Breast cancer abutting the pectoralis major muscle on breast MRI: what are the clinical implications?

OBJECTIVES: Defining the posterior extent of breast cancer prior to surgery has clinical implications. However, there are limited data available to guide the interpretation of breast cancers seen on MRI that abut the pectoralis muscle but lack associated muscle enhancement. METHODS: In this retrospective study of breast MRIs performed between May 2008 and July 2019, 43 female patients demonstrated breast cancers abutting the pectoralis muscle without enhancement of the muscle itself. Imaging features of the cancers as well as pathologic and clinical outcomes were recorded. Statistical analyses of associations between imaging findings and clinical outcomes were performed using Fisher's exact test, logistic regression, a Mann-Whitney U test and/or Student's t-test. RESULTS: The pectoralis major muscle was pathologically invaded by carcinoma in 4/43 (9.3%). There was no significant association between pectoralis muscle invasion and any MR imaging feature of the breast cancer. Tumors causing deformation of the muscle contour by MRI, tumors larger in size, tumors with a larger extent abutting the muscle and tumors in which the imaging feature abutting the muscle was a mass or non-mass enhancement (rather than a spicule) were more commonly seen in patients with muscle invasion, although these did not reach statistical significance (p > 0.05). CONCLUSION: In this study, a lack of pectoralis muscle enhancement by MRI did not exclude pathologic muscle invasion by breast cancers abutting the muscle. ADVANCES IN KNOWLEDGE: Knowledge of the likelihood of pectoralis muscle involvement for breast cancers abutting the pectoralis muscle on MRI may guide accurate interpretation and definition of the posterior extent of disease.

Contemporary Management of Bulbar Urethral Strictures.

Urethral stricture disease (USD) is a progressive scar-forming disease commonly encountered by urologists and is challenging to manage. USD most frequently occurs in the bulbar urethra. Patients typically present with chronic obstructive voiding symptoms but may develop recurrent urinary tract infections, detrusor failure, or renal disease. The authors review the pathophysiology, diagnostic workup, and evidence-based management of bulbar urethral strictures (BUS). There are multiple surgical options to treat BUS. Endoscopic techniques (eg, dilation and urethrotomy) are suitable for the initial management of short strictures but new evidence-based guidelines recommend against repeated endoscopic treatment. Urethroplasty is the gold standard treatment for BUS of all lengths, with anastomotic techniques appropriate for strictures <2 cm and tissue substitution performed for longer strictures. New techniques, such as non-transecting urethroplasty, lack long-term data but may represent a paradigm shift in the field. Future treatments may utilize tissue-engineered grafts and agents that inhibit inflammation and scar formation.

Cyanobacterial neurotoxin BMAA and brain pathology in stranded dolphins.

Dolphin stranding events occur frequently in Florida and Massachusetts. Dolphins are an excellent sentinel species for toxin exposures in the marine environment. In this report we examine whether cyanobacterial neurotoxin, ß-methylamino-L-alanine (BMAA), is present in stranded dolphins. BMAA has been shown to bioaccumulate in the marine food web, including in the muscles and fins of sharks. Dietary exposure to BMAA is associated with the occurrence of neurofibrillary tangles and ß-amyloid plaques in nonhuman primates. The findings of protein-bound BMAA in brain tissues from patients with Alzheimer's disease has advanced the hypothesis that BMAA may be linked to dementia. Since dolphins are apex predators and consume prey containing high amounts of BMAA, we examined necropsy specimens to determine if dietary and environmental exposures may result in the accumulation of BMAA in the brains of dolphins. To test this hypothesis, we measured BMAA in a series of brains collected from dolphins stranded in Florida and Massachusetts using two orthogonal analytical methods: 1) high performance liquid chromatography, and 2) ultra-performance liquid chromatography with tandem mass spectrometry. We detected high levels of BMAA (20-748 µg/g) in the brains of 13 of 14 dolphins. To correlate neuropathological changes with toxin exposure, gross and microscopic examinations were performed on cortical brain regions responsible for acoustico-motor navigation. We observed increased numbers of ß-amyloid+ plaques and dystrophic neurites in the auditory cortex compared to the visual cortex and brainstem. The presence of BMAA and neuropathological changes in the stranded dolphin brain may help to further our understanding of cyanotoxin exposure and its potential impact on human health.

