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JACS CME-1 featured articles, volume 200, February 2005
CONTINUING MEDICAL EDUCATION PROGRAM
JACS CME-1 FEATURED ARTICLES, VOLUME 200, FEBRUARY 2005 Male breast disease Wise GJ, Roorda AK, Kalter R J Am Coll Surg 2005;200:255–269 Cervical spine evaluation in urban trauma centers: Lowering institutional costs through helical CT scan Grogan EL, Morris JA, Dittus RS, et al J Am Coll Surg 2005;200:160–165
Objectives: After reading the featured articles published in this issue of the Journal of the American College of Surgeons (JACS) participants in the JACS CME program should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice. Objectives are stated at the beginning of each featured article; the questions follow with five response choices, and a critique discussing the objective. The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The JACS CME program fulfills the ACCME essentials. The American College of Surgeons designates this educational activity for a maximum of 1 Category 1 credits toward the AMA Physician’s Recognition Award.
Each physician should claim only those credits that he/ she actually spent in the educational activity. You can earn two CME credits using JACS CME Online, at http://jacscme.facs.org, or you can earn one CME credit if you submit this page by fax (see instructions in box below). JACS CME Online provides four articles from each issue for two credits per month. The articles this month on JACS CME Online are: Male breast disease. Wise GJ, Roorda AK, Kalter R. Cervical spine evaluation in urban trauma centers: Lowering institutional costs and complications through helical CT scan. Grogan EL, Morris JA, Dittus RS, et al. Transfusions in surgical patients. Englesbe MJ, Pelletier SJ, Diehl KM, et al. Monitoring performance: Longterm impact of trauma verification and review. Ehrlich PF, McClellan WT, Wesson DE.
Questions: Wendy Cowles Husser, MA, MPA Executive Editor, JACS 633 N Saint Clair Street, Chicago, IL 60611 312-202-5306 (ph) 312-202-5027 (fax) [email protected]
© 2005 by the American College of Surgeons Published by Elsevier Inc.
A27
ISSN 1072-7515/05/$30.00 doi:10.1016/j.jamcollsurg.2004.11.006
A28
Continuing Medical Education Program
J Am Coll Surg
Male breast disease
Wise GJ, Roorda AK, Kalter R J Am Coll Surg 2005;200:255–269 Learning Objectives: After study of this article, sur-
geons should have a better understanding of the causes, diagnostic methods, and treatment of breast disease in males. Question 1
All of the following statements about breast enlargement in men are true except: a) Gynecomastia is prevalent during puberty and declines in incidence after age 44. b) Gynecomastia may be associated with an increased risk of testicular cancer. c) Gynecomastia is associated with generalized obesity. d) Male breast cancer is uncommon and is histologically similar to breast cancers in women. e) Men with breast cancer have a high prevalence of metastatic disease at the time of diagnosis. Critique: Approximately half of boys ages 10 to 15 years
have gynecomastia as defined by a palpable mass of breast tissue 2 cm or more in diameter, usually bilateral. With advancing age, the prevalence rises to well over 50%, and is especially common in obese subjects. Some studies report a prevalence of more than 70% in the fifth through sixth decades. A single study of Swedish men with gynecomastia found an increase risk of both testicular cancer and squamous cell cancer of the skin. Male breast cancer represents less than 1% of all cancers in men. The most common histopathology is infiltrating ductal adenocarcinoma, and the histopathology mirrors that of breast cancer in women (Fig). Perhaps because of delayed diagnosis, men with breast cancer have a poorer prognosis than women, are older on average, and often have metastatic disease at the time of first diagnosis.
Figure. Male breast carcinoma. This photograph (hematoxylin and eosin ⫻ 100) of a male breast carcinoma shows intraductal and infiltrating duct carcinoma, histologically indistinguishable from the same lesion of the female breast.
Critique: When a man develops enlargement of the
breast, the surgeon must consider the possibility of hormone-producing tumors such as a testicular or retroperitoneal tumor. Other diagnostic possibilities include chromosome abnormalities such as Klinefelter syndrome. Anabolic steroid abuse should be assessed in athletes who develop breast changes. Breast enlargement has occurred with the use of anabolic steroids in sports. In a survey of ,667 British sports participants, 9.1% of the men and 2.3% of the women had taken androgen—anabolic steroids (AS) at some time, and 6% of the men and 1.4% of the women were current users. Of the 97 men interviewed, 56% reported testicular atrophy, 52% gynecomastia, 36% elevated blood pressure, 56% fluid retention, 26% injuries to tendons, 22% nosebleeds, and 16% more frequent colds.
Question 2
A 25-year-old male marathon runner develops bilateral breast enlargement. What steps should be taken to determine the cause?
