CT-Guided Core Needle Biopsy of Nonspinal Bone Lesions: Comparison of Occult and Visible Bone Lesions.

BACKGROUND. CT guidance may be used for biopsy of indeterminate bone lesions detected by MRI or PET/CT that are not visible (i.e., occult) on CT owing to equipment-, patient-, and operator-related factors. OBJECTIVE. The purpose of this study was to assess diagnostic yield (DY) and diagnostic performance of CT-guided core needle biopsy (CNB) of occult nonspinal bone lesions and to identify the most common benign and malignant diagnoses for occult lesions undergoing CNB. METHODS. This retrospective study included 1033 adult patients who underwent CT-guided nonspinal bone CNB between January 2004 and December 2020. Lesions were classified as occult or visible on CT; biopsies of occult lesions were performed by targeting anatomic landmarks using prebiopsy MRI or PET/CT. Pathologic results of CNB were classified as diagnostic or nondiagnostic to calculate DY of CNB. For nondiagnostic CNBs, final diagnoses were established by subsequent pathologic, clinical, and imaging follow-up. RESULTS. The sample included 70 patients with occult lesions (mean age, 56.8 years; 38 women, 32 men) and 963 patients with visible lesions (mean age, 59.6 years; 475 women, 488 men). Malignancy rate was lower for occult than for visible lesions (42.9% vs 60.9%, p = .004). DY was lower for occult than for visible lesions (37.1% vs 76.9%, p < .001). Diagnostic performance for detecting malignancy on the basis of final diagnoses was lower for occult than for visible lesions in terms of sensitivity (76.7% vs 93.7%, p = .003), specificity (7.9% vs 56.5%, p < .001), and accuracy (38.2% vs 80.0%, p < .001). Final diagnoses among malignant occult and visible lesions included metastasis (frequencies of 63.3% vs 65.4%), leukemia/lymphoma (33.3% vs 11.6%), and myeloma (3.3% vs 10.4%); final diagnoses among benign occult and visible lesions included red marrow (34.2% vs 8.2%), reactive marrow (26.3% vs 11.8%), and fracture (18.4% vs 3.8%). Occult lesions detected by MRI versus PET/CT had lower malignancy rate (39.3% vs 68.0%, p = .03) and lower DY (30.4% vs 60.0%, p = .01). CONCLUSION. At CT-guided CNB, malignancy rate and DY are lower for occult than for visible lesions. Leukemia/lymphoma and red marrow are more common among occult than visible lesions. CLINICAL IMPACT. Understanding these characteristics can help guide radiologists', referring providers', and patients' expectations when CNB of occult bone lesions is requested and performed.

Safety of omitting routine bleeding tests prior to image-guided musculoskeletal core needle biopsy.

PURPOSE: To evaluate the safety of withholding preprocedure international normalized ratio (INR) and platelet testing in patients undergoing musculoskeletal (MSK) core needle biopsy (CNB). MATERIAL AND METHODS: Initially, a retrospective review of 1,162 consecutive patients undergoing MSK CNB with preprocedural INR and platelet testing was performed. Clinical (age, gender, bleeding disorder, liver disease, anticoagulation use, INR > 2, platelet count <50,000/ul) and biopsy factors (imaging modality, lesion type, biopsy needle gauge, number biopsy samples) were tested for association with bleeding complications. During the second phase, an additional 188 biopsies performed without preprocedural coagulation testing were studied. Categorical variables were compared using Chi-squared or Fisher's exact tests, continuous variables with a student t-test. Multivariate analysis was performed using logistic regression. RESULTS: In the first phase, there was a complication rate of 2.6%, 30/1162. Of the 11 clinical and biopsy factors, soft tissue lesions (p = 0.029) and lesions biopsied under ultrasound (p = 0.048) had a higher rate of bleeding than bone lesions or lesions biopsied under CT, respectively. Only three patients had an INR >2, 0.3% (3/1162) and only four patients had platelet count <50,000/ul, 0.3% (4/1162). No patient with a bleeding complication had an abnormal preprocedure bleeding test. In the second phase, there was a bleeding complication rate of 1.1% (2/188). CONCLUSION: Bleeding complications from MSK biopsy are low, even when preprocedure coagulation testing is omitted.

