENTARY A single-institution analysis of reflector-guided localization using SAVI SCOUT® in nonpalpable breast carcinoma compared to traditional wire localization Nicholas Bercovici DO, Nicholas Bercovici DO orcid.org/0000-0001-6581-4150 Departments of Pathology, Surgery, and Radiology, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, Massachusetts, USASearch for more papers by this authorVladislav Makarenko MD, Vladislav Makarenko MD Departments of Pathology, Surgery, and Radiology, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, Massachusetts, USASearch for more papers by this authorGopal Vijayaraghavan MD, Gopal Vijayaraghavan MD Departments of Pathology, Surgery, and Radiology, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, Massachusetts, USASearch for more papers by this authorAnne Larkin MD, Anne Larkin MD Departments of Pathology, Surgery, and Radiology, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, Massachusetts, USASearch for more papers by this authorJennifer Lafemina MD, Jennifer Lafemina MD Departments of Pathology, Surgery, and Radiology, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, Massachusetts, USASearch for more papers by this authorJennifer Clark MD, Jennifer Clark MD Departments of Pathology, Surgery, and Radiology, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, Massachusetts, USASearch for more papers by this authorDina Kandil MD, Corresponding Author Dina Kandil MD [email protected] Departments of Pathology, Surgery, and Radiology, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, Massachusetts, USA Correspondence Dina Kandil, Department of Pathology, UMass Memorial Medical Center, University of Massachusetts Medical School, Biotech 3, 1 Innovation Dr, Worcester, MA 01605, USA. Email: [email protected]Search for more papers by this author Nicholas Bercovici DO, Nicholas Bercovici DO orcid.org/0000-0001-6581-4150 Departments of Pathology, Surgery, and Radiology, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, Massachusetts, USASearch for more papers by this authorVladislav Makarenko MD, Vladislav Makarenko MD Departments of Pathology, Surgery, and Radiology, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, Massachusetts, USASearch for more papers by this authorGopal Vijayaraghavan MD, Gopal Vijayaraghavan MD Departments of Pathology, Surgery, and Radiology, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, Massachusetts, USASearch for more papers by this authorAnne Larkin MD, Anne Larkin MD Departments of Pathology, Surgery, and Radiology, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, Massachusetts, USASearch for more papers by this authorJennifer Lafemina MD, Jennifer Lafemina MD Departments of Pathology, Surgery, and Radiology, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, Massachusetts, USASearch for more papers by this authorJennifer Clark MD, Jennifer Clark MD Departments of Pathology, Surgery, and Radiology, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, Massachusetts, USASearch for more papers by this authorDina Kandil MD, Corresponding Author Dina Kandil MD [email protected] Departments of Pathology, Surgery, and Radiology, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, Massachusetts, USA Correspondence Dina Kandil, Department of Pathology, UMass Memorial Medical Center, University of Massachusetts Medical School, Biotech 3, 1 Innovation Dr, Worcester, MA 01605, USA. Email: [email protected]Search for more papers by this author First published: 24 June 2021 https://doi.org/10.1111/tbj.14243Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume27, Issue9September 2021Pages 737-738 RelatedInformation

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The COVID-19 pandemic has presented unprecedented challenges and opportunities for medical schools in the United States. In this Invited Commentary, the authors describe a unique collaboration between the University of Massachusetts Medical School (UMMS), the only public medical school in the state; the University of Massachusetts Memorial Medical Center (UMMMC); and the Commonwealth of Massachusetts. Through this partnership, UMMS was able to graduate fourth-year medical students 2 months early and deploy them to UMMMC to care for patients and alleviate workforce shortages during the COVID-19 surge, which peaked in Massachusetts in April 2020. The authors describe how they determined if students had fulfilled graduation requirements to graduate early, what commencement and the accompanying awards ceremony looked like this year as virtual events, the special emergency 90-day limited license these new graduates were given to practice at UMMMC during this time, and the impact these new physicians had in the hospital allowing residents and attendings to be redeployed to care for COVID-19 patients.

