Breast magnetic resonance imaging: are those who need it getting it?

BACKGROUND: Indications for breast magnetic resonance imaging (mri), a very sensitive but less-specific tool for breast investigation, remain controversial, and accessibility is limited. The purposes of our study were to determine the proportion of breast mri exams performed for various clinical indications, to assess the wait times for breast mri, and to create a list of evidence-based indications for breast mri. METHODS: The indications for breast mri exams performed in September 2013 at our academic centre were audited. A multidisciplinary meeting held in May 2014 established a list of evidence-based indications for breast mri, after which, in September 2014 and 2015, breast mri exams were re-audited for clinical indications, and pending requests were calculated. RESULTS: In September 2013, surveillance of women with a prior diagnosis of breast cancer represented 21% of breast mri exams (24 of 113), with preoperative staging representing 18% of exams (20 of 113) and high-risk screening representing 12% (13 of 113). Of pending mri requests, 230 were within the recommended delay period, and 457 exceeded the recommended delay. After elaboration of evidence-based guidelines, repeat audits in September 2014 and September 2015 showed that mri performed for women with a prior breast cancer diagnosis represented 23% (33 of 141) and 7% (10 of 143) of exams respectively, with preoperative staging having declined to 9% (13 of 141) and 11% (16 of 143) of exams, and high-risk screening having increased to 36% (51 of 141) and 46% (66 of 143) of exams. Overall, wait times were improved for all breast mri indications. CONCLUSIONS: Through multidisciplinary discussion, we actualized a list of breast mri indications, prioritized requests more adequately, and improved wait times.

Recommendations on breast cancer screening and prevention in the context of implementing risk stratification: impending changes to current policies.

In recent years, risk stratification has sparked interest as an innovative approach to disease screening and prevention. The approach effectively personalizes individual risk, opening the way to screening and prevention interventions that are adapted to subpopulations. The international perspective project, which is developing risk stratification for breast cancer, aims to support the integration of its screening approach into clinical practice through comprehensive tool-building. Policies and guidelines for risk stratification-unlike those for population screening programs, which are currently well regulated-are still under development. Indeed, the development of guidelines for risk stratification reflects the translational aspects of perspective. Here, we describe the risk stratification process that was devised in the context of perspective, and we then explain the consensus-based method used to develop recommendations for breast cancer screening and prevention in a risk-stratification approach. Lastly, we discuss how the recommendations might affect current screening policies.

The role of community pharmacists in the prevention and management of osteoporosis and the risk of falls: results of a cross-sectional study and qualitative interviews.

UNLABELLED: In a mailed survey and qualitative interviews, it was observed that community pharmacists and public health authorities believe that pharmacists should play a significant role in the prevention and management of osteoporosis and the risk of falls. However, pharmacists acknowledge a wide gap between their ideal and actual levels of involvement. INTRODUCTION: The aim of this study was to explore perceptions of community pharmacists and public health authorities regarding the role of pharmacists in providing services in relation to osteoporosis and risk of falls and the barriers to providing them. METHODS: Using a modified five-step version of Dillman's tailored design method, a questionnaire was mailed to a random sample of 1,250 community pharmacists practicing in Montreal (Quebec, Canada) and surrounding areas. A similar questionnaire was sent to public health officers in these regions. Additionally, telephone interviews were conducted with regional and ministry level public health officers. RESULTS: Of the 1,250 pharmacists contacted, 28 were ineligible. In all, 571 of 1,222 (46.7 %) eligible community pharmacists and all the public health officers returned the questionnaire. Six public health officers (five regional and one at ministry level) were interviewed. Most pharmacists believed they should be involved in screening for osteoporosis (46.6 %) and risk of falls (50.3 %); however, fewer reported actually being involved in such services (17.4 % and 19.2 %, respectively). In their view, the main barriers to providing these services in current practice were lack of time (78.8 %), lack of clinical tools (65.4 %), and lack of coordination with other healthcare professionals (54.5 %). Public health authorities also thought community pharmacists should play a significant role in providing osteoporosis and fall risk services. However, few community pharmacist-mediated activities are in place in the participating regions. CONCLUSIONS: Although community pharmacists and public health authorities believe pharmacists should play a significant role with regard to osteoporosis and the risk of falls, they acknowledge a wide gap between the ideal and actual levels of pharmacist involvement.