JOURNAL CLUB: Utility of Repeat Core Needle Biopsy of Musculoskeletal Lesions With Initially Nondiagnostic Findings.

OBJECTIVE: The purpose of the present study is to assess the utility of repeat image-guided core needle biopsy (CNB) of musculoskeletal lesions in the setting of initially nondiagnostic CNB findings. MATERIALS AND METHODS: A retrospective review was conducted of 1302 consecutive CNBs performed on bone or soft-tissue lesions at a single institution. Pediatric cases and spine lesions were not included. All cases for which a repeat biopsy of the same lesion was performed because biopsy results were nondiagnostic were included in the study. Tumor characteristics, such as lesion size and type (i.e., bone vs soft tissue), were correlated with the diagnostic yield on repeat biopsy. Technical factors, including the modality used, the number of passes performed, the gauge of the biopsy device, the time between biopsies, the radiologist performing the procedure, and the portion of the lesion biopsied, were also correlated. RESULTS: Twenty-six of the 1302 CNBs (2.0%) performed had been referred for repeat biopsy. A diagnosis was obtained for 10 of these 26 cases (38.5%) after repeat CNB. For five of the cases (19.2%), repeat CNB yielded a diagnosis of malignancy. Overall, 11 cases ultimately had histologic findings indicating malignancy, and five of these cases (45.4%) had diagnostic findings after rebiopsy. Of the 14 cases that were found to be benign, five (35.7%) had diagnostic findings after rebiopsy. One case was lost to follow-up. A statistically significant difference in the diagnostic yield was found in association with an increase in the number of passes (p = 0.047) and an increase in time (p = 0.020) between biopsies. CONCLUSION: Repeat CNB of musculoskeletal lesions with initially nondiagnostic biopsy findings can be useful. Increasing the number of passes on the second biopsy attempt is recommended.

Comparison of Battery-Powered and Manual Bone Biopsy Systems for Core Needle Biopsy of Sclerotic Bone Lesions.

OBJECTIVE: The purpose of this study was to compare manual and battery-powered bone biopsy systems for diagnostic yield and procedural factors during core needle biopsy of sclerotic bone lesions. MATERIALS AND METHODS: A total of 155 consecutive CT-guided core needle biopsies of sclerotic bone lesions were performed at one institution from January 2006 to November 2014. Before March 2012, lesions were biopsied with manual bone drill systems. After March 2012, most biopsies were performed with a battery-powered system and either noncoaxial or coaxial biopsy needles. Diagnostic yield, crush artifact, CT procedure time, procedure radiation dose, conscious sedation dose, and complications were compared between the manual and battery-powered core needle biopsy systems by Fisher exact test and t test. One-way ANOVA was used for subgroup analysis of the two battery-powered systems for procedure time and radiation dose. RESULTS: The diagnostic yield for all sclerotic lesions was 60.0% (93/155) and was significantly higher with the battery-powered system (73.0% [27/37]) than with the manual systems (55.9% [66/118]) (p = 0.047). There was no significant difference between the two systems in terms of crush artifact, procedure time, radiation dose, conscious sedation administered, or complications. In subgroup analysis, the coaxial battery-powered biopsies had shorter procedure times (p = 0.01) and lower radiation doses (p = 0.002) than the coaxial manual systems, but the noncoaxial battery-powered biopsies had longer average procedure times and higher radiation doses than the coaxial manual systems. CONCLUSION: In biopsy of sclerotic bone lesions, use of a battery-powered bone drill system improves diagnostic yield over use of a manual system.

Imaging of adult flatfoot: correlation of radiographic measurements with MRI.