Rates of prophylactic mastectomy are increasing in the United States and might be elected for prevention in women with a hereditary predisposition to breast cancer. Using the American College of Surgeons National Surgical Quality Improvement Program database to study 30,803 patients, the data show that women who undergo prophylactic, rather than therapeutic, mastectomy, show a 5.8-fold increased risk of deep venous thrombosis. Introduction: The objective of the study was to evaluate the morbidity, mortality, and postoperative outcomes associated with simple or subcutaneous mastectomy in the management of prophylactic versus therapeutic resection. In this study we aimed to assess if simple or subcutaneous mastectomy for prophylaxis affects perioperative outcomes compared with resection performed for biopsy proven malignancy. Materials and Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for subjects who underwent simple or subcutaneous mastectomy between 2007 and 2012. Patient demographic characteristics, comorbid conditions, and postoperative complications were analyzed. Results: Of the 30,803 patients, 30,644 (99.5%) underwent therapeutic mastectomy and 159 (0.5%) underwent prophylactic mastectomy. Subjects who underwent prophylactic surgery were more likely to be younger (45 vs. 58 years; P < .01) and white (134 [84%] vs. 20,647 [67%]; P < .01). Surgery time was significantly greater in the prophylactic group (265 vs. 166 minutes; P < .01). There was no significant difference in mortality between groups. There was a trend toward greater 30-day morbidity (15 [9%] vs. 1835 [6%]; P = .09) and occurrence of deep venous thrombosis (DVT; 2 [1%] vs. 74 [0.2%]; P = .06) in those who underwent prophylactic mastectomy. After age adjustment, the prophylactic group showed a nearly sixfold increase in DVT (odds ratio [OR], 5.77; 95% confidence interval [CI], 1.37-24.22), which persisted when controlling for surgery time (OR, 4.95; 95% CI, 1.18-20.86). Conclusion: Prophylactic simple or subcutaneous mastectomy incurs significant additional 30-day postoperative morbidity related to perioperative DVT. Risk-mitigating strategies should be considered in the perioperative care of this patient population. (C) 2019 Elsevier Inc. All rights reserved.

Hendrix, Ryan J. MD; Beqari, Jorind; Mackey, Emily E. MD; Davids, Jennifer S. MD, FACS, FASCRS; Torres, Ulises MD, FACS; Larkin, Anne C. MD, FACS; LaFemina, Jennifer MD, FACS Author Information

Hendrix, Ryan J. MD; Beqari, Jorind; Winton, Michael MD; Davids, Jennifer S. MD, FACS; Torres, Ulises MD; Larkin, Anne C. MD, FACS; LaFemina, Jennifer MD, FACS Author Information

Rosai-Dorfman disease (also known as sinus histiocytosis with massive lymphadenopathy) is a rare benign proliferative disorder of histiocytes that typically involves the lymph nodes and can also involve extranodal sites. Rosai-Dorfman disease confined to the breast is extremely rare, but important to recognize as it can mimic malignancy. We present the case of a 63-year-old woman who presented with a palpable breast lump that was highly suspicious for malignancy based on mammogram and ultrasound appearance. Biopsy revealed inflammatory tissue with lymphoplasmacytic and histiocytic predominance. The diagnosis of Rosai-Dorfman was made based on characteristic staining of histiocytes with S-100 and the presence of emperipolesis. Early recognition of this benign disease entity spared the patient further investigation and surgical intervention.