Tips and techniques in breast MRI.

The standard breast MRI protocol includes T2 sequences (anatomy and signal analysis), T1 gradient-echo sequences which can detect markers placed after biopsy, and injected dynamic 3D sequences for performing volume and multiplanar reconstructions, which are particularly useful for locating lesions well. Good patient positioning is essential and is obtained by using foam wedges for small breasts, ensuring there are no folds, and the correct position of the nipples. These aspects limit movement artefacts which alter subtraction sequences, so that it must always be possible for reading these sequences to be assisted by comparing them with the native sequences. New functional imaging sequences are now appearing in an attempt to increase the specificity of MRI, which is one of its main limitations. Of these, magnetic resonance spectroscopy appears to be the most promising, highlighting an abnormal choline peak in malignant lesions. This molecular signature provides early information (24 hours after beginning neoadjuvant treatment) on the chemosensitivity of a breast tumour.

Use of a dual-labelled oligonucleotide as a DNA dosemeter for radiological exposure detection.

A reporter molecule consisting of a synthetic oligonucleotide is being characterised for a novel damage detection scenario for its potential use as a field-deployable, personal deoxyribonucleic acid (DNA) dosemeter for radiation detection. This dosemeter is devoid of any biological properties other than being naked DNA and therefore has no DNA repair capabilities. It supports biodosimetry techniques, which require lengthy analysis of cells from irradiated individuals, and improves upon inorganic dosimetry, thereby providing for a more relevant means of measuring the accumulated dose from a potentially mixed-radiation field. Radiation-induced single strand breaks (SSBs) within the DNA result in a quantifiable fluorescent signal. Proof of concept has been achieved over 250 mGy-10 Gy dose range in radiation fields from 6°Co, with similar results seen using a linear accelerator X-ray source. Further refinements to both the molecule and the exposure/detection platform are expected to lead to enhanced levels of detection for mixed-field radiological events.

Effectiveness of interventions to improve the detection and treatment of osteoporosis in primary care settings: a systematic review and meta-analysis.

This study aims to evaluate the effectiveness of primary care interventions to improve the detection and treatment of osteoporosis. Eight electronic databases and six gray literature sources were searched. Randomized controlled trials, controlled clinical trials, quasi-randomized trials, controlled before-after studies, and interrupted time series written in English or French from 1985 to 2009 were considered. Eligible studies had to include patients at risk (women ≥ 65 years, men ≥ 70 years, and men/women ≥ 50 years with at least one major risk factor for osteoporosis) or at high risk (men/women using oral glucocorticoids or with previous fragility fractures) for osteoporosis and fractures. Outcomes included bone mineral density (BMD) testing, osteoporosis treatment initiation, and fractures. Data were pooled using a random effects model when applicable. Thirteen studies were included. The majority were multifaceted and involved patient educational material, physician notification, and/or physician education. Absolute differences in the incidence of BMD testing ranged from 22% to 51% for high-risk patients only and from 4% to 18% for both at-risk and high-risk patients. Absolute differences in the incidence of osteoporosis treatment initiation ranged from 18% to 29% for high-risk patients only and from 2% to 4% for at-risk and high-risk patients. Pooling the results of six trials showed an increased incidence of osteoporosis treatment initiation (risk difference (RD) = 20%; 95% CI: 7-33%) and of BMD testing and/or osteoporosis treatment initiation (RD = 40%; 95% CI: 32-48%) for high-risk patients following intervention. Multifaceted interventions targeting high-risk patients and their primary care providers may improve the management of osteoporosis, but improvements are often clinically modest.

Multimodality breast cancer screening in women with a familial or genetic predisposition.