Long-term outcomes of twins based on gestational age at delivery.

OBJECTIVE: Prematurity is associated with adverse outcomes. However, there are less data regarding long-term outcomes of twins based on gestational age at delivery. Our objective was to identify the association between gestational age at delivery and long-term outcomes in twins. STUDY DESIGN: All patients with a twin pregnancy ≥24 weeks delivered by a single Maternal Fetal Medicine practice from 2005 to 2014 were surveyed regarding pediatric outcomes at or after 2 years of life. We excluded twins with aneuploidy or major fetal anomalies. The survey was mail-based, with phone follow-up for nonresponses or for clarification. Using logistic regression analysis, we compared long-term outcomes between twins born in four gestational age groups: 24 to 27-6/7 weeks, 28 to 31-6/7 weeks, 32 to 35-6/7 weeks, and 36 weeks or later. RESULTS: Six hundred fifty-three twin deliveries met inclusion criteria and 425 (65.1%) mothers responded. Mean age at the time of survey completion was 6.0 ± 2.4 years. Earlier gestational age was significantly associated with neonatal death (14, 2, 0, and 0% in the four groups, respectively, p < .001). Prematurity was associated with a composite of major adverse outcomes (death; cerebral palsy; necrotizing enterocolitis; chronic renal, heart, or lung disease) (14, 7, 4, and 2% in the four groups, p = .036), as well as minor adverse outcomes (learning disability; need for speech, occupational, or physical therapy) (83, 69, 54, and 38%, p < .001). CONCLUSIONS: Long-term morbidity in twin pregnancies is inversely related to gestational age at delivery. However, for twins born after 28 weeks, neonatal death and severe long-term morbidity are rare.

The association between obstetrical history and preterm birth in women with uterine anomalies.

OBJECTIVE: To estimate the association between obstetric history and preterm birth in women with uterine anomalies. METHODS: This was a retrospective cohort study of women with uterine anomalies managed by one maternal-fetal medicine practice from 2005 to 2016. Women were separated into three groups based on their most recent pregnancy outcome: preterm birth <37 weeks, nulliparous, and term birth. Delivery outcomes were compared across the three groups, with the primary outcome being preterm birth <37 weeks. A subgroup analysis was performed in women with major uterine anomalies (unicornuate, bicornuate, and didelphys). RESULTS: A total of 283 women with uterine anomalies were included. Preterm birth <37 weeks was 60.4% in women with prior preterm birth versus 18.2% in nulliparous women, versus 15.8% in women with a prior term birth (p < .001). The difference between nulliparous women and women with a prior term birth was not significant (p = .635). Among the 118 women with major uterine anomalies, the likelihood of preterm birth was also highest in the prior preterm birth group (71.4 versus 26.1 versus 25.0%, p < .001), and the difference between nulliparous women and women with a prior term birth was not significant (p = .906). CONCLUSIONS: In women with uterine abnormalities, a prior preterm birth is significantly associated with recurrent preterm birth. However, a prior term birth does not lower the risk of preterm birth as compared to nulliparous women.

The association between second trimester estimated fetal weight and small for gestational age at birth.