OBJECTIVE. The purpose of this study is to determine whether radiographic foot measurements can predict injury of the posterior tibial tendon (PTT) and the supporting structures of the medial longitudinal arch as diagnosed on MRI. MATERIALS AND METHODS. After institutional review board approval, 100 consecutive patients with radiographic and MRI examinations performed within a 2-month period were enrolled. Thirty-one patients had PTT dysfunction clinically, and 69 patients had other causes of ankle pain. Talonavicular uncoverage angle, incongruency angle, calcaneal pitch angle, Meary angle, cuneiform-to-fifth metatarsal height, and talar tilt were calculated on standing foot or ankle radiographs. MRI was used to assess for abnormalities of the PTT (tenosynovitis, tendinosis, and tear) and supporting structures of the medial longitudinal arch (spring ligament, deltoid ligament, and sinus tarsi). Statistical analysis was performed using the chi-square and Fisher exact tests for categoric variables; the Student t test was used for continuous variables. RESULTS. There was a statistically significant association of PTT tear with abnormal talonavicular uncoverage angle, calcaneal pitch angle, Meary angle, and cuneiform-to-fifth metatarsal height. PTT tendinosis and isolated tenosynovitis had a poor association with most radiologic measurements. If both calcaneal pitch and Meary angles were normal, no PTT tear was present. An abnormal calcaneal pitch angle had the best association with injury to the supporting medial longitudinal arch structures. CONCLUSION. Radiographic measurements, especially calcaneal pitch and Meary angles, can be useful in detecting PTT tears. Calcaneal pitch angle provides the best assessment of injury to the supporting structures of the medial longitudinal arch.

A Practical Guide to MR Imaging Safety: What Radiologists Need to Know.

Magnetic resonance (MR) imaging can provide critical diagnostic and anatomic information while avoiding the use of ionizing radiation, but it has a unique set of safety risks associated with its reliance on large static and changing magnetic fields, high-powered radiofrequency coil systems, and exogenous contrast agents. It is crucial for radiologists to understand these risks and how to mitigate them to protect themselves, their colleagues, and their patients from avoidable harm and to comply with safety regulations at MR imaging sites. Basic knowledge of MR imaging physics and hardware is necessary for radiologists to understand the origin of safety regulations and to avoid common misconceptions that could compromise safety. Each of the components of the MR imaging unit can be a factor in injuries to patients and personnel. Safety risks include translational force and torque, projectile injury, excessive specific absorption rate, burns, peripheral neurostimulation, interactions with active implants and devices, and acoustic injury. Standards for MR imaging device safety terminology were first issued in 2005 and are required by the U.S. Food and Drug Administration, with devices labeled as "MR safe," "MR unsafe," or "MR conditional." MR imaging contrast agent safety is also discussed. Additional technical and safety policies relate to pediatric, unconscious, incapacitated, or pregnant patients and pregnant imaging personnel. Division of the MR imaging environment into four distinct, clearly labeled zones--with progressive restriction of entry and increased supervision for higher zones--is a mandatory and key aspect in avoidance of MR imaging-related accidents. All MR imaging facilities should have a documented plan to handle emergencies within zone IV, including cardiac arrest or code, magnet quench, and fires. Policies from the authors' own practice are provided for additional reference. Online supplemental material is available for this article.

Radiographic scoring system to evaluate union of distal radius fractures.

PURPOSE: To evaluate the intra- and interobserver reliability of a scoring system for distal radius fracture union based on specific radiographic parameters obtainable from x-rays. METHODS: Two sets of 35 anteroposterior and lateral x-rays were obtained by retrospective review of consecutive patients with distal radius fractures (AO types A and C) treated by a single surgeon in 2009. One set was assembled for those patients treated nonsurgically and 1 set for those treated with open reduction and internal fixation (ORIF) with volar plating. Radius union scoring system (RUSS) scores were compiled from a 5-person review panel consisting of hand surgeons and musculoskeletal radiologists. Union of each of the 4 cortices was graded on a 3-point scale (0, fracture line visible with no callus; 1, callus formation but fracture line present; 2, cortical bridging without clear fracture line). Reviewers also recorded their overall impression of fracture union (united or not united). Each set of radiographs was reviewed twice by the 5 reviewers, 2 weeks apart. Inter- and intraobserver reliability were determined using intraclass correlation coefficients. RESULTS: For nonsurgically treated fractures, substantial agreement in union scores was found with regard to both intra- and interobserver reliability. For fractures treated with ORIF, substantial agreement was found in union scores with regard to intraobserver reliability and moderate agreement with regard to interobserver reliability. In addition, when using the reviewers' overall assessment of union as a reference standard, RUSS had a statistically significant predictive value in being able to differentiate between united and not united fractures. CONCLUSIONS: This radiographic union tool demonstrated substantial intra- and interobserver reliability for the determination of fracture union in the distal radius. The RUSS is a simple method for a standardized assessment of radiographic union of DRF treated nonsurgically or with ORIF. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/decision analysis IV.

Spectrum and detection of musculoskeletal findings on trauma-related CT torso examinations.

