Effectiveness of a Simulation Curriculum on Clinical Application: A Randomized Educational Trial.

INTRODUCTION: The use of simulation to develop clinical reasoning and medical decision-making skills for common events is poorly established. Validated head trauma rules help identify children at low risk for clinically important traumatic brain injury and guide the need for neuroimaging. We predicted that interns trained using a high-fidelity, immersive simulation would understand and apply these rules better than those trained using a case-based discussion. Our primary outcomes were to determine the effectiveness of a single targeted intervention on an intern's ability to learn and apply the rules. METHODS: This was a prospective randomized controlled trial. Interns were randomized to participate in either a manikin-based simulation or a case discussion. Knowledge and application of the Pediatric Emergency Care Applied Research Network Head Trauma tool were assessed both under testing conditions using standardized vignettes and in clinical encounters. In both settings, interns completed a validated assessment tool to test their knowledge and application of the Pediatric Emergency Care Applied Research Network Head Trauma tool when assessing patients with head injury. RESULTS: Under testing conditions, both being in the simulation group and shorter time from training were independently associated with higher score under testing conditions using standardized vignettes (P = 0.038 and P < 0.001), but not with clinical encounters. CONCLUSIONS: Interns exposed to manikin-based simulation training demonstrated performance competencies that are better than those in the case discussion group under testing conditions using standardized vignettes, but not in real clinical encounters. This study suggests that information delivery and comprehension may be improved through a single targeted simulation-based education.

Unna Boot With Keystone Advancement Flap Leads to Excellent Outcomes for Lower Extremity Reconstruction.

BACKGROUND: The reconstruction of lower extremity defects can be technically challenging. The keystone island perforator flap is a workhorse reconstructive option for difficult-to-repair regions, including the lower limb. The goal of this study is to evaluate outcomes using the keystone flap in combination with the zinc oxide compression dressing (Unna boot) for repair of lower extremity defects. METHODS: We retrospectively evaluated 96 patients who underwent resection of malignancies or atypical neoplasms on the lower legs. A total of 114 defects were repaired with the keystone flap in combination with the Unna boot. Post-operative outcomes were assessed. RESULTS: The combination of the keystone flap with postoperative Unna boot application led to excellent outcomes. There was no association between complication rates and patient co-morbidities. CONCLUSION: The combination of the keystone flap with the Unna boot is a safe and efficacious approach for reconstruction of lower extremity defects. J Drugs Dermatol. 2021;20(12):1308-1312. doi:10.36849/JDD.5915.

Systematic Reviews and Meta-Analyses of Portal Vein Embolization, Associated Liver Partition and Portal Vein Ligation, and Radiation Lobectomy Outcomes in Hepatocellular Carcinoma Patients.

PURPOSE OF REVIEW: To understand portal vein embolization (PVE), associated liver partition and portal vein ligation (ALPPS) and radiation lobectomy (RL) outcomes in hepatocellular carcinoma (HCC) patients. Systematic reviews of future liver remnant (FLR) percent hypertrophy, proportion undergoing hepatectomy and proportion with major complications following PVE, ALPPS, and RL were performed by searching Ovid MEDLINE, Ovid EMBASE, The Cochrane Library, and Web of Science. Separate meta-analyses using random-effects models with assessment of study heterogeneity and publication bias were performed whenever allowable by available data. RECENT FINDINGS: Of the 10,616 articles screened, 21 articles with 636 subjects, 4 articles with 65 subjects, and 4 articles with 195 subjects met the inclusion criteria for systematic reviews and meta-analyses for PVE, ALPPS, and RL, respectively. The pooled estimate of mean percent FLR hypertrophy was 30.9% (95%CI: 22-39%, Q = 4034.8, p < 0.0001) over 40.3 +/- 26.3 days for PVE, 54.9% (95%CI: 36-74%, Q = 73.8, p < 0.0001) over 11.1 +/- 3.1 days for ALPPS, and 29.0% (95%CI: 23-35%, Q = 56.2, p < 0.0001) over 138.5 +/- 56.5 days for RL. The pooled proportion undergoing hepatectomy was 91% (95%CI: 83-95%, Q = 43.9, p = 0.002) following PVE and 98% (95%CI: 50-100%, Q = 0.0, p = 1.0) following ALPPS. The pooled proportion with major complications was 5% (95%CI: 2-10%, Q = 7.3, p = 0.887) following PVE and 38% (95%CI: 18-63%, Q = 10.0, p = 0.019) following ALPPS. Though liver hypertrophy occurs following all three treatments in HCC patients, PVE balances effective hypertrophy with a short time frame and low major complication rate.