We attempted to determine the feasibility of studying prehabilitation exercises to improve shoulder pain and abduction range of motion (ROM) after breast cancer surgery. We evaluated methods of exercise teaching and assessed effect on postsurgical seroma formation. This was a feasibility study with two non-blinded groups of subjects randomized by timing of appointment. This single-site study was performed at an academic tertiary medical center. Sixty cancer patients were randomly assigned to either group 1, in-person teaching arm, n = 36, or group 2, video-only teaching arm, n = 24. Forty-five patients completed the study. Shoulder exercises were assigned to both groups 1 month prior to surgery during evaluation. Group 1 received in-person instruction on exercises, plus an information sheet with exercises and a link to an online video. Group 2 received only the information sheet with exercises and a link to the online video. The primary outcomes considered are as follows: exercise compliance, shoulder pain (via visual analog scale), shoulder abduction ROM (via goniometer), and presence or absence of seroma. Seventy-six percent of study patients chose to exercise. There was no difference in exercise compliance between in-person teaching versus video teaching (75 %, 24/32 vs. 77 %, 10/13, OR = 1.03). Sixty-six of patients (20/30) lost greater than 10° shoulder abduction ROM at 1 month post surgery. Twenty-nine of patients (9/31) had worse shoulder pain than baseline at 1 month post surgery (24 %, 6/25 exercisers, and 50 %, 3/6 non-exercisers). Fifteen percent of patients (4/27) had worse shoulder pain than baseline at 3 months post surgery (8 %, 2/23 exercisers, and 100 %, 2/2 non-exercisers). Prehabilitation exercise program inferred no additional risk of seroma formation (Exercisers 21 %, 7/33 vs. non-exercisers 22 %, 2/9, OR = 0.94). Our subjects were able to perform three exercises independently in the preoperative period. A high-quality randomized controlled trial is necessary to assess the appropriate timing and efficacy of this intervention.

BACKGROUND: A short course of potassium iodide (SSKI) has been traditionally used to prepare patients with Graves' disease for thyroidectomy. The rationale for this treatment has evolved over time; from control of hyperthyroidism to facilitating surgery by making the gland less friable and bloody.METHODS: Randomized trial of preoperative SSKI vs no SSKI to test whether that is true.RESULTS: Mean estimated blood loss in the SSKI group (62 mL) was less than in the control group (162 mL) as was the median estimated blood loss (50 vs 140 mL). Mean (142 vs 162 minutes) and median (138 vs 150 minutes) operative times were also less in the SSKI arm. Subjective difficulty of operation was similar. Multivariable comparisons of groups with analysis of covariance showed the SSKI group suffered a mean blood loss 35% of the no treatment group (P = .036), the 9.2% decrease in Operating Room (OR) time between the SSKI group and the no treatment group was not statistically different (P = .464).CONCLUSIONS: SSKI given before operation in patients with Graves' disease reduces blood loss during thyroidectomy. (C) 2016 Elsevier Inc. All rights res erved.

BACKGROUND:Neoadjuvant chemotherapy has been shown to increase the rate of breast conservation in clinical trials and small institutional series, but it has never been studied on a national level. STUDY DESIGN:We performed a retrospective review of the National Cancer Database (NCDB). The NCDB is a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society and contains about 80% of the cancer cases in the United States. All women in the NCDB diagnosed with invasive breast cancer from 2006 through 2011, who underwent definitive breast surgery and received either neoadjuvant or adjuvant chemotherapy, excluding patients with distant metastases or T4 tumors, were included and rates of breast preservation were determined. RESULTS:Of 354,204 patients who met the inclusion criteria, 59,063 (16.7%) underwent neoadjuvant chemotherapy. This proportion steadily increased from 13.9% in 2006 to 20.5% in 2011 (p<0.001). Receipt of neoadjuvant chemotherapy was associated with larger tumor size (7% cT1, 25% cT2, and 58% cT3; p<0.001), more advanced nodal disease (11% cN0, 39% cN1-3; p<0.001), younger patient age (21%<50 years vs 14%>50 years; p<0.001), higher tumor grade (18% grade 3, 15% grade 2, vs 12% grade 1; p<0.001), and estrogen receptor (ER)-negative tumors (21% ER negative vs 15% ER postive; p<0.001). Multivariate logistic regression showed that when adjusted for the above variables, patients with tumors larger than 3 cm undergoing neoadjuvant chemotherapy were more likely to receive breast preservation than those who opted for primary surgery (odds ratio 1.7, 95% CI 1.6 to 1.8). CONCLUSIONS:Neoadjuvant chemotherapy increases breast preservation for patients with breast tumor size larger than 3 cm.