Surveillance for second breast cancer events in women with a personal history of breast cancer using breast MRI: a systematic review and meta-analysis.

PURPOSE: Women with personal history of breast cancer (PHBC) are currently recommended to receive annual mammography for surveillance of breast cancer recurrence or new primary. However, given issues in accuracy with mammography, there is a need for evolving evidence-based surveillance recommendations with supplemental imaging. In this systematic review, we compiled and compared existing studies that describe the test performance of surveillance breast MRI among women with PHBC. METHODS: We searched PubMed and EMBASE using MeSH terms for studies (2000-2019) that described the diagnostic characteristics of breast MRI in women with PHBC. Search results were reviewed and included based on PICOTS criteria; quality of included articles was assessed using QUADAS-2. Meta-analysis of single proportions was conducted for diagnostic characteristics of breast MRI, including tests of heterogeneity. RESULTS: Our review included 11 articles in which unique cohorts were studied, comprised of a total of 8338 women with PHBC and 12,335 breast MRI done for the purpose of surveillance. We predict intervals (PI) for cancer detection rate per 1000 examinations (PI 9-15; I2 = 10%), recall rate (PI 5-31%; I2 = 97%), sensitivity (PI 58-95%; I2 = 47%), specificity (PI 76-97%; I2 = 97%), and PPV3 (PI 16-40%; I2 = 44%). CONCLUSIONS: Studies addressing performance of breast MRI are variable and limited in population-based studies. The summary of evidence to date is insufficient to recommend for or against use of breast MRI for surveillance among women with PHBC.

Surveillance Breast MRI and Mammography: Comparison in Women with a Personal History of Breast Cancer.

Background There is lack of consensus regarding the use of breast MRI for routine surveillance for second breast cancer events in women with a personal history of breast cancer. Purpose To compare performance of surveillance mammography with breast MRI. Materials and Methods This observational cohort study used prospectively collected data and included 13 266 women age 18 years and older (mean age, 60 years ± 13) with stage 0-III breast cancer who underwent 33 938 mammographic examinations and 2506 breast MRI examinations from 2005 to 2012 in the Breast Cancer Surveillance Consortium. Women were categorized into two groups: mammography alone (n = 11 745) or breast MRI (n = 1521). Performance measures were calculated by using end-of-day assessment and occurrence of second breast cancer events within 1 year of imaging. Logistic regression was used to compare performance for breast MRI versus mammography alone, adjusting for women, examination, and primary breast cancer characteristics. Analysis was conducted on a per-examination basis. Results Breast MRI was associated with younger age at diagnosis, chemotherapy, and higher education and income. Raw performance measures for breast MRI versus mammography were as follows, respectively: cancer detection rates, 10.8 (95% confidence interval [CI]: 6.7, 14.8) versus 8.2 (95% CI: 7.3, 9.2) per 1000 examinations; sensitivity, 61.4% (27 of 44; 95% CI: 46.5%, 76.2%) versus 70.3% (279 of 397; 95% CI: 65.8%, 74.8%); and biopsy rate, 10.1% (253 of 2506; 95% CI: 8.9%, 11.3%) versus 4.0% (1343 of 33 938; 95% CI: 3.7%, 4.2%). In multivariable models, breast MRI was associated with higher biopsy rate (odds ratio [OR], 2.2; 95% CI: 1.9, 2.7; P < .001) and cancer detection rate (OR, 1.7; 95% CI: 1.1, 2.7; P = .03) than mammography alone. However, there were no differences in sensitivity (OR, 1.1; 95% CI: 0.4, 2.9; P = .84) or interval cancer rate (OR, 1.1; 95% CI: 0.6, 2.2; P = .70). Conclusion Comparison of the performance of surveillance breast MRI with mammography must account for patient characteristics. Whereas breast MRI leads to higher biopsy and cancer detection rates, there were no significant differences in sensitivity or interval cancers compared with mammography. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Newell in this issue.

Patterns of Breast Imaging Use Among Women with a Personal History of Breast Cancer.