Evaluation of the LI-RADS treatment response algorithm in hepatocellular carcinoma after trans-arterial chemoembolization.

PURPOSE: To evaluate the diagnostic performance of LI-RADS treatment response algorithm (LR-TRA) and modified RECIST (mRECIST) for the detection of viable hepatocellular carcinoma (HCC) on MRI after trans-arterial chemoembolization (TACE). MATERIALS AND METHODS: This retrospective study includes cirrhotic patients that underwent trans-arterial chemoembolization prior to liver transplantation from 2013 to 2017 with a pre- and post-treatment MRI available. Three blinded readers assigned a LR-TRA and mRECIST category to each lesion. Lesions on MRI and explant pathology were matched and characterized as complete (100% necrosis) or incomplete necrosis (≤99% necrosis). Diagnostic performance of LR-TRA and mRECIST were calculated with a generalized estimating equation. RESULTS: A total of 52 patients with 71 lesions were included, 47 with incomplete and 24 with complete necrosis. In consensus, 45 lesions were categorized as LR-TR Nonviable, of which 62.2% (28/45) had incomplete and 37.8% (17/45) had complete necrosis. Six lesions were categorized as LR-TR Equivocal, of which 33.3% (2/6) had incomplete and 66.7% (4/6) had complete necrosis. Twenty lesions were categorized as LR-TR Viable of which 85.0% (17/20) had incomplete and 15.0% (3/20) had complete necrosis. The sensitivity of LR-TR Viable for detecting incompletely necrotic tumor when LR-TR Equivocal was considered as viable, in consensus was 40.4%; specificity 70.8%; accuracy 50.7%. The sensitivity of mRECIST for detecting incompletely necrotic tumor was 37.0%; specificity 79.2%; accuracy 51.4%. There was no significant difference in diagnostic performance between mRECIST and LR-TRA (p = 0.14-0.33). Agreement for LR-TRA category was moderate (k = 0.53 [95% CI: 0.45, 0.67]). CONCLUSION: LI-RADS treatment response algorithm demonstrates high specificity and low to moderate sensitivity for the detection of viable HCC after TACE in a North American cirrhotic cohort, without significant difference in diagnostic performance between LR-TRA and mRECIST.

Symptomatic Improvement of Lower Urinary Tract Symptoms of Benign Prostatic Hyperplasia: A Comparative Systematic Review and Meta-Analysis of 4 Different Minimally Invasive Therapies.

PURPOSE: To review and compare the outcomes of prostatic artery embolization (PAE) with 3 other minimally invasive surgical treatments for benign prostatic hyperplasia, including photoselective vaporization (PVP), prostatic urethral lift (PUL), and water vapor thermal therapy (WV). METHODS: A literature review was used to identify 35 publications, which included 2,653 patients (studies, patients): PVP (13, 949), PUL (9, 577), WV (3, 330), and PAE (10, 728). The international prostate symptom score (IPSS) and the international index of erectile function (IIEF-5) and quality of life (QOL) scores were recorded at baseline, 6 months, and 12 months. Meta-analyses, pooling the standardized mean difference between scores recorded before and after treatment, were conducted for each modality and time point to assess the magnitude of a therapy's effect to yield pooled effect sizes. A negative score indicates IPSS and QOL improvement. A positive score indicates IIEF-5 improvement. RESULTS: At 6 and 12 months, the IPSS and QOL were most improved after PVP, followed by that after PAE, PUL, and, lastly, WV (measured only at 12 months). Between 6 and 12 months, the IPSS and QOL improved with PAE and worsened with PVP and PUL. Only PAE demonstrated statistical improvement in the IIEF-5, which improved from 6 to 12 months. CONCLUSIONS: PVP and PAE resulted in the largest improvements in the IPSS and QOL. Only PAE resulted in improvement of the IIEF-5.

Mode of detection matters: Differences in screen-detected versus symptomatic breast cancers.