This study aims (1) to evaluate the spectrum of musculoskeletal (MSK) findings detected on trauma-related torso CT exams performed in the emergency department and (2) to identify the findings of high clinical importance that are underreported. Following IRB approval, two fellowship-trained MSK radiologists independently reviewed 200 consecutive trauma CT torso examinations performed at a level 1 trauma center, focusing on MSK findings. Discrepancies were resolved by consensus. Findings were categorized as of high, moderate, or low clinical importance based on criteria established with an orthopedic trauma surgeon. Findings evident on only one series (scout, axial, or sagittal/coronal reformations) were documented. The consensus reading was compared to the final report. Unreported findings of high clinical importance were entered into our departmental QA system. Eighty-two percent (164/200) of the studies had at least one MSK finding. There were 433 total findings of varying importance and the overall detection rate was 61 % (266/433). The detection rate for high importance findings was 80 % (177/221) with the majority representing acute fractures (99 %). For findings of high clinical importance, the lowest detection rates were for fractures of the sternum, proximal humerus, and forearm. Of the high severity findings, 6.3 % (14/221) were detected only on sagittal or coronal reformatted or scout images. Twenty percent of musculoskeletal findings of high clinical importance on trauma-related CT torso exams were not reported. Fractures of the sternum, proximal humerus, and forearm were the most commonly missed fractures and review of scout and multiplanar reformations can increase detection.

On-call musculoskeletal radiographs: discrepancy rates between radiology residents and musculoskeletal radiologists.

OBJECTIVE: The purpose of this study was to determine the rate of discrepancy between radiology residents and attending musculoskeletal radiologists in interpretation of on-call musculoskeletal radiographs. MATERIALS AND METHODS: We performed a retrospective review of 2219 consecutive musculoskeletal radiology reports on patients who visited the emergency department between January 2009 and December 2010. The images were initially interpreted overnight by on-call residents (postgraduate years 3-5), and a final interpretation was rendered the next morning by a musculoskeletal radiologist. The reports were evaluated for major discrepancies, such as missed fractures, osteomyelitis, foreign bodies, tumors, and acute arthritic conditions, which were defined as cases in which a change in clinical management was needed and required notification of the emergency care provider. RESULTS: The overall discrepancy rate was 1.8% (40/2219). Fractures accounted for 62.5% (25/40) of missed findings. Fractures involving the upper extremity, particularly the hand and wrist (2.2% [9/405]), were the most frequently missed. Radial fractures accounted for 50% (7/14) of the missed upper extremity fractures. Foreign bodies (10% [4/40]) and tumorlike lesions (7.5% [3/40]) accounted for the next most common misses. Finally, independent resident readings in the on-call setting had little adverse effect on patient care. CONCLUSION: In the on-call setting, the low discrepancy rate between interpretations of musculoskeletal radiographs by residents and by musculoskeletal attending radiologists is comparable to that reported for other body parts and modalities. Residents should be aware of the relatively high rate of missed pathologic findings in the upper extremity, especially the radius.

Lipomatosis of the sciatic nerve secondary to compression by a desmoid tumor.

Lipomatosis of nerve is a rare benign tumor-like process characterized by infiltration of the epineurium by adipose and fibrous tissue leading to nerve enlargement. We describe a case of lipomatosis of the sciatic nerve compressed by an adjacent desmoid tumor. This case supports the hypothesis that lipomatosis of nerve may form as a result of irritation or compression by adjacent structures.

Clinical and radiologic predictive factors of septic hip arthritis.