BACKGROUND: National patterns of breast imaging in women with a personal history of breast cancer (PHBC) are unknown making evaluation of annual surveillance recommendations a challenge. OBJECTIVE: To describe variation in use of mammography and breast magnetic resonance imaging (MRI) examinations beginning 6 months after diagnosis among women with PHBC in US community practice. We report on the breast imaging indication, imaging intervals, and time since breast cancer diagnosis by examination type. DESIGN: Longitudinal study using cross-sectional data. SETTING: Breast Cancer Surveillance Consortium breast imaging facilities. PARTICIPANTS: 19,955 women diagnosed between 2005 and 2012 with AJCC stage 0-III incident breast cancer who had 69,386 mammograms and 3,553 breast MRI examinations from January 2005 to September 2013; median follow-up of 37.6 months (interquartile range, 22.1-60.7). MAIN MEASURES: Breast imaging indication, imaging intervals, and time since breast cancer diagnosis by examination type. KEY RESULTS: Among women with a PHBC who received breast imaging, 89.4% underwent mammography alone, 0.8% MRI alone, and 10.3% had both mammography and MRI. About half of mammograms and MRIs were indicated for surveillance vs. diagnostic, with an increase in the proportion of surveillance exams as time from diagnosis increased (mammograms, 45.7% at 1 year to 72.2% after 5 years; MRIs, 54.8% at 1 year to 78.6% after 5 years). In the first post-diagnosis period, 32.8% of women had > 2 breast imaging examinations and of these, 65.8% were less than 6 months apart. During the first 5-year post-diagnosis, the frequency of examinations per year decreased and the interval between examinations shifted towards annual examinations. CONCLUSION: In women with a PHBC who received post-diagnosis imaging, a third underwent multiple breast imaging examinations per year during the first 2-year post-diagnosis despite recommendations for annual exams. As time since diagnosis increases, imaging indication shifts from diagnostic to surveillance.

Similarity and match rates of the human dentition in three dimensions: relevance to bitemark analysis.

Uniqueness of the human dentition is a fundamental premise in bitemark analysis. Despite the importance of this key aspect of bitemark methodology, systematic studies of large populations have been limited. Furthermore, there have been no investigations of the significance of the third dimension with regard to dental uniqueness. One hundred digitally scanned mandibular models were analyzed in both 2D and three dimension (3D) using Landmark software. Additionally, 500 3D maxillary and mandibular sets were investigated for determining dental match rate. Statistical analysis was performed with geometric morphometric methods. Results show that measurements in 3D preserve more information about the dentition, reducing but not eliminating random matches in a sample population of 100 mandibular dentitions. Examination of pairs of maxillary and mandibular dentitions showed a substantial number of random matches (197 maxillary, 51 mandibular, one of both maxillary and mandibular). Conclusions indicate that a zero match rate cannot be claimed for the population studied.

The use of ultraviolet LED illumination for composite resin removal: an in vitro study.

It may be difficult to recognize composite resin restorations that are correctly shade-matched and well-placed by visual and tactile inspection alone--which can make the replacement of an existing resin restoration challenging. Many composite resins fluoresce under UV light, which can help dentists to detect resin material. This article explores a technique that utilizes a UV LED to cause composite resin to fluoresce. A UV/visible light spectrofluorometer was used to measure fluorescence excitation and emission maxima of 14 composite resin brands. Control samples of dentin and enamel were measured in a similar manner. Subsequently, each brand of composite resin was placed in extracted teeth and relative fluorescence was assessed. The composite resins were then removed and each tooth was inspected using UV light to detect remaining resin. Results from this study indicated that the optimal excitation wavelength was 385-395 nm, while 460 nm was determined to be the mean emission maxima. This study revealed three types of resin: highly fluorescent, moderately fluorescent, and weakly fluorescent. In each instance, the UV light revealed the presence of resin after all resin was believed to have been removed. Based on the results of this study, the use of UV illumination can be a useful technique for determining if composite resin has been removed completely.

Improved opioid analgesic effect following opioid dose reduction.