OBJECTIVE: Although extensive analyses evaluating screening mammography for breast cancer have been published, some utilized databases do not distinguish between modes of detection, which confounds the conclusions made about the impact of screening mammography. METHODS: A retrospective cohort study of women at our institution with pathologically-proven breast cancer from January 2015 to April 2018 was conducted. Subjects were categorized by their mode of diagnosis: screening or non-screening. Patient demographics, tumor characteristics, and treatments were compared between detection methods using Wilcoxon rank-sum test for continuous variables and chi-squared or Fisher's exact test. RESULTS: 1026 breast cancers were analyzed. 80.8% of screen-detected breast cancers were invasive. Compared to symptomatically detected cancers, screen-detected were smaller (median size 8 mm vs. 15 mm, p < 0.001), less invasive (80.8% vs. 94.3), had a lower pathologic grade (29% grade 3 vs. 45.7%, p < 0.001), a lower clinical stage, and less aggressive histology (51.9% low Ki67 vs. 30.5%, and 88.2% HER2 negative vs. 76.6%, p < 0.001). Screen-detected cancers were less likely to have extramammary disease (13.2% positive lymph nodes vs. 34.0% and 0.4% distant metastases vs. 6.9%, p < 0.001). Women with screen-detected cancers were more likely to undergo conservative treatment (74.8% underwent lumpectomy vs. 59.9%, and 80.0% received no chemotherapy vs. 51.3%, p < 0.001). CONCLUSION: In this study, while the vast majority of screen-detected cancers were invasive, they were more likely to be smaller, less aggressive, and a lower pathologic grade and clinical stage. Furthermore, women with screen-detected cancers were less likely to have extramammary disease and more likely to undergo conservative treatment.

Preadmission predictors of severe COVID-19 in patients with diabetes mellitus.

OBJECTIVE: To explore predictors of severe COVID-19 disease in patients with diabetes hospitalized for COVID-19. METHODS: This is a retrospective observational study of adults with diabetes admitted for COVID-19. Bivariate tests and multivariable Cox regression were used to identify risk factors for severe COVID-19, defined as a composite endpoint of intensive care unit admission/intubation or in-hospital death. RESULTS: In 1134 patients with diabetes admitted for COVID-19, more severe disease was associated with older age (HR 1.02, p<0.001), male sex (HR 1.28, p=0.017), Asian race (HR 1.34, p=0.029 [reference: white]), and greater obesity (moderate obesity HR 1.59, p=0.015; severe obesity HR 2.07, p=0.002 [reference: normal body mass index]). Outpatient diabetes medications were not associated with outcomes. CONCLUSIONS: Age, male sex, Asian race, and obesity were associated with increased risk of severe COVID-19 disease in adults with type 2 diabetes hospitalized for COVID-19. SUMMARY: In patients with type 2 diabetes hospitalized for COVID-19 disease, we observed that age, male sex, Asian race, and obesity predicted severe COVID-19 outcomes of intensive care unit admission, intubation, or in-hospital death. The risk conferred by obesity increased with worsening obesity. Outpatient diabetes medications were not observed to be significant predictors of study outcomes.

Breast cancer in women under age 40: A decade of trend analysis at a single institution.

BACKGROUND: Women should be evaluated for breast cancer risk by age 30 to assess for screening need. Recent trends in breast cancer in this population may further inform recommendations. OBJECTIVE: The aim of this study was to analyze trends over time in the rate of breast cancer, tumor characteristics and treatment in women under age 40. METHODS: Retrospective cohort study of women under age 40 at our institution diagnosed with breast cancer from January 2007 to April 2018 was conducted. Patient demographics, tumor characteristics and treatment outcomes were collected. Descriptive statistics and the Mann-Kendell Trend test were calculated. Two-proportion z-tests were used to compare proportions of stage, pathology and treatment between 2007-2013 and 2014-2018. RESULTS: 197 women under age 40 were treated for a new diagnosis of breast cancer at our institution. A higher proportion of women were diagnosed with invasive carcinoma in 2013-2018 (91%) compared to 2007-2012 (78%), p = 0.008. A higher proportion of women were diagnosed with advanced stage disease (stage III-IV) in 2013-2018 (24%) compared to 2007-2012 (2%), p = 0.001. No statistically significant evidence for an increasing trend of overall rate of breast cancer over the last 11 years (p = 0.419) was observed. CONCLUSIONS: While no statistically significant increase in overall rate of breast cancer was noted, an increase in invasive and later staged breast cancers was observed. CLINICAL IMPACT: Rise in more aggressive cancers in a population that is largely not screened may have implications both on the individual young woman's morbidity as well as on a public health level.

