Solitary Dilated Ducts Revisited: Malignancy Rate and Implications for Management.

RATIONALE AND OBJECTIVES: A solitary dilated duct (SDD) is a single asymmetrically dilated breast duct with diameter more than 2 mm. The Breast Imaging Reporting and Data System (BI-RADS) fifth edition recommends additional imaging and biopsy for SDDs without demonstrated benign etiology, however management of this rare entity remains controversial. This study describes practice patterns, malignancy rate, and features associated with high-risk/malignant SDDs to better stratify patients requiring biopsy versus follow-up. MATERIALS AND METHODS: This IRB-approved retrospective study identified mammographic, sonographic and MRI exams utilizing the term "solitary dilated duct" at a multisite academic institution between 1/1/2010 and 12/31/2020. Clinical and imaging features, BI-RADS assessments, and outcomes were analyzed. Univariate and multivariate analyses identified predictors of high-risk/malignant histology. RESULTS: SDDs identified in 49 women (mean age 56.1 years) were assessed as BI-RADS 4/5 (31/49, 63%), BI-RADS 3 (9/49, 18%), or BI-RADS 2 (9/49, 18%). Most sampled lesions were benign (16/31, 52%) and the remaining were high-risk (15/31, 48%, all papillary lesions). The only papilloma with atypia on core biopsy upgraded to grade 2 DCIS on excision (malignancy rate 1/49, 2%). All anechoic SDDs were benign (n=13), and all benign SDDs lacked internal vascularity. SDDs with associated masses were associated with malignant/high-risk outcomes on multivariate analysis (p < .001). CONCLUSION: The BI-RADS fifth edition recommends biopsy for SDDs without demonstrated benign etiology. In our 11-year study period, practice patterns were variable with a low malignancy rate of 2%. Our findings suggest that anechoic SDDs may be followed, and SDDs with associated masses or internal vascularity require biopsy.

Comparison of the Bond Strength of Composite Resin to Zirconia and Composite Resin to Polyether Ether Ketone: An In Vitro Study.

AIM: The aim of the study was to compare the shear bond strength of composite resin bonded to polyether ether ketone (PEEK) and zirconia, and also to evaluate the effect of thermocycling on the shear bond strength. MATERIALS AND METHODS: A total of 22 zirconia (Group 1) and 22 PEEK (Group 2) specimens (disks of 10 mm in diameter and 10 mm in thickness) were machine milled using computer-aided design (CAD)/computer-aided manufacturing (CAM) from commercially available zirconia and PEEK. These specimens were air abraded with 110-µm aluminum oxide. Following which these two groups were subdivided into four groups, that is, Group 1A: 11 zirconia specimens before thermocycling, Group 1B: 11 zirconia specimens after thermocycling, Group 2A: 11 PEEK specimens before thermocycling, and Group 2B: 11 PEEK specimens after thermocycling. These four groups of specimens were embedded in an acrylic block, and bonding agent was applied over the upper surfaces of the disks of each of these specimens. Composite resin was then cured, and then Group 1B and group 2B were thermocycled under a standard temperature. The bond strength of the specimen was tested using universal testing machine. RESULT: The result showed that there was no significant difference in shear bond strength between the groups, although higher shear bond strength was observed in the PEEK group. CONCLUSION: Shear bond strength of PEEK is similar to zirconia. The results suggest that the pretreatment method and primers used were effective in improving the bonding of resin cements to zirconia ceramic and the bonding properties of the veneering resin to the PEEK surface.

Prevalence of rheumatoid cachexia in rheumatoid arthritis: a systematic review and meta-analysis.

