The aim of the study is to compare the efficacy of SPIO as a tracer in sentinel node biopsy (SNB) in breast cancer with Tc and patent blue in a multicentre prospective study and perform a meta-analysis of all published studies. It also aims to follow skin discoloration after SPIO injection and describe when and how it resolves. Totally 206 patients with early breast cancer were recruited. Tc and patent blue were administered in standard fashion. Patients were injected with SPIO (Sienna+) preoperatively. SNB was performed and detection rates were recorded for both methods. Skin discoloration was followed and documented postoperatively. Data extraction and subsequent meta-analysis of all previous studies were also performed. SN detection rates were similar between standard technique succeeded and SPIO both per patient (97.1 vs. 97.6 %, p = 0.76) as well as per node (91.3 vs. 93.3 %, p = 0.34), something which was not affected by the presence of malignancy. Concordance rates were also consistently high (98.0 % per patient and 95.9 % per node). Discoloring was present in 35.5 % of patients postoperatively, almost exclusively in breast conservation. It fades slowly and is still detectable in 8.6 % of patients after 15 months. Meta-analysis depicted similar detection rates (p = 0.71) and concordance rates (p = 0.82) per patient. However, it seems that SPIO is characterized by higher nodal retrieval (p < 0.001). SPIO is an effective method for the detection of SN in patients with breast cancer. It is comparable to the standard technique and seems to simplify logistics. Potential skin discoloration is something of consideration in patients planned for breast conservation.

Introduction Emergency medicine (EM) is a high-risk specialty for burnout. COVID-19 has had and will continue to have important consequences on wellness and burnout for EM physicians in Canada. Baseline data are crucial to monitor the health of EM physicians in Canada, and evaluate any interventions designed to help during and after COVID-19. Objectives To describe the rates of burnout, depression, and suicidality in practicing EM physicians in Canada, just before the COVID-19 pandemic. Methods A modified snowball method was used for survey distribution. Participants completed the Maslach Burnout Inventory – Health Services Tool (MBI-HSS), a screening measure for depression (PHQ-9), and a question regarding if the physician had ever or in the past 12 months contemplated suicide. Results A total of 384 respondent surveys were included in the final analysis: 86.1% (329/382) met at least one of the criteria for burnout, 58% (217/374) scored minimal to none on the PHQ-9 screening tool for depression, 14.3% (53/371) had contemplated suicide during their staff career in EM, and of those, 5.9% (22/371) had actively considered suicide in the past year. Conclusion Canadian EM physicians just before the COVID-19 pandemic had an alarming number of respondents meet the threshold for burnout, confirming EM as a high-risk specialty. This important baseline information can be used to monitor the physical and mental risks to EM physicians during and after COVID-19, and evaluate support for mental health and wellness, which is urgently needed now and post pandemic.

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A decreased risk of breast cancer has been reported among patients given bisphosphonates. The present aims were to study potential associations between different antiosteoporosis drugs, including bisphosphonates, and the risk of breast cancer before and after start of treatment and to appraise possible dose-effect relationships. From national Danish registers, all female users of bisphosphonates aged ≥40 years and other drugs against osteoporosis between 1996 and 2006 were identified (n = 87,104). This cohort was compared with a control group, where each patient was matched on age with three nonexposed women from the general population (n = 261,322). Before start of most drugs against osteoporosis an increased risk of breast cancer was seen compared to controls (e.g., adjusted OR = 1.09, 95% CI 1.04-1.16 for alendronate). This excess risk was higher in younger women (e.g., OR = 4.48, 95% CI 2.98-6.75 for alendronate in women ≤50 years) and disappeared in women older than 70 years (e.g., OR = 0.95, 95% CI 0.88-1.01 for alendronate). In contrast, a decreased risk of breast cancer was seen after start of alendronate (HR = 0.53, 95% CI 0.38-0.73), etidronate (HR = 0.80, 95% CI 0.73-0.89), and raloxifene (HR = 0.53, 95% CI 0.38-0.73). No dose-response relationship was present for alendronate and etidronate, whereas a decreasing risk was seen with increasing daily dose of raloxifene. Bisphosphonate treatment in women was associated with a reduced risk of breast cancer. However, no causal relationship seemed to be present.

Symptom management and end-of-life care are core skills for all physicians, although in ordinary times many anesthesiologists have fewer occasions to use these skills. The current coronavirus disease (COVID-19) pandemic has caused significant mortality over a short time and has necessitated an increase in provision of both critical care and palliative care. For anesthesiologists deployed to units caring for patients with COVID-19, this narrative review provides guidance on conducting goals of care discussions, withdrawing life-sustaining measures, and managing distressing symptoms.

Introduction: Emergency medicine point-of-care ultrasonography (EM-PoCUS) is a core competency for residents in the Royal College of Physicians and Surgeons of Canada and College of Family Physicians of Canada emergency medicine (EM) training programs. Although EM-PoCUS fellowships are currently offered in Canada, there is little consensus regarding what training should be included in a Canadian EM-PoCUS fellowship curriculum or how this contrasts with the training received in an EM residency. Objectives: To conduct a systematic needs assessment of major stakeholders to define the essential elements necessary for a Canadian EM-PoCUS fellowship training curriculum. Methods: We carried out a national survey of experts in EMPoCUS, EM residency program directors, and EM residents. Respondents were asked to identify competencies deemed either nonessential to EM practice, essential for general EM practice, essential for advanced EM practice, or essential for EM-PoCUS fellowship trained (''expert'') practice. Results: The response rate was 81% (351 of 435). PoCUS was deemed essential to general EM practice for basic cardiac, aortic, trauma, and procedural imaging. PoCUS was deemed essential to advanced EM practice in undifferentiated symptomatology, advanced chest pathologies, and advanced procedural applications. Expert-level PoCUS competencies were identified for administrative, pediatric, and advanced gynecologic applications. Eighty-seven percent of respondents indicated that there was a need for EM-PoCUS fellowships, with an ideal length of 6 months. Conclusion: This is the first needs assessment of major stakeholders in Canada to identify competencies for expert training in EM-PoCUS. The competencies should form the basis for EM-PoCUS fellowship programs in Canada.

After a median latency of 2 years, the initial late colorectal radiation injuries in 182 patients were: stricture (37 percent), minor lesions (36 percent), rectovaginal fistula (22 percent), and gangrene or other fistulas (5 percent). Due to progression, new colorectal injuries, primarily stricture (55 percent) and fistula (42 percent), occurred in 68 patients (37 percent). Resection provided the best results. However, the resectability rate was low (46 percent) and resection was primarily performed in patients with a circumscript well-defined stricture of the proximal rectum or sigmoid colon with an anastomotic leakage rate of 5 percent. The prevailing management of 78 patients with fistula or stricture with synchronous fistula was defunctioning colostomy, primarily end-sigmoidostomy, providing fair results in half of the patients. Stomal complications occurred in 15 percent. The radiation-induced colorectal mortality was 8 percent. Colorectal fistula and associated radiation injuries of the urinary tract, and especially of the small bowel, were the major determinants of fatal outcome, yielding an overall radiation-induced mortality of 25 percent. After a median observation time of 13 years, half of the patients were alive at follow-up; 56 percent of these had a fair outcome whereas the remaining patients continued to have mild symptoms responding to conservative measures (34 percent) or disabling symptoms (10 percent).

Bleeding gastric ulcer is associated with a relatively low long-term recurrence rate, except in a few patients with a history of previous bleeding ulcer, who have an increased risk of recurrence. Patients with bleeding gastric ulcer have an excess mortality not related to the ulcer disease.