The Independent Risk of Obesity and Diabetes and Their Interaction in COVID-19: A Retrospective Cohort Study.

OBJECTIVE: This study aimed to assess whether diabetes mellitus (DM) or obesity is an independent risk factor for severe coronavirus disease 2019 (COVID-19) outcomes and to explore whether the risk conferred by one condition is modified by the other. METHODS: This retrospective cohort study of inpatient adults with COVID-19 used multivariable Cox regression to determine the independent effects of DM and obesity on the composite outcome of intubation, intensive care unit admission, or in-hospital mortality. Effect modification between DM and obesity was assessed with a statistical interaction term and an exploration of stratum-specific effects. RESULTS: Out of 3,533 patients, a total of 1,134 (32%) had DM, 1,256 (36%) had obesity, and 430 (12%) had both. DM and obesity were independently associated with the composite outcome (hazard ratio [HR] 1.14 [95% CI: 1.01-1.30] and HR 1.22 [95% CI: 1.05-1.43], respectively). A statistical trend for potential interaction between DM and obesity was observed (P = 0.20). Stratified analyses showed potential increased risk with obesity compared with normal weight among patients with DM (HR 1.34 [95% CI: 1.04-1.74]) and patients without DM (HR 1.18 [95% CI: 0.96-1.43]). CONCLUSIONS: DM and obesity are independent risk factors associated with COVID-19 severity. Stratified analyses suggest that obesity may confer greater risk to patients with DM compared with patients without DM, and this relationship requires further exploration.

Cognitive Recovery During Inpatient Rehabilitation Following Pediatric Traumatic Brain Injury: A Pediatric Brain Injury Consortium Study.

OBJECTIVES: To characterize the demographics, clinical course, and predictors of cognitive recovery among children and young adults receiving inpatient rehabilitation following pediatric traumatic brain injury (TBI). DESIGN: Retrospective observational, multicenter study. SETTING: Eight acute pediatric inpatient rehabilitation facilities in the United States with specialized programs for treating patients with TBI. PARTICIPANTS: Children and young adults (0-21 years) with TBI (n = 234) receiving inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Admission and discharge status assessed by the WeeFIM Cognitive Developmental Functional Quotient (DFQ) and Cognitive and Linguistic Scale (CALS). RESULTS: Patients admitted to pediatric inpatient rehabilitation are diverse in cognitive functioning. While the majority of patients make improvements, cognitive recovery is constrained for those admitted with the most severe cognitive impairments. Age, time since injury to rehabilitation admission, and admission WeeFIM Cognitive DFQ are significant predictors of cognitive functioning at discharge from inpatient rehabilitation. CONCLUSIONS: This work establishes a multicenter Pediatric Brain Injury Consortium and characterized the demographics and clinical course of cognitive recovery during inpatient rehabilitation of pediatric patients with TBI to aid in prospective study design.

A specific biomarker for amyotrophic lateral sclerosis: Quantitative susceptibility mapping.

OBJECTIVE: Accurate and timely diagnosis of amyotrophic lateral sclerosis (ALS) is a diagnostic challenge given the lack of specific diagnostic and imaging biomarkers as well as the significant clinic overlap with mimic syndromes. We hypothesize that MR quantitative susceptibility mapping (QSM) can help differentiate ALS from mimic diagnoses. METHODS: In a blinded retrospective study of MRIs with QSM from 2015 to 2018, we compared motor cortex susceptibility along the hand and face homunculi in ALS patients and patients with similar clinical presentations. Inclusion required a confirmed ALS or a mimic diagnosis. Comparative groups included age-matched patients with MRIs performed for non-motor neuron symptoms that were reported as normal or demonstrated leukoaraiosis. Quantitative susceptibility values were compared with ANOVA and Tukey-Kramer (post-hoc). ROC analysis and Youden's index were used to identify optimal cutoff values. RESULTS: Fifty ALS, 35 mimic, and 70 non-motor neuron symptom patients (35 normal, 35 leukoaraiosis) were included. Hand and face homunculus mean susceptibility values were significantly higher in the ALS group compared to the mimic (p=0.001, p=0.004), leukoaraiosis (p<0.001, p=0.003), and normal (p<0.001, p<0.001) groups. ROC curve analysis comparing ALS to mimics resulted in an area under the curve of 0.71 and 0.67 for the hand and face homunculus measurements, respectively. In differentiating ALS from mimics, Youden's index showed 100% specificity and 36% sensitivity for hand homunculus measurements. CONCLUSIONS: QSM has diagnostic potential in the assessment of suspected ALS patients, demonstrating very high specificity in differentiating ALS from mimic diagnoses.