INTRODUCTION: Traditionally, opioids have been the cornerstone of therapy for patients suffering from cancer pain, regardless of the potential to develop opioid tolerance. In chronic pain patients who experience worsening pain despite increasing doses of opioids, the clinical role of opioid-induced hyperalgesia is gaining more recognition. CASE: Presented here is the case of a 56-year-old man with recurrent squamous cell lung carcinoma and spinal metastases, suffering with intractable 8/10 pain on the visual analog scale in his chest, lower thoracic spine, and upper lumbar spine. He was admitted five times for pain control. In spite of escalating doses of oxycodone, morphine, and hydromorphone, the patient continued to experience severe pain. Also, he endured undesirable sedation, fatigue, and generalized weakness. The clinical picture suggested the possibility of opioid-induced hyperalgesia. We decreased the hydromorphone dose by 40-50% and started methadone. The patient's pain level dropped to a more acceptable 3/10. He was more alert, and his pain was tolerable until his death. DISCUSSION: Opioid-induced hyperalgesia might be considered in a patient who has no evidence of disease progression, who is on clinically reasonable doses of opioids, and whose pain escalates as opioid doses are increased. A reduction of opioids and the addition of a low-dose N-methyl-D-aspartate receptor antagonist may provide a favorable clinical outcome in those patients who have failed to benefit from opioid rotation and other adjunctive pain treatments.

Analytical survey of restorative resins by SEM/EDS and XRF: databases for forensic purposes.

Frequently in forensic cases, unknown substances must be identified. Automated databases can ease the burden of comparison as materials may be compared against many known standards in a relatively short period of time. It has been shown that dental resins can be named according to brand or brand group even in conditions as harsh as cremation. Databases are already in use for many materials, but no such database exists for dental resins. Thus, two databases were generated. One utilized a laboratory-based method, scanning electron microscopy with energy dispersive X-ray spectroscopy (SEM/EDS), in conjunction with the Spectral Library Identification and Classification Explorer (SLICE) software. The other was based on portable X-ray fluorescence (XRF). The ability to perform database comparison with portable instrumentation can thus be brought directly to the field. Both the SLICE and XRF databases were evaluated by testing unknown resins. EDS is a well-established technique and the SLICE program was demonstrated to be a good tool for unknown resin identification. Portable XRF is a relatively new instrument in this regard and its databases have been constructed mostly for metal alloy comparison and environmental soil testing. However, by creation of a custom spectral library, it was possible to distinguish resin brand and bone and tooth from other substances.

Identification of incinerated root canal filling materials after exposure to high heat incineration.

With the increase in global terrorism there is a higher probability of having to identify victims of incineration events secondary to incendiary explosive devices. The victims of incineration events challenge forensic odontologists when coronal restorations are no longer present to compile postmortem data. With 40 million root canals being completed annually in the United States, a very large pool of antemortem data is available to the forensic odontologist to make positive identifications. When complete and thorough dental records exist, individuals that have undergone surgical and nonsurgical root canal therapy may have materials present in the canal that may aid in identification. This study provides elemental fingerprints of root canal obturation materials to be utilized as a forensic identification aid. This study used scanning electron microscopy/energy dispersive X-ray spectroscopy (SEM/EDS) to assess the elemental composition of materials before and after high temperature incineration. Sixteen endodontic materials were analyzed pre-incineration and placed in extracted teeth. The filled teeth were subjected to incineration at 900 degrees C for 30 min to simulate incineration events or cremation. Incinerated materials were radiographed and re-analyzed to determine if they retained their original elemental composition. Endodontic sealers, gutta percha, root-end filling materials, silver points, and separated files were distinguishable in the canal and traceable after incineration. The authors present a fingerprint of the endodontic obturation materials that are capable of withstanding high heat incineration to be used as an aid for postmortem identification. This work represents the initial stage of database generation for root canal filling materials for use as an aid in forensic identification.

Ultraviolet illumination as an adjunctive aid in dental inspection.