OBJECTIVE: The purpose of our study was to identify the clinical and radiologic factors associated with a positive culture during image-guided hip joint aspiration. MATERIALS AND METHODS: We performed a retrospective analysis of 167 consecutive hip aspirations for septic arthritis at a large tertiary medical center. Chart review was performed on the following clinical factors: serum WBC count≥11×10(3)/µL, serum erythrocyte sedimentation rate (ESR)≥20 mm/h, C-reactive protein (CRP)≥100 mg/L, synovial fluid WBC count, synovial fluid polymorphonuclear (PMN) leukocytes≥90%, fever, immunosuppression, antibiotic use, diabetes, presence of a prosthesis, and IV drug use (IVDU). Radiologic studies were reviewed for the following imaging and technical factors: presence of a sinus tract, fluid turbidity, volume of fluid (mL) aspirated, and whether the fluid analyzed was primarily aspirated or reaspirated after lavage. Logistic regression was used to calculate odds ratio (OR) and 95% CI. RESULTS: Of the 167 aspirations, 29 (17.4%) had positive cultures; 6 of 29 (20.7%) positive cultures occurred in reaspirated lavage fluid. On multivariate analysis using logistic regression with stepwise backward elimination, the significant clinical and radiologic predictors were elevated WBC (OR, 4.4; 95% CI, 1.1-17.3), high percentage of synovial fluid PMN leukocytes (OR, 10.6; 95% CI, 2.9-39.8), IVDU (OR, 9.0; 95% CI, 1.3-64.7), and fluid turbidity (OR, 20.5; 95% CI, 6.9-61.4). CONCLUSION: Positive hip cultures are associated with elevated serum WBC, IVDU, high percentage of synovial fluid PMN leukocytes, and fluid aspirate turbidity. Reaspiration of lavage fluid with either nonbacteriostatic saline or contrast material can yield positive cultures.

Correlation between quantified breast densities from digital mammography and 18F-FDG PET uptake.

To correlate breast density quantified from digital mammograms with mean and maximum standardized uptake values (SUVs) from positron emission tomography (PET). This was a prospective study that included 56 women with a history of suspicion of breast cancer (mean age 49.2 +/- 9.3 years), who underwent 18F-fluoro-2-deoxyglucose (FDG)-PET imaging of their breasts as well as digital mammography. A computer thresholding algorithm was applied to the contralateral nonmalignant breasts to quantitatively estimate the breast density on digital mammograms. The breasts were also classified into one of four Breast Imaging Reporting and Data System categories for density. Comparisons between SUV and breast density were made using linear regression and the Student's t-test. Linear regression of mean SUV versus average breast density showed a positive relationship with a Pearson's correlation coefficient of R(2) = 0.83. The quantified breast densities and mean SUVs were significantly greater for mammographically dense than nondense breasts (p < 0.0001 for both). The average quantified densities and mean SUVs of the breasts were significantly greater for premenopausal than postmenopausal patients (p < 0.05). 8/51 (16%) of the patients had maximum SUVs that equaled 1.6 or greater. There is a positive linear correlation between quantified breast density on digital mammography and FDG uptake on PET. Menopausal status affects the metabolic activity of normal breast tissue, resulting in higher SUVs in pre- versus postmenopausal patients.

Clinical and Radiologic Predictive Factors of Rib Fractures in Outpatients With Chest Pain.

PURPOSE: To identify the clinical and radiologic predictive factors of rib fractures in stable adult outpatients presenting with chest pain and to determine the utility of dedicated rib radiographs in this population of patients. METHOD AND MATERIALS: Following Institutional Review Board approval, we performed a retrospective review of 339 consecutive cases in which a frontal chest radiograph and dedicated rib series had been obtained for chest pain in the outpatient setting. The frontal chest radiograph and dedicated rib series were sequentially reviewed in consensus by two fellowship-trained musculoskeletal radiologists blinded to the initial report. The consensus interpretation of the dedicated rib series was used as the gold standard. Multiple variable logistic regression analysis assessed clinical and radiological factors associated with rib fractures. Fisher exact test was used to assess differences in medical treatment between the 2 groups. RESULTS: Of the 339 patients, 53 (15.6%) had at least 1 rib fracture. Only 20 of the 53 (37.7%) patients' fractures could be identified on the frontal chest radiograph. The frontal chest radiograph had a sensitivity of 38% and specificity of 100% when using the rib series as the reference standard. No pneumothorax, new mediastinal widening or pulmonary contusion was identified. Multiple variable logistic regression analysis of clinical factors associated with the presence of rib fractures revealed a significant association of trauma history (odds ratio 5.7 [p < 0.05]) and age ≥40 (odds radio 3.1 [p < 0.05]). Multiple variable logistic regression analysis of radiographic factors associated with rib fractures in this population demonstrated a significant association of pleural effusion with rib fractures (odds ratio 18.9 [p < 0.05]). Patients with rib fractures received narcotic analgesia in 47.2% of the cases, significantly more than those without rib fractures (21.3%, p < 0.05). None of the patients required hospitalization. CONCLUSION: In the stable outpatient setting, rib fractures have a higher association with a history of minor trauma and age ≥40 in the adult population. Radiographic findings associated with rib fractures include pleural effusion. The frontal chest radiograph alone has low sensitivity in detecting rib fractures. The dedicated rib series detected a greater number of rib fractures. Although no patients required hospitalization, those with rib fractures were more likely to receive narcotic analgesia.