Acute Imaging Findings Predict Recovery of Cognitive and Motor Function after Inpatient Rehabilitation for Pediatric Traumatic Brain Injury: A Pediatric Brain Injury Consortium Study.

Traumatic brain injury (TBI) is a major cause of morbidity and mortality in children; survivors experience long-term cognitive and motor deficits. To date, studies predicting outcome following pediatric TBI have primarily focused on acute behavioral responses and proxy measures of injury severity; unsurprisingly, these measures explain very little of the variance following heterogenous injury. In adults, certain acute imaging biomarkers help predict cognitive and motor recovery following moderate to severe TBI. This multi-center, retrospective study, characterizes the day-of-injury computed tomographic (CT) reports of pediatric, adolescent, and young adult patients (2 months to 21 years old) who received inpatient rehabilitation services for TBI (n = 247). The study also determines the prognostic utility of CT findings for cognitive and motor outcomes assessed by the Pediatric Functional Independence Measure, converted to age-appropriate developmental functional quotient (DFQ), at discharge from rehabilitation. Subdural hematomas (66%), contusions (63%), and subarachnoid hemorrhages (59%) were the most common lesions; the majority of subjects had less severe Rotterdam CT scores (88%, ≤ 3). After controlling for age, gender, mechanism of injury, length of acute hospital stay, and admission DFQ in multivariate regression analyses, the highest Rotterdam score (ß = -25.2, p < 0.01) and complete cisternal effacement (ß = -19.4, p < 0.05) were associated with lower motor DFQ, and intraventricular hemorrhage was associated with lower motor (ß = -3.7, p < 0.05) and cognitive DFQ (ß = -4.9, p < 0.05). These results suggest that direct detection of intracranial injury provides valuable information to aid in prediction of recovery after pediatric TBI, and needs to be accounted for in future studies of prognosis and intervention.

Utility of Targeted Ultrasound to Predict Malignancy Among Lesions Detected on Contrast-Enhanced Digital Mammography.

BACKGROUND. Targeted ultrasound (US) can be performed to characterize and potentially biopsy areas of enhancement detected on contrast-enhanced mammography (CEM). OBJECTIVE. The purpose of this study was to assess the utility of targeted US in predicting malignancy of lesions with indeterminate or suspicious enhancement on CEM. METHODS. One thousand consecutive CEM examinations with same-day targeted breast US at one institution between October 2013 and May 2018 were retrospectively reviewed. All patients with indeterminate or suspicious enhancement detected on CEM that underwent US evaluation were included. Patients with palpable or symptomatic lesions, those with suspicious findings on low-energy mammograms or images obtained with another modality, and those with less than 1 year of follow-up were excluded. Medical records, imaging, and pathology data were reviewed. Histopathologic analysis was used as the reference standard for biopsied lesions, and follow-up imaging was used for unbiopsied lesions. Associations between pathologic diagnosis, presence of a US correlate, and lesion characteristics were assessed by Fisher exact, chi-square, and Wilcox-on rank sum tests. RESULTS. Among 153 enhancing lesions detected on CEM in 144 patients, 47 (31%) had a US correlate. The frequency of a correlate between CEM and US was significantly higher among enhancing masses (28/43 [65%]) than among lesions exhibiting nonmass enhancement (19/110 [17%]) (p < .001). The likelihood of malignancy was significantly greater among lesions with a US correlate (12/47 [26%]) than among those without a US correlate (11/106 [10%]) (p = .03), and among mass lesions (11/43 [26%]) than among nonmass lesions (12/110 [11%]) (p = .04). The PPV of US-guided biopsy after CEM-directed US was 32%. CONCLUSION. Enhancing CEM-detected lesions that have a US correlate are more likely to be malignant and can be evaluated with US-guided biopsy to obviate additional breast MRI. CLINICAL IMPACT. CEM-directed US of enhancing lesions is useful given that lesions with a US correlate are more likely to be malignant and can be used as targets for US-guided biopsy until a CEM biopsy system becomes commercially available.