Tooth-colored resin fillings have become increasingly popular as restorative materials. Their presence in the dentition presents a challenge to the clinician and the forensic odontologist, as detection of the fillings can be difficult both visually and radiographically. As they necessarily form part of the unique dentition of an individual, recognition of the resins is important for forensic identification. Alternative light sources have been used with success in various fields of forensic science. In recent years small LED flashlights emitting at specific wavelengths in the ultraviolet light (UV) range have been developed. Their low cost, small size, and ready availability makes their use practical in both forensic dental inspection and clinical settings. UV inspection is of interest because enamel, dentin and dental materials all have differing fluorescent properties when illuminated by UV light. It was one goal of this research to quantitatively assess the fluorescence properties of modern restorative resins in order to predict their behavior during inspection using UV illumination. The second goal was to demonstrate practical use of UV in dental inspection with examples of how different materials fluoresce. Quantitative measurements were obtained for optical emission wavelength and intensity for 15 modern resins using a spectrophotometer. Results indicated that resin brands fluoresce at different wavelengths and with varying intensities. Practical use and comparison of the flashlights revealed that the most useful excitation wavelengths for resin detection were in the UVA range (365 and 380 nm). Porcelain restorations and composite resin fillings exhibited different responses to these two wavelengths and thus use of both is recommended for forensic dental inspection.

Imagine a world where...2008 Ryley-Jeffs Memorial lecture.

The health and well-being of individuals and the prosperity of the country require a well-nourished population. Canadians face unprecedented challenges to the goal of healthy eating and physical activity. The challenges are complex and dietitians have a collective responsibility to respond as thoughtful, competent practitioners. As we embrace the future, we need to understand our past and reflect on how we will create a future that will support nutritional health and well-being for all Canadians. Dietitians, in partnership with others, must play a key role.

Eating well with Canada's Food Guide (2007): development of the food intake pattern.

A food intake pattern specifying amounts and types of food was created for Canada's revised food guide, Eating Well with Canada's Food Guide (2007), using a two-step modeling process. In step one, food composites were manipulated to develop a food intake pattern. The second step used the step one food intake pattern to create 500 simulated diets for each of 16 age and gender groups. The resulting nutrient content distributions were evaluated relative to Dietary Reference Intake reference values. The modeling cycled between these two steps until a satisfactory pattern was achieved. The final pattern reflects modeling, a review of associations between foods and chronic disease, and input received during consultation.

Identification through X-ray fluorescence analysis of dental restorative resin materials: a comprehensive study of noncremated, cremated, and processed-cremated individuals.

Tooth-colored restorative materials are increasingly being placed in the practice of modern dentistry, replacing traditional materials such as amalgam. Many restorative resins have distinct elemental compositions that allow identification of brand. Not only are resins classifiable by elemental content, but they also survive extreme conditions such as cremation. This is of significance to the forensic odontologist because resin uniqueness adds another level of certainty in victim identification, especially when traditional means are exhausted. In this three-part study, unique combinations of resins were placed in six human cadavers (total 70 restorations). Simulated ante-mortem dental records were created. In a blind experiment, a portable X-ray fluorescence (XRF) unit was used to locate and identify the resin brands placed in the dentition. The technique was successful in location and brand identification of 53 of the restorations, which was sufficient to enable positive victim identification among the study group. This part of the experiment demonstrated the utility of portable XRF in detection and analysis of restorative materials for victim identification in field or morgue settings. Identification of individuals after cremation is a more difficult task, as the dentition is altered by shrinkage and fragmentation, and may not be comparable with a dental chart. Identification of processed cremains is a much greater challenge, as comminution obliterates all structural relationships. Under both circumstances, it is the nonbiological artifacts that aid in identification. Restorative resin fillings can survive these conditions, and can still be named by brand utilizing elemental analysis. In a continuation of the study, the cadavers were cremated in a cremation retort under standard mortuary conditions. XRF was again used to analyze retrieved resins and to identify the individuals based on restorative materials known to exist from dental records. The cremains were then processed and the analysis was repeated to determine whether restorative resins could be found under this extreme condition. Under both circumstances, sufficient surviving resin material was found to distinguish positively each individual in the study group. This study showed the utility of XRF as an analytical tool for forensic odontology and also the significance of the role of restorative resins in victim identification, even after cremation.

Eating Well with Canada's Food Guide: "A tool for the times".

This article outlines the processes undertaken to revise Canada's Food Guide and shares the updated science that underpins the dietary pattern. The Dietary Reference Intakes provide updated nutrient requirement values and better tools for dietary assessment and planning. Alignment with this updated science was an important component of defining and communicating accurate dietary guidance for Canada. Ensuring that stakeholders had access to the updated review of requirements led to the development of the text Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Equally important was ensuring that stakeholders were provided opportunity to influence the approach taken to giving dietary guidance, both content and the elements of the final package. A combination of research, consultation and expert advice guided the process to the release of Eating Well with Canada's Food Guide (2007).