BACKGROUND: Women with a predisposition for breast cancer require a tailored screening program for early cancer detection. We evaluated the performance of mammography (MG), ultrasonography (US), and magnetic resonance imaging (MRI) screening in these women. PATIENTS AND METHODS: In asymptomatic women either confirmed as BRCA1/2 carriers, or having a greater than 30% probability of being so as estimated by brcapro [Berry D, Parmigiani G. Duke SPORE (Specialized Program of Research Excellence) in Breast Cancer. 1999], we conducted a prospective comparative trial consisting of annual MRI and MG, and biannual US and clinical breast examination. All evaluations were done within 30 days of one another. For each screening round, imaging tests were independently interpreted by three radiologists. RESULTS: The study enrolled 184 women, and 387 screening rounds were performed, detecting 12 cancers (9 infiltrating, 3 in situ), for an overall cancer yield of 6.5%. At diagnosis, 7 infiltrating cancers were smaller than 2 cm (T1); only 1 woman presented with axillary nodal metastases. All tumours were negative for the human epidermal growth factor receptor 2. Of the 12 cancers, MRI detected 10, and MG, 7; US did not identify any additional cancers. The overall recall rate after MRI was 21.8%, as compared with 11.4% for US and 16.1% for MG. Recall rates declined with successive screening rounds. In total, 45 biopsies were performed: 21 as a result of an US abnormality; 17, because of an MRI lesion; and 7, because of a MG anomaly. INTERPRETATION: In high-risk women, MRI offers the best sensitivity for breast cancer screening. The combination of yearly MRI and MG reached a negative predictive value of 100%. The recall rate is greatest with MRI, but declines for all modalities with successive screening rounds.

Impact of a primary care physician workshop on osteoporosis medical practices.

SUMMARY: Attendance at a fragility-fractures-prevention workshop by primary care physicians was associated with higher rates of osteoporosis screening and treatment initiation in elderly female patients and higher rates of treatment initiation in high-risk male and female patients. However, osteoporosis management remained sub-optimal, particularly in men. INTRODUCTION: Rates of osteoporosis-related medical practices of primary care physicians exposed to a fragility-fractures-prevention workshop were compared with those of unexposed physicians. METHODS: In a cluster cohort study, 26 physicians exposed to a workshop were matched with 260 unexposed physicians by sex and year of graduation. For each physician, rates of bone mineral density (BMD) testing and osteoporosis treatment initiation among his/her elderly patients 1 year following the workshop were computed. Rates were compared using multilevel logistic regression models controlling for potential patient- and physician-level confounders. RESULTS: Twenty-five exposed physicians (1,124 patients) and 209 unexposed physicians (9,663 patients) followed at least one eligible patient. In women, followed by exposed physicians, higher rates of BMD testing [8.5% versus 4.2%, adjusted OR (aOR) = 2.81, 95% CI 1.60-4.94] and treatment initiation with bone-specific drugs (BSDs; 4.8% vs. 2.4%, aOR = 1.95, 1.06-3.60) were observed. In men, no differences were detected. In patients on long-term glucocorticoid therapy or with a previous osteoporotic fracture, higher rates of treatment initiation with BSDs were observed in women (12.0% vs. 1.9%, aOR = 7.38, 1.55-35.26), and men were more likely to initiate calcium/vitamin D (5.3% vs. 0.8%, aOR = 7.14, 1.16-44.06). CONCLUSIONS: Attendance at a primary care physician workshop was associated with higher rates of osteoporosis medical practices for elderly women and high-risk men and women. However, osteoporosis detection and treatment remained sub-optimal, particularly in men.

Better adherence to antihypertensive agents and risk reduction of chronic heart failure.

AIMS: Antihypertensive (AH) agents have been shown to reduce the risk of major cardiovascular events including chronic heart failure (CHF). However, the impact of changes in patterns of AH agents use on CHF is unknown. Our objective was to estimate to which different patterns of AH agent use is associated with the occurrence of CHF in a population-based study. METHOD AND RESULTS: A cohort of 82 320 patients was reconstructed using the Régie de l'assurance maladie du Québec's databases. Patients were eligible if they were between 45 to 85 years of age, had no indication of cardiovascular disease and were newly treated with AH therapy between 1999 and 2004. A nested case-control design was used to study the occurrence of CHF. Every case of CHF was matched for age and duration of follow-up to a maximum of 15 randomly selected controls. Adherence level was reported as a medication possession ratio. Conditional logistic regression models were used to estimate the rate ratio (RR) of CHF adjusting for different covariables. The mean patient age was 65 years, 37% were male, 8% had diabetes, 19% had dyslipidaemia and mean time of follow-up at 2.7 years. High adherence level (95%) to AH therapy compared with lower adherence level (60%) was associated with an additional reduction of CHF events (RR: 0.89; 0.80-0.99). Risk factors for CHF were being on social assistance, diabetes, dyslipidaemia, higher chronic disease score and developing a cardiovascular condition during follow-up. CONCLUSION: Our study suggests that a better adherence is associated with a significant risk reduction of CHF. Adherence to AH therapy needs to be improved to optimize benefits.