Diagnostic Performance of LI-RADS Version 2018, LI-RADS Version 2017, and OPTN Criteria for Hepatocellular Carcinoma.

OBJECTIVE. Liver Imaging Reporting and Data System (LI-RADS) was updated in 2018 (LI-RADS version 2018 [LI-RADSv2018]) to facilitate integration into the American Association for the Study of Liver Diseases 2018 clinical practice guidelines and involved changes in LR-5 categorization and threshold growth definitions. There are also differences between the criteria for LI-RADSv2018 LR-5 category and the criteria for Organ Procurement and Transplantation Network (OPTN) class 5. The objective of our study was to compare the diagnostic performances of LI-RADSv2018, LI-RADS version 2017 (LI-RADSv2017), and OPTN criteria for diagnosing hepatocellular carcinoma (HCC) on MRI. MATERIALS AND METHODS. In this retrospective study, 122 patients with 159 observations were included who met LI-RADS criteria for at risk for HCC and had at least one hepatic observation on MRI performed between January 1, 2015, and January 1, 2018 and who had histopathology results (n = 104) or follow-up imaging (n = 55) as reference standards. Three abdominal radiologists assigned categories independently and in consensus using LI-RADSv2017, LI-RADSv2018, and OPTN criteria. Diagnostic performance was compared among the guidelines with a generalized estimating equation. RESULTS. Fourteen of 159 (8.8%) observations were assigned a different category according to LI-RADSv2018 compared with LI-RADSv2017. Eight of 31 (25.8%) LR-4 observations using v2017 were recategorized as LR-5 using v2018, and all eight were HCC. Six of 31 (19.4%) LR-4 observations based on v2017 were recategorized as LR-3 using v2018, and all six were non-HCCs. Seven of 114 (6.1%) observations not meeting OPTN class 5 criteria were LR-5 using v2018, and all seven were HCC. Sensitivity for HCC of LR-5 and LR-TIV+5 (i.e., LR-TIV [tumor in vein] definitely due to HCC) categories based on v2018 was significantly higher than that based on v2017 (63.9% vs 55.2%, respectively; p = 0.008) without a difference in specificity (97.3% vs 97.3%; p = 1.00). Sensitivity of LR-5 and LR-TIV+5 in LI-RADSv2018 was significantly higher than the sensitivity of class 5 in OPTN criteria (63.9% vs 53.6%; p = 0.004) without a difference in specificity (97.3% vs 97.3%; p = 1.00). Reader agreement was moderate for overall LIRADSv2017 and LI-RADSv2018 categories (κ = 0.504 and 0.561, respectively); substantial for LR-5 and LR-TIV+5 categories as diagnostic of HCC versus other categories for both v2017 and v2018 (κ = 0.758 and 0.802, respectively); and substantial for OPTN class 5 criteria (κ = 0.756). CONCLUSION. The diagnostic performance of LI-RADSv2018 is higher, with higher sensitivity and similar specificity, than the diagnostic performance of LI-RADSv2017 and OPTN criteria for HCC.

Joint periviability counseling between neonatology and obstetrics is a rare occurrence.

OBJECTIVE: To investigate the frequency with which neonatal and maternal-fetal medicine (MFM) providers perform joint periviability counseling (JPC), compare content of counseling, and identify perceived barriers to JPC. STUDY DESIGN: An anonymous REDCap survey was e-mailed to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine and to members of the Society for MFM. RESULTS: There were 424 neonatal and 115 MFM participants. Fifty-two percent of neonatal and 35% of MFM respondents reported rarely/never performing JPC (p < 0.001), while 80% and 82%, respectively felt it would improve counseling. Content of counseling was similar, except for length of stay with 93% of neonatal vs. 85% of MFM respondents addressing this (p = 0.03). The majority (>60%) of respondents in both groups reported that clinical duties posed a significant/great barrier to JPC. CONCLUSION: JPC is recommended but infrequently performed, with both specialties interested in further collaboration to strengthen the counseling provided.

Clinicopathologic features of endometrial cancer with mismatch repair deficiency.