BACKGROUND: Low muscle mass occurs in patients with rheumatoid arthritis without weight loss; this condition is referred as rheumatoid cachexia. The aim of the current study was to perform a systematic review with meta-analysis to determine the rheumatoid cachexia prevalence. METHODS: A systematic review with meta-analysis of observational studies published in English, between 1994 and 2016, was conducted using MEDLINE (via PubMed) and other relevant sources. Search strategies were based on pre-defined keywords and medical subject headings. The methodological quality of included studies was assessed using the Newcastle-Ottawa Scale. Meta-analysis was used to estimate the prevalence, and because studies reported different methods and criteria to estimate body composition and prevalence of rheumatoid cachexia, subgroup analyses were performed. Meta-regression adjusted for the 28-joint disease activity score and disease duration (years) was performed (significance level at P ≤ 0.05). RESULTS: Of 136 full articles (one duplicate publication) screened for inclusion in the study, eight were included. The estimated overall prevalence of rheumatoid cachexia was 19% [95% confidence interval (CI) 07-33%]. This prevalence was 29% (95% CI 15-46%) when body composition was measured by dual-energy X-ray absorptiometry. When the diagnostic criteria were fat-free mass index below the 10th percentile and fat mass index above the 25th percentile, rheumatoid cachexia prevalence was 32% (95% CI 14-52%). The 28-joint disease activity score and disease duration had no influence on the estimated prevalence of rheumatoid cachexia (P > 0.05). Most studies were rated as having moderate methodological quality. CONCLUSIONS: Meta-analysis showed a prevalence of rheumatoid cachexia of 15-32%, according to different criteria, demonstrating that this condition is a frequent comorbidity of rheumatoid arthritis. To better understand its clinical impact, more studies using standardized definitions and prospective evaluations are urgently needed.

The Safety of CT-Guided Epidural Steroid Injections in an Older Patient Cohort.

BACKGROUND: Epidural steroid injections (ESIs) are a common method for treating lower back pain, which is one of the most prevalent health-related complaints in the adult US population. Although the safety of CT-guided ESIs has been extensively studied in adults, there is limited data concerning the procedure's safety profile in an older patient population. OBJECTIVE: This retrospective study analyzed safety data among a single-center cohort of patients > 65 years-old who received one or more CT-guided interlaminar ESIs from 2012 to 2015. STUDY DESIGN: An Institutional Review Board (IRB)-approved retrospective chart review. SETTING: University hospital center. METHODS: A total of 688 CT-guided ESI procedures were evaluated and a linear regression analysis was conducted to examine the relationship between dose length product (DLP), body mass index (BMI), procedure duration, and kVp/mA settings. Further analysis was performed on a sample of long procedure time, average-DLP and high-DLP procedures. RESULTS: Average age was 75.77 years, with 44% having a BMI > 30. The mean DLP was 55.58 mGy x cm and the mean procedure duration was 5.94 minutes. All procedures were technically successful and no complications were observed during or after any of the procedures, including at one-month follow-up office visits. The kVp and mA settings were the strongest predictors of DLP, followed by procedure time. The high-DLP cases had a greater number of needle placement series, more intervertebral disc spaces included in each planning series and higher machine settings (kVp 120; mA 87.5) than the average-DLP cases (kVp 100; mA 49.9). LIMITATIONS: This study is limited by its retrospective design. CONCLUSION: CT-guided interlaminar ESIs can be performed safely, with low procedure times, relatively low DLP's and without complications in an older patient population. Key words: Epidural steroid injection, interlaminar approach, CT-guidance, older adults, back pain, lumbar spine, thoracic spine, cervical spine, dose length product, radiation exposure.

Evaluating an Image Gently and Image Wisely Campaign in a Multihospital Health Care System.

PURPOSE: The efficacy of an Image Gently(®)/Image Wisely(®) radiology departmental campaign consisting of the optimization of CT protocols to reduce dose while maintaining quality, and an educational effort to alter the ordering patterns of referring physicians at a multihospital academic center, was evaluated. METHODS: The numbers of CT, MR, and ultrasound studies performed at inpatient, outpatient, and emergency facilities in the hospital system before and after the initiation of the departmental campaign (2010) were obtained for a 10-year period (2004-2014) using a radiology information system. For the same time period, dose per scan (volumetric CT dose index) was obtained through the Dose Index Registry(®)/National Radiology Data Registry for frequently performed studies. Descriptive statistics were used to analyze temporal trends in radiation dose and utilization across differing age groups: <20, 20 to 39, and 40 to 59 years. RESULTS: The radiology information system yielded 865,879 imaging examinations and 4,508,030 patients. Although patient and imaging volume grew annually over the study period (by 6.8% and 4.9%, respectively), CT utilization as a percentage of total imaging decreased, compensated for by an increase in ultrasound use. This was most marked in the youngest age group. MR use as a percentage of total imaging was unchanged. The median volumetric CT dose index for each study protocol was reduced or stabilized. CONCLUSIONS: The campaign resulted in a reduction in CT utilization, a reduction in radiation dose per study, and a compensatory rise in ultrasound use. An interactive aggressive educational campaign directed toward referring providers combined with protocol dose reduction efforts can be successful in reducing patient exposure from medical radiation.