Effect of storage media, temperature, and time on preservation of Cryptosporidium parvum oocysts for PCR analysis.

The effect of storage media, temperature, and time on suitability of oocysts for use in subsequent molecular studies was examined. Cryptosporidium parvum oocysts were stored for 3, 6, 9, or 12 months in sterile dH(2)O, 70 or 95% ethanol, (room temperature [RT], 4, -20, and -70 degrees C), 10% formalin (RT and 4 degrees C), PBS, TE buffer, antibiotic-antimycotic (A-A) solution (4, -20 and -70 degrees C), 2% sulphuric acid, 2.5% potassium dichromate (4 degrees C), and gDNA from 10(4) oocysts was extracted in triplicate and subjected to PCR. To determine the effect of storage media on PCR sensitivity, gDNA from 10(4), 10(2), and 10(0) oocysts stored for 15 months in the media listed above at RT or 4 degrees C was also extracted in triplicate and subjected to PCR. At RT, ethanol was suitable for up to 15 months, while gDNA from oocysts stored in dH(2)O amplified inconsistently after 3 months. At 4 degrees C, all tested media except dH(2)O and formalin were suitable for storage of 10(4) oocysts up to 15 months, but only 70% ethanol, A-A solution, 2% sulphuric acid and 2.5% potassium dichromate supported amplification of gDNA from fewer than 100 oocysts. At -20 degrees C, 95% ethanol, PBS, or TE were suitable for up to 9 months, while 70% ethanol and A-A solution were effective up to 12 months, and gDNA from oocysts stored in dH(2)O was inconsistently amplified after 6 months. Storage at -70 degrees C for up to 12 months was effective regardless of media type. Oocysts stored in formalin at RT or 4 degrees C could not be amplified by PCR despite washing prior to gDNA extraction. To maintain gDNA quality suitable for PCR, it is recommended that coccidian oocysts be stored at -70 degrees C in dH(2)O, ethanol, PBS, TE or A-A solution, at 4 degrees C in A-A or ethanol, or at RT in ethanol where refrigerated storage is unavailable.

Persistence and determinants of statin therapy among middle-aged patients for primary and secondary prevention.

AIMS: Statins have been shown to significantly reduce morbidity and mortality in patients with coronary artery disease (CAD), and also in patients with dyslipidaemia when statins are taken regularly. Middle-aged patients have the highest level of forecasting benefit and little is known about persistence rate of these therapies in a real-life setting. The objective was to evaluate the persistence rate of middle-aged patients initiating a statin therapy and its relation with several determinants for primary and secondary prevention. METHODS: A cohort was reconstructed using the RAMQ databases. All patients aged 50-64 years-old who received at least one statin prescription between 1 January, 1998 and 31 December, 2000 for a new intention of treatment for dyslipidaemia were included in the cohort and followed up until 30 June, 2001. The date of the first prescription of statin was defined as the index date. There were 4316 patients in the secondary prevention (CAD diagnosis) and 13,642 patients in primary prevention cohort. The cumulative persistence rate was estimated using Kaplan-Meier, and Cox regression models were used to estimate the hazard ratio of ceasing statins. RESULTS: We found that persistence with statins had fallen to 71% after 6 months of treatment, and had declined to 45% after 3 years in the secondary prevention cohort; the corresponding figures were 65% and 35% in the primary prevention cohort. Our results suggest that patients with dyslipidaemia in primary prevention compared with those in secondary prevention (HR: 1.18; 1.11-1.25) are less likely to be persistent. Patients with other cardiovascular risk factors such as age (HR: 0.99; 0.98-0.99), diabetes (HR: 0.84; 0.79-0.90), hypertension (HR: 0.76; 0.72-0.80) were most likely to be persistent with statins. We observed lower persistence in patients who have used the greatest number of pharmacies and prescribing physicians. CONCLUSION: This analysis indicates that barriers to persistence occur early in the therapeutic course. Overall persistence with statins is low, and particularly among patients with few other cardiovascular risk factors.