The inclusion of DNA mismatch repair (MMR) evaluation as a standard of care for endometrial cancer management will result in a growing population of patients with MMR deficiency and negative germline Lynch syndrome testing (MMR-deficient). In this systematic review and study, the clinicopathologic features of endometrial cancer in patients with MMR-intact, MLH1 methylation positive, MMR-deficient or Lynch syndrome are evaluated. A systematic search of online databases between 1990 and 2018 identified studies of endometrial cancer patients with tumour testing (MMR protein immunohistochemistry or microsatellite instability) and germline assessment for Lynch syndrome. Extracted data included tumour testing, germline genetic testing, age, body mass index (BMI), family history, tumour stage, grade and histologic type. Associations between MMR-intact, MLH1 methylation positive, MMR-deficient and Lynch syndrome groups were analysed using descriptive statistics. The comprehensive search produced 4,400 publications, 29 met inclusion criteria. A total of 7,057 endometrial cancer cases were identified, 1,612 with abnormal immunohistochemistry, 977 with microsatellite instability. Nine-hundred patients underwent germline genetic testing, identifying 212 patients with Lynch syndrome. Patients in the Lynch syndrome and MMR-deficient groups were significantly younger than patients in the MMR-intact and MLH1 methylation positive groups. Patients with MMR-intact tumours had the highest BMI, followed by MMR-deficient, then Lynch syndrome. MMR-intact tumours were more likely to be grade I at diagnosis than other groups. Patients with Lynch syndrome and MMR-deficient tumours were less likely to have stage I disease as compared to patients with MMR-intact tumours. Endometrial cancer patients with MMR-deficient tumours have similar features to those with germline Lynch syndrome mutations, including age, grade, histology and stage. Even in the absence of a germline mutation, tumour evaluation for MMR status may have important clinical implications.

The Effects of Primary Defect Characteristics on Reconstruction Type and Adjunctive Intervention in Mohs Micrographic Surgery: A Retrospective Review.

BACKGROUND: Cosmetic concerns following Mohs Micrographic surgery (MMS) are significant and may require adjunctive treatments for unsatisfactory appearance. OBJECTIVE: To determine factors associated with adjunctive cosmetic intervention for facial defects following MMS. METHODS AND MATERIALS: A retrospective review of 699 patients undergoing repair of facial defects after MMS from 2008-2018 was performed. Tumor types, defect sizes, patient demographics, repair methods, complications, and post-operative cosmetic interventions were examined. RESULTS: 666 Mohs cases and resultant defects were analyzed. The most common method of repair following MMS was primary closure (52.3%), and the most common post-operative intervention was steroid injection (18.3%). The lip subunit was more than twice as likely as other locations to be treated with steroid injections (P<.001). The lip subunit also had the highest frequency of scar revision (13%; P<0.001). Patients who had primary closure were less likely to require scar revision (P=0.003) or dermabrasion (P=0.042), and there was no significant association between skin graft repair and cosmetic intervention. CONCLUSIONS: Both defect subunit and closure type were independently associated with adjunctive cosmetic intervention following MMS. Defect size was not significantly associated with an adjunctive intervention in our study. Understanding the factors affecting the need for adjunctive cosmetic interventions may improve patient counseling prior to Mohs repair. J Drugs Dermatol. 2020;19(3): doi:10.36849/JDD.2020.4701.

Improved targeting of the globus pallidus interna using quantitative susceptibility mapping prior to MR-guided focused ultrasound ablation in Parkinson's disease.

PURPOSE: Magnetic resonance guided focused ultrasound (MRgFUS) of the globus pallidus interna (GPi) has shown promise in the treatment of drug-resistant Parkinson's disease, though direct visualization of the GPi remains challenging with MRI. The purpose of this study was to compare various preoperative MR imaging techniques and to evaluate the utility of quantitative susceptibility imaging (QSM) in the depiction of the GPi prior to MRgFUS ablation. MATERIALS AND METHODS: Six patients with medication refractory advanced idiopathic Parkinson's disease were referred for preoperative MR imaging prior to MRgFUS pallidotomy. Axial T1WI and T2WI, Fast Gray Matter Acquisition T1 Inversion Recovery (FGATIR), and QSM sequences were acquired. DTI tractography was performed to delineate the corticospinal tracts. Qualitative visualization scores and contrast to noise ratios (CNR) were recorded and measured on all images. RESULTS: QSM had significantly higher median qualitative visualization scores (3.00) compared with the T1WI (1.00), T2WI (1.50), and FGATIR sequences (1.50) (p < 0.05). QSM provided superior CNR for GPi depiction in each category (GPi-GPe and GPi-IC), respectively. For GPi-GPe, median CNR for T1WI, T2WI, FGATIR, and QSM was 1.13, 1.68, 0.79, and 10.78. For GPi-IC, median CNR for T1WI, T2WI, FGATIR, and QSM was 1.48, 4.63, 4.24, and 40.26, respectively (p < 0.05). CONCLUSION: QSM offers improved visualization of the GPi compared with the traditional and currently recommended MR sequences prior to MRgFUS ablation in patients with Parkinson's disease. These results suggest that QSM should be considered as part of all preoperative imaging protocols prior to MRgFUS pallidotomy.