The Science of Quality Improvement.

Scientific rigor should be consistently applied to quality improvement (QI) research to ensure that healthcare interventions improve quality and patient safety before widespread implementation. This article provides an overview of the various study designs that can be used for QI research depending on the stage of investigation, scope of the QI intervention, constraints on the researchers and intervention being studied, and evidence needed to support widespread implementation. The most commonly used designs in QI studies are quasi-experimental designs. Randomized controlled trials and cluster randomized trials are typically reserved for large-scale research projects evaluating the effectiveness of QI interventions that may be implemented broadly, have more than a minimal impact on patients, or are costly. Systematic reviews of QI studies will play an important role in providing overviews of evidence supporting particular QI interventions or methods of achieving change. We also review the general requirements for developing quality measures for reimbursement, public reporting, and pay-for-performance initiatives. A critical part of the testing process for quality measures includes assessment of feasibility, reliability, validity, and unintended consequences. Finally, publication and critical appraisal of QI work is discussed as an essential component to generating evidence supporting QI initiatives in radiology.

Radiology Research in Quality and Safety: Current Trends and Future Needs.

Promoting quality and safety research is now essential for radiology as reimbursement is increasingly tied to measures of quality, patient safety, efficiency, and appropriateness of imaging. This article provides an overview of key features necessary to promote successful quality improvement efforts in radiology. Emphasis is given to current trends and future opportunities for directing research. Establishing and maintaining a culture of safety is paramount to organizations wishing to improve patient care. The correct culture must be in place to support quality initiatives and create accountability for patient care. Focused educational curricula are necessary to teach quality and safety-related skills and behaviors to trainees, staff members, and physicians. The increasingly complex healthcare landscape requires that organizations build effective data infrastructures to support quality and safety research. Incident reporting systems designed specifically for medical imaging will benefit quality improvement initiatives by identifying and learning from system errors, enhancing knowledge about safety, and creating safer systems through the implementation of standardized practices and standards. Finally, validated performance measures must be developed to accurately reflect the value of the care we provide for our patients and referring providers. Common metrics used in radiology are reviewed with focus on current and future opportunities for investigation.

How-I-Do-It: Teaching Root Cause Analysis.

We describe our method of exposing radiology residents to root cause analysis. Our interactive case-based, small-group teaching session uses a flipped classroom approach which allows the session to focus primarily on working through the case in small groups. This methodology can be easily integrated at other institutions.

Teaching Principles of Patient-Centered Care During Radiology Residency.

RATIONALE AND OBJECTIVES: Patient-centered healthcare delivery has become increasingly established as a cornerstone of quality medical care, but teaching these principles in a radiology residency setting is often difficult and ineffective in a traditional lecture format. We developed a novel educational session in which actual patient letters about a healthcare provider are used to facilitate a case-based discussion of key principles of patient-centered care. MATERIALS AND METHODS: A novel patient letter-facilitated, case-based session was conducted at two different university-based teaching institutions. Prior to the educational session, patient letters introducing the principles of patient-centered care were distributed to residents for review. During the session, radiology-specific cases were discussed in the context of the principles introduced by the letters. A post-session survey was administered to evaluate the efficacy and usefulness of the session. RESULTS: Forty-six of the 61 session attendees (75%) completed the post session survey. Most respondents (93%) preferred this case-based, interactive session to a typical didactic session. A majority of the residents indicated that both the patient letters (64%) and radiology specific cases (73%) helped them think differently about how they interact with patients. They indicated that the session enhanced their understanding of professionalism (3.7 out of 5.0 [95% CI 3.4-4.0]) and increased their motivation to become more patient-centered (3.0 out of 4.0 [95% CI 2.8-3.3]). CONCLUSIONS: Our findings suggest that patient letter-facilitated, case-based sessions may influence resident attitudes regarding the principles of patient-centered care and may help to increase resident motivation to become more patient-centered in their own practice.