Cervical spine evaluation in urban trauma centers: Lowering institutional costs through helical CT scan
a) b) c) d) e)
Learning Objectives: After study of this article, sur-
Mammogram Scrotal sonogram Chromosome analysis Abdominal CT scan Assessment for anabolic steroid use
Grogan EL, Morris JA, Dittus RS, et al J Am Coll Surg 2005;200:160–165 geons should be able to describe the basics of decision analysis techniques and conclude which is the most cost
Vol. 200, No. 2, February 2005
Continuing Medical Education Program
A29
effective technique (helical CT scan versus plain films) used to evaluate the cervical spine in the moderate- and high-risk trauma patient. Question 1
Decision analysis techniques are used to examine the possible outcomes, including cost effectiveness, of therapeutic or diagnostic options and include all of the following components except: a) defining the perspective of the analysis. b) calculating the costs of the expected outcomes. c) performing sensitivity analyses to examine the impact of the baseline assumptions on the outcomes. d) developing a model that that includes the clinical outcomes that could occur for an individual patient. e) picking the probabilities that are most likely to give the desired outcome. Critique: Decision analysis is an analytic technique that
can be used to examine the relative costs, effectiveness, and cost-effectiveness of alternative therapeutic and diagnostic strategies. The components of decision analysis include: 1) defining the problem, objectives, and perspective of the analysis; 2) delineating all of the relevant alternative strategies to be examined; 3) delineating the consequences (clinical outcomes) of each pathway that could be traversed by a patient within each strategy; 4) estimating the probabilities of those pathways and associated consequences; 5) calculating the expected outcome of each alternative strategy; 6) ranking the alternatives in order of preference; and 7) examining the impact of the baseline assumptions and changes in the estimated probabilities on expected value and preferred order of the alternative strategies.
Figure. Algorithm for the management and treatment of breast disease in males.
Question 2
Helical CT scan is the most cost effective technique used to evaluate the cervical spine in the moderate- to highrisk trauma patient in all of the following except: a) if indemnity payments for missed injuries were expected to be greater than $58,180. b) if the probability of cervical spine fracture at the institution exceeded 0.9%. c) if the probability of paralysis after a missed injury was greater than 1.7%. d) if the cost of plain films were $100. e) if the cost of helical CT scan were less than $1,918. Critique: This model demonstrated that potential in-
demnity payments from missed injuries resulting in paralysis made helical CT scan the most cost effective strategy even if the cost of plain films were zero. This was driven by the low sensitivity of plain films in the moderate to high-risk trauma patient and the high sensitivity of helical CT scan.
JACS CME-1 FEATURED ARTICLES, VOLUME 200, FEBRUARY 2005 Male breast disease Wise GJ, Roorda AK, Kalter R J Am Coll Surg 2005;200:255–269 Cervical spine evaluation in urban trauma centers: Lowering institutional costs through helical CT scan Grogan EL, Morris JA, Dittus RS, et al J Am Coll Surg 2005;200:160–165
Objectives: After reading the featured articles published in this issue of the Journal of the American College of Surgeons (JACS) participants in the JACS CME program should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice. Objectives are stated at the beginning of each featured article; the questions follow with five response choices, and a critique discussing the objective. The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The JACS CME program fulfills the ACCME essentials. The American College of Surgeons designates this educational activity for a maximum of 1 Category 1 credits toward the AMA Physician’s Recognition Award.
Each physician should claim only those credits that he/ she actually spent in the educational activity. You can earn two CME credits using JACS CME Online, at http://jacscme.facs.org, or you can earn one CME credit if you submit this page by fax (see instructions in box below). JACS CME Online provides four articles from each issue for two credits per month. The articles this month on JACS CME Online are: Male breast disease. Wise GJ, Roorda AK, Kalter R. Cervical spine evaluation in urban trauma centers: Lowering institutional costs and complications through helical CT scan. Grogan EL, Morris JA, Dittus RS, et al. Transfusions in surgical patients. Englesbe MJ, Pelletier SJ, Diehl KM, et al. Monitoring performance: Longterm impact of trauma verification and review. Ehrlich PF, McClellan WT, Wesson DE.
Questions: Wendy Cowles Husser, MA, MPA Executive Editor, JACS 633 N Saint Clair Street, Chicago, IL 60611 312-202-5306 (ph) 312-202-5027 (fax) [email protected]
© 2005 by the American College of Surgeons Published by Elsevier Inc.