Women's experiences and preferences regarding breast imaging after completing breast cancer treatment.

BACKGROUND: After treatment for breast cancer, most women receive an annual surveillance mammography to look for subsequent breast cancers. Supplemental breast MRI is sometimes used in addition to mammography despite the lack of clinical evidence for it. Breast imaging after cancer treatment is an emotionally charged experience, an important part of survivorship care, and a topic about which limited patient information exists. We assessed women's experiences and preferences about breast cancer surveillance imaging with the goal of determining where gaps in care and knowledge could be filled. PARTICIPANTS AND METHODS: We conducted six focus groups with a convenience sample of 41 women in California, North Carolina, and New Hampshire (USA). Participants were aged 38-75 years, had experienced stage 0-III breast cancer within the previous 5 years, and had completed initial treatment. We used inductive thematic analysis to identify key themes from verbatim transcripts. RESULTS: Women reported various types and frequencies of surveillance imaging and a range of surveillance imaging experiences and preferences. Many women experienced discomfort during breast imaging and anxiety related to the examination, primarily because they feared subsequent cancer detection. Women reported trust in their providers and relied on providers for imaging decision-making. However, women wanted more information about the treatment surveillance transition to improve their care. CONCLUSION: There is significant opportunity in breast cancer survivorship care to improve women's understanding about breast cancer surveillance imaging and to provide enhanced support to them at the time their initial treatment ends and at the time of surveillance imaging examinations.

Detection and classification of composite resins in incinerated teeth for forensic purposes.

The great demand for esthetic restorations has resulted in placement of large numbers of composite resin fillings. The popularity of these materials is reflected in the quantity and variety of resin brands currently on the market. The ability to distinguish resin brands can aid in positive identification of burn victims, assuming that appropriate dental records exist. Scanning electron microscopy/energy dispersive X-ray spectroscopy (SEM/EDS) was used to characterize the structure and composition of 10 modern resins. The structure of each resin was unique to manufacturer, and elemental analysis allowed separation into distinct groups. These 10 resins were also placed in extracted teeth and incinerated at 900 degrees C for 30 min, simulating near cremation conditions. The resins were identifiable by SEM/EDS after incineration, and the elemental composition remained almost unchanged. The data produced are immediately useful for resin identification in forensics, and comparative analysis can be readily performed using standard equipment. This work represents the initial stage of database generation.

The patient voice in research-evolution of a role.

PLAIN ENGLISH SUMMARY: Engaging patients in research studies is becoming more common because it makes research and its results more relevant for patients. It is important to understand the best ways for patients and researchers to work together. Patients who are included as active partners in research can provide useful input on what it is like to work on a research team but very little has been written about this from the patient's perspective. As patient partners and researchers on a breast cancer study, we share our experience to develop a patient-centered project and the inclusion of patient collaborators as scientific experts. Over time, the role of the patient partner has developed to include unanticipated roles and responsibilities. We use our experience to share how the patient voice can affect the execution of a research study and to provide a model for meaningfully engaging patients in research. ABSTRACT: Engaging patients in research studies is becoming more common because it makes research and its results more relevant for patients. It is important to understand the best ways for patients and researchers to work together. Patients who are included as active partners in research can provide useful input on what it is like to work on a research team but very little has been written about this from the patient's perspective. As patient partners and researchers on a breast cancer study, we share our experience to develop a patient-centered project and the inclusion of patient collaborators as scientific experts. Over time, the role of the patient partner has developed to include unanticipated roles and responsibilities. We use our experience to share how the patient voice can affect the execution of a research study and to provide a model for meaningfully engaging patients in research.

Forensic bitemark identification: weak foundations, exaggerated claims.