Effect of a communication lecture tutorial on breast imaging trainees' confidence with challenging breast imaging patient interactions.

PURPOSE: The aim of the study was to evaluate the effect of a one-hour lecture based communication curriculum on breast imaging trainees' confidence in communicating with patients in a challenging communication setting such as delivering bad news or radiologic error disclosure. METHODS: 12 breast imaging trainees from an academic fellowship program completed questionnaires before and after a communication tutorial. A four breast imaging specific scenario questionnaire assessed confidence by asking the trainees to rank agreement with statements related to their attitude in those specific settings. 12-month follow-up questionnaire was sent to the graduating fellows assessing their -overall confidence in patient communication, the contribution of the curriculum to their self-perceived communication skill and their likelihood in disclosing a radiologic error to a patient. RESULTS: All trainees completed the pre and post lecture questionnaire. After the communication tutorial, all trainees reported increased confidence in communicating with patients in a variety of challenging settings with pre lecture survey mean confidence score of 38/98 and post lecture survey mean score of 85.3/98, P = 0.003. Three of eight trainees who completed the 12-month follow up questionnaire reported confidence in their communication skills and reported that the tutorial significantly contributed to their communication skill development. All three agreed that they would be likely to disclose a medical error should they encounter it in their future career. CONCLUSIONS: A limited resource one-hour lecture communication tutorial provides effective communication training for breast imaging fellows and is a promising part of a breast imaging curriculum.

Performance of 2D Synthetic Mammography Versus Digital Mammography in the Detection of Microcalcifications at Screening.

OBJECTIVE. The purpose of this study is to compare the performance of 2D synthetic mammography (SM) to that of full-field digital mammography (FFDM) in the detection of microcalcifications and to evaluate radiologists' preference between the two imaging modalities for assessing calcifications. MATERIALS AND METHODS. A fully crossed, mode-balanced, paired-case (n = 160), retrospective, multireader (n = 3) performance study was implemented to compare screening mammograms acquired with digital breast tomosynthesis and both FFDM and SM between 2015 and 2017. The study cohort included 70 patients with mammograms recalled for microcalcifications (35 with malignant findings and 35 with benign findings) and was supplemented with 90 patients with mammograms with negative findings. In separate sessions, readers interpreted SM or FFDM images by recording a BI-RADS assessment and the probability of malignancy. In a final session that included 70 mammograms with microcalcifications, readers recorded their subjective assessment of microcalcification conspicuity and diagnostic confidence. RESULTS. There was no difference in diagnostic accuracy as assessed by comparing the likelihood of malignancy based on the AUC of plotted ROCs, with AUCs of 91% (95% CI, 83-97%) and 88% (95% CI, 79-95%) observed for SM and FFDM, respectively (p = 0.392), and with noninferiority of SM compared with FFDM (p = 0.011). No significant difference was observed between SM and FFDM in terms of sensitivity (77% vs 73%, respectively; p = 0.366) or negative predictive value (84% vs 82%, respectively; p = 0.598). The specificity and positive predictive value of SM were lower than those of FFDM (91% vs 98%, respectively [p = 0.034], and 87% vs 96%, respectively [p = 0.034]). All readers found calcifications to be more conspicuous on SM (p < 0.0001); however, no significant difference in subjective diagnostic confidence was seen. CONCLUSION. SM is noninferior to FFDM in the detection of microcalcifications. Despite the increased conspicuity of microcalcifications on SM, the subjective diagnostic confidence in the two modalities is comparable.