Health-related quality of life with coronary heart disease prevention and treatment.

Estimating the net benefits of dyslipidemia treatment is limited by the lack of comprehensive and standardized information on the preference for dyslipidemia and coronary heart disease. In a hospital-based study, we measured the health-related quality of life (HRQOL) of healthy participants without dyslipidemia (n = 307) and with dyslipidemia (n = 251) and patients with coronary heart disease (n = 320). Compared to the healthy participants without dyslipidemia, those with dyslipidemia reported lower adjusted mean scores on the Rating Scale (-2.8 points, P = 0.02) and the SF-36 General Health Scale (-3.3 points, P = 0.02). No differences were observed on the Time Trade-off and the Standard Gamble Scales. Coronary patients reported lower scores on all preference scales and most SF-36 scales. The causes of the small but real reduction in HRQOL reported by dyslipidemic individuals should be identified in order to optimize the net benefits of lipid therapy.

Variation over time of the effects of prognostic factors in a population-based study of colon cancer: comparison of statistical models.

The authors compare the performance of different regression models for censored survival data in modeling the impact of prognostic factors on all-cause mortality in colon cancer. The data were for 1,951 patients, who were diagnosed in 1977-1991, recorded by the Registry of Digestive Tumors of Côte d'Or, France, and followed for up to 15 years. Models include the Cox proportional hazards model and its three generalizations that allow for hazard ratio to change over time: 1) the piecewise model where hazard ratio is a step function; 2) the model with interaction between a predictor and a parametric function of time; and 3) the non-parametric regression spline model. Results illustrate the importance of accounting for non-proportionality of hazards, and some advantages of flexible non-parametric modeling of time-dependent effects. The authors provide empirical evidence for the dependence of the results of piecewise and parametric models on arbitrary a priori choices, regarding the number of time intervals and specific parametric function, which may lead to biased estimates and low statistical power. The authors demonstrate that a single, a priori selected spline model recovers a variety of patterns of changes in hazard ratio and fits better than other models, especially when the changes are non-monotonic, as in the case of cancer stages.

Comparing the psychometric properties of preference-based and nonpreference-based health-related quality of life in coronary heart disease. Canadian Collaborative Cardiac Assessment Group.

A cross-sectional survey (n = 878) was conducted to compare the psychometric properties of three preference-based and one nonpreference-based health-related quality of life measures among healthy subjects with and without treatment for dyslipidemia and/or hypertension and patients with coronary heart disease (CHD). All measures were stable over a 3 to 6 week period. Compared to the Time Trade-off (TTO) and the Standard Gamble (SG), the Rating Scale (RS) correlated with the SF-36 Health Survey most highly. In contrast to the SF-36 General Health Perception (GHP), the SF-36 Physical Component scale and the RS, the TTO and SG were less able to discriminate CHD patients with various levels of physical disability. Only the SF-36 GHP subscale and the RS were able to differentiate healthy participants from participants receiving dyslipidemia and/or hypertension treatment. Neither the SF-36 Physical or Mental Component scales were able to discriminate these two groups. Overall, these results suggest that unlike the RS, the TTO and the SG, as administered in this study, may not be sufficiently sensitive to measure the impact of primary cardiovascular disease prevention strategies on the health-related quality of life of the participants.

Conventional and chained standard gambles in the assessment of coronary heart disease prevention and treatment. Canadian Collaborative Cardiac Assessment Group.