Several forensic sciences, especially of the pattern-matching kind, are increasingly seen to lack the scientific foundation needed to justify continuing admission as trial evidence. Indeed, several have been abolished in the recent past. A likely next candidate for elimination is bitemark identification. A number of DNA exonerations have occurred in recent years for individuals convicted based on erroneous bitemark identifications. Intense scientific and legal scrutiny has resulted. An important National Academies review found little scientific support for the field. The Texas Forensic Science Commission recently recommended a moratorium on the admission of bitemark expert testimony. The California Supreme Court has a case before it that could start a national dismantling of forensic odontology. This article describes the (legal) basis for the rise of bitemark identification and the (scientific) basis for its impending fall. The article explains the general logic of forensic identification, the claims of bitemark identification, and reviews relevant empirical research on bitemark identification-highlighting both the lack of research and the lack of support provided by what research does exist. The rise and possible fall of bitemark identification evidence has broader implications-highlighting the weak scientific culture of forensic science and the law's difficulty in evaluating and responding to unreliable and unscientific evidence.

Complex layered dental restorations: Are they recognizable and do they survive extreme conditions?

Recent research has shown that restorative dental materials can be recognized by microscopy and elemental analysis (scanning electron microscopy/energy dispersive X-ray spectroscopy and X-ray fluorescence; SEM/EDS and XRF) and that this is possible even in extreme conditions, such as cremation. These analytical methods and databases of dental materials properties have proven useful in DVI (disaster victim identification) of a commercial plane crash in 2009, and in a number of other victim identification cases. Dental materials appear on the market with ever expanding frequency. With their advent, newer methods of restoration have been proposed and adopted in the dental office. Methods might include placing multiple layers of dental materials, where they have different properties including adhesion, viscosity, or working time. These different dental materials include filled adhesives, flowable resins, glass ionomer cements, composite resins, liners and sealants. With possible combinations of different materials in these restorations, the forensic odontologist is now confronted with a new difficulty; how to recognize each individual material. The question might be posed if it is even possible to perform this task. Furthermore, an odontologist might be called upon to identify a victim under difficult circumstances, such as when presented with fragmented or incinerated remains. In these circumstances the ability to identify specific dental materials could assist in the identification of the deceased. Key to use of this information is whether these new materials and methods are detailed in the dental chart. Visual or radiographic inspection may not reveal the presence of a restoration, let alone the possible complex nature of that restoration. This study demonstrates another scientific method in forensic dental identification.

Setting dietary guidance: the Canadian experience.

This article outlines processes underlying recent dietary guidance in Canada. In 1977, Nutrition Recommendations for Canadians were adapted from the Report of the Committee on Diet and Cardiovascular Disease. In the late 1980s, as science revealed new relationships between dietary patterns and chronic disease, the unified front of consistent dietary guidelines began to crumble when researchers and health organizations began to provide "unique" dietary advice. Evolution in health promotion concepts during this time, combined with the need for updated dietary guidance, influenced Health Canada to appoint two advisory committees in 1987. The Scientific Review Committee was charged with describing the dietary pattern that would supply recommended levels of essential nutrients while reducing risk of chronic disease, resulting in updated Nutrition Recommendations. The Communications and Implementation Committee translated the scientific recommendations into dietary advice for the public, leading to Canada's Guidelines to Healthy Eating. From this process, Canada's Food Guide to Healthy Eating emerged. The development of the Dietary Reference Intakes has resulted in updated nutrient requirement values and better tools for dietary assessment and planning. Health Canada recognizes the need to ensure alignment with this updated science through continuing leadership in defining and communicating accurate dietary guidance for Canada.

Distortion in fingerprints: a statistical investigation using shape measurement tools.

Friction ridge impression appearance can be affected due to the type of surface touched and pressure exerted during deposition. Understanding the magnitude of alterations, regions affected, and systematic/detectable changes occurring would provide useful information. Geometric morphometric techniques were used to statistically characterize these changes. One hundred and fourteen prints were obtained from a single volunteer and impressed with heavy, normal, and light pressure on computer paper, soft gloss paper, 10-print card stock, and retabs. Six hundred prints from 10 volunteers were rolled with heavy, normal, and light pressure on soft gloss paper and 10-print card stock. Results indicate that while different substrates/pressure levels produced small systematic changes in fingerprints, the changes were small in magnitude: roughly the width of one ridge. There were no detectable changes in the degree of random variability of prints associated with either pressure or substrate. In conclusion, the prints transferred reliably regardless of pressure or substrate.