A27
ISSN 1072-7515/05/$30.00 doi:10.1016/j.jamcollsurg.2004.11.006
A28
Continuing Medical Education Program
J Am Coll Surg
Male breast disease
Wise GJ, Roorda AK, Kalter R J Am Coll Surg 2005;200:255–269 Learning Objectives: After study of this article, sur-
geons should have a better understanding of the causes, diagnostic methods, and treatment of breast disease in males. Question 1
All of the following statements about breast enlargement in men are true except: a) Gynecomastia is prevalent during puberty and declines in incidence after age 44. b) Gynecomastia may be associated with an increased risk of testicular cancer. c) Gynecomastia is associated with generalized obesity. d) Male breast cancer is uncommon and is histologically similar to breast cancers in women. e) Men with breast cancer have a high prevalence of metastatic disease at the time of diagnosis. Critique: Approximately half of boys ages 10 to 15 years
have gynecomastia as defined by a palpable mass of breast tissue 2 cm or more in diameter, usually bilateral. With advancing age, the prevalence rises to well over 50%, and is especially common in obese subjects. Some studies report a prevalence of more than 70% in the fifth through sixth decades. A single study of Swedish men with gynecomastia found an increase risk of both testicular cancer and squamous cell cancer of the skin. Male breast cancer represents less than 1% of all cancers in men. The most common histopathology is infiltrating ductal adenocarcinoma, and the histopathology mirrors that of breast cancer in women (Fig). Perhaps because of delayed diagnosis, men with breast cancer have a poorer prognosis than women, are older on average, and often have metastatic disease at the time of first diagnosis.
Figure. Male breast carcinoma. This photograph (hematoxylin and eosin ⫻ 100) of a male breast carcinoma shows intraductal and infiltrating duct carcinoma, histologically indistinguishable from the same lesion of the female breast.
Critique: When a man develops enlargement of the
breast, the surgeon must consider the possibility of hormone-producing tumors such as a testicular or retroperitoneal tumor. Other diagnostic possibilities include chromosome abnormalities such as Klinefelter syndrome. Anabolic steroid abuse should be assessed in athletes who develop breast changes. Breast enlargement has occurred with the use of anabolic steroids in sports. In a survey of ,667 British sports participants, 9.1% of the men and 2.3% of the women had taken androgen—anabolic steroids (AS) at some time, and 6% of the men and 1.4% of the women were current users. Of the 97 men interviewed, 56% reported testicular atrophy, 52% gynecomastia, 36% elevated blood pressure, 56% fluid retention, 26% injuries to tendons, 22% nosebleeds, and 16% more frequent colds.
Question 2
A 25-year-old male marathon runner develops bilateral breast enlargement. What steps should be taken to determine the cause?
Cervical spine evaluation in urban trauma centers: Lowering institutional costs through helical CT scan
a) b) c) d) e)
Learning Objectives: After study of this article, sur-
Mammogram Scrotal sonogram Chromosome analysis Abdominal CT scan Assessment for anabolic steroid use
Grogan EL, Morris JA, Dittus RS, et al J Am Coll Surg 2005;200:160–165 geons should be able to describe the basics of decision analysis techniques and conclude which is the most cost
Vol. 200, No. 2, February 2005
Continuing Medical Education Program
A29
effective technique (helical CT scan versus plain films) used to evaluate the cervical spine in the moderate- and high-risk trauma patient. Question 1
Decision analysis techniques are used to examine the possible outcomes, including cost effectiveness, of therapeutic or diagnostic options and include all of the following components except: a) defining the perspective of the analysis. b) calculating the costs of the expected outcomes. c) performing sensitivity analyses to examine the impact of the baseline assumptions on the outcomes. d) developing a model that that includes the clinical outcomes that could occur for an individual patient. e) picking the probabilities that are most likely to give the desired outcome. Critique: Decision analysis is an analytic technique that
can be used to examine the relative costs, effectiveness, and cost-effectiveness of alternative therapeutic and diagnostic strategies. The components of decision analysis include: 1) defining the problem, objectives, and perspective of the analysis; 2) delineating all of the relevant alternative strategies to be examined; 3) delineating the consequences (clinical outcomes) of each pathway that could be traversed by a patient within each strategy; 4) estimating the probabilities of those pathways and associated consequences; 5) calculating the expected outcome of each alternative strategy; 6) ranking the alternatives in order of preference; and 7) examining the impact of the baseline assumptions and changes in the estimated probabilities on expected value and preferred order of the alternative strategies.
Figure. Algorithm for the management and treatment of breast disease in males.
Question 2
Helical CT scan is the most cost effective technique used to evaluate the cervical spine in the moderate- to highrisk trauma patient in all of the following except: a) if indemnity payments for missed injuries were expected to be greater than $58,180. b) if the probability of cervical spine fracture at the institution exceeded 0.9%. c) if the probability of paralysis after a missed injury was greater than 1.7%. d) if the cost of plain films were $100. e) if the cost of helical CT scan were less than $1,918. Critique: This model demonstrated that potential in-
demnity payments from missed injuries resulting in paralysis made helical CT scan the most cost effective strategy even if the cost of plain films were zero. This was driven by the low sensitivity of plain films in the moderate to high-risk trauma patient and the high sensitivity of helical CT scan.