The authors compared the abilities of descriptive and valuational health-related quality-of-life measures to discriminate healthy participants (n=39) from those on diets for dyslipidemia (n=35) and angina patients (n=30). On the rating scale, the time tradeoff, and the General Health Perception subscale of the SF-36 Health Survey, the participants with dyslipidemia or angina reported lower mean scores than the healthy participants. No differences were detected between these groups on conventional or chained standard gamble (SG) scales. The distribution of the conventional and the chained SG scores was very skewed, with the vast majority of scores being equal or very close to the maximum score. It is concluded that in this study the discriminant ability of the chained SG was comparable to that of the conventional SG and inferior to descriptive and non-risky valuational scaling techniques. This may be explained by the distortion of probabilities, by a misunderstanding of the SG chained assessment, and by a strong certainty effect.

Level of suspicion of a mammographic lesion: use of features defined by BI-RADS lexicon and correlation with large-core breast biopsy.

OBJECTIVE: To determine whether the categories defined in the Breast Imaging Reporting and Data System (BI-RADS) are useful predictors of malignancy and to assess their positive predictive value. PATIENTS AND METHODS: A retrospective study was undertaken from July 1, 1994, to June 30, 1995. Of 568 abnormal mammograms for which largecore biopsy was recommended, 495 were available for review. The mammographic features of the lesions, as defined by the BI-RADS lexicon, were used to assess the level of suspicion. The lesions were classified as "probably benign," "suspicious" or "highly suggestive of malignancy." These diagnostic impressions were then correlated with the histologic diagnosis made after core biopsy. RESULTS: The diagnostic impressions before core biopsy were as followed: 16 (3%) benign lesions, 397 (80%) suspicious lesions and 82 (17%) lesions highly suggestive of malignancy. All benign lesions remained in the same category after core biopsy, whereas, of the suspicious lesions, 91% were diagnosed as benign, only 4% as malignant, and the other 5% as atypical hyperplasia. Among the lesions highly suggestive of malignancy according to the BI-RADS lexicon, 54% were found to be malignant at core biopsy. CONCLUSION: The BI-RADS lexicon is helpful in discriminating between lesions that are probably benign and probably malignant from the mammographic features. However, the rate of malignancy in the "suspicious" category is low.

Exposure to ionizing radiation increases responsiveness to neural secretory stimuli in the ferret jejunum in vitro.

Experiments were designed to determine the effects of ionizing radiation on jejunal epithelial function in the ferret in vitro. Basal and stimulated electrolyte transport were determined in Ussing chambers at 0.5, 2, 24 and 48 h post-irradiation. Tissue histamine and 5-hydroxytryptamine levels were measured. Myeloperoxidase activity was also measured as an index of inflammation. Basal short circuit current was reduced at 2 h post-irradiation, but was elevated at 48 h. Basal conductance was significantly increased by 24 and 48 h. Responsiveness to electrical field stimulation was depressed at 0.5 h, and was greater than control by 24 and 48 h post-irradiation. Similarly, short circuit current responses to prostaglandin E2 were depressed at 0.5 h and elevated at 24 h. No significant change was observed in the response to carbachol post-irradiation, indicating that alterations in responsiveness were not likely at the level of the enterocyte. Changes in responsiveness to electrical field stimulation correlated significantly with increases in mucosal mast cell numbers. Myeloperoxidase activity, indicative of neutrophil infiltration, did not increase post-irradiation, nor was there histological evidence of an inflammatory cell infiltrate. There were no changes in tissue histamine or 5-hydroxytryptamine. Histology also revealed little microscopic morphological change from shams in tissue from irradiated ferrets. The results of this study demonstrate effects of irradiation on electrolyte transport in the ferret jejunum. The enhanced neurally evoked electrolyte transport observed at 24-48 h post-irradiation was not correlated with the development of inflammation, but was correlated with changes in mast cell numbers.

Pseudoaneurysm of the proper hepatic artery with duodenal fistula appearing as a late complication of blunt abdominal trauma.

Posttraumatic pseudoaneurysms of the hepatic artery are rare and usually occur as a complication of open abdominal trauma. Even less common is the coexisting presence of enteric fistulization. We report a patient with upper gastrointestinal hemorrhage occurring 3 years after blunt abdominal trauma resulting from a pseudoaneurysm of the proper hepatic artery with duodenal fistulization. The patient was treated successfully by ligation of the proper hepatic artery and closure of the duodenal opening.