OBJECTIVE: To analyze diagnostic accuracy of second trimester ultrasound fetal growth parameters as predictors of small for gestational age (SGA) birth weight. METHODS: We reviewed the fetal biometry from 714 consecutive patients with second trimester ultrasounds. The estimated fetal weight (EFW) and abdominal circumference (AC) percentiles were tested as predictors of SGA at birth (<10‰). RESULTS: 87 (12.2%) patients had an SGA baby. Patients with a second trimester EFW ≤25‰ were significantly more likely to have SGA at birth (24.2% versus 10.3%, p < 0.001). Similar results were seen for women with second trimester AC ≤25‰ (likelihood of SGA 21.9% versus 11.2%, p = 0.013). A second trimester EFW ≤25‰ was a better predictor of SGA at birth than a second trimester EFW ≤ 10‰ (Positive likelihood ratio 2.30 versus 2.09). In the second trimester, only 9 (1.3%) patients had an EFW 0-10‰, only 43 (6%) patients had an EFW 11-20‰, and only 46 (6.4%) patients had an EFW 91-99‰. Each other EFW centile had more than 10% of the patients. CONCLUSIONS: The incidence of second trimester EFW or AC ≤10‰ is less common than expected from standard tables. An EFW ≤25‰ and an AC ≤25‰ should be considered the second trimester marker for risk of SGA at birth. However, due to the low likelihood ratio of, it is not clear if second trimester ultrasound should be used as a predictor of SGA at birth.

Preterm birth or small for gestational age in a singleton pregnancy and risk of recurrence in a subsequent twin pregnancy.

OBJECTIVE: To evaluate whether a history of preterm birth or small for gestational age (SGA) in a singleton pregnancy is associated with an increased risk of recurrence of the same condition in a subsequent twin pregnancy. METHODS: Retrospective cohort study of twin pregnancies delivered in one maternal-fetal medicine practice from 2005 to 2014. Patients with a history of singleton preterm birth at less than 37 weeks of gestation were compared with patients with a history of singleton term birth and nulliparous patients. A similar analysis was performed for a history of SGA (birth weight less than 10%). RESULTS: Six hundred forty-seven twin pregnancies were included. The prior singleton gestational age at delivery was significantly positively correlated with the twin gestational age at delivery (P<.001), and the prior singleton birth weight was significantly positively correlated with the birth weight of the larger twin (P<.001) and the smaller twin (P<.001). The rate of twin preterm birth before 32 weeks of gestation was 3.5% in patients with a prior term birth, 9.2% in nulliparous patients, and 26% in patients with a prior preterm birth (P<.001). The rate of SGA in patients with a prior birth not complicated by SGA was 42.1%, in nulliparous women it was 54.4%, and in patients with a history of SGA it was 65.2% (P=.007). On regression analysis, prior preterm birth and SGA of a singleton pregnancy were independently associated with recurrence of the same condition in a subsequent twin pregnancy. CONCLUSION: Prior preterm birth and SGA in a singleton pregnancy increase the risk of the same condition in a subsequent twin pregnancy. We postulate that the extrinsic mechanism responsible for the pathophysiology of adverse outcomes in twin pregnancies overlaps with that in singleton pregnancies.

The association between maternal weight gain and spontaneous preterm birth in twin pregnancies.

OBJECTIVE: To estimate the association between maternal weight gain and SPTB in twin pregnancies. METHODS: A case-control study of patients with twin pregnancies and a normal prepregnancy BMI (18.5-24.9 kg/m(2)) in one maternal-fetal medicine practice from 2005 to 2013. We reviewed maternal weight in six time periods: prepregnancy, 12-15 6/7 weeks, 16-19 6/7 weeks, 20-23 6/7 weeks, 24-27 6/7 weeks and 28-31 6/7 weeks. We compared maternal weight gain patterns across pregnancy between patients who did and did not have SPTB <32 weeks. Student's t-test and chi-square were used for analysis. RESULTS: In total, 382 patients were included, 29 (7.6%) of whom had SPTB <32 weeks. The baseline height, weight and BMI did not differ between the groups, nor did maternal age, IVF status, race or chorionicity. Patients with SPTB <32 weeks had significantly less weight gain as early as 15 6/7 weeks (2.9 ± 4.6 versus 7.3 ± 6.6 lb, p < 0.001), and this continued until 31 6/7 weeks (25.3 ± 8.7 versus 30.8 ± 10.9 lb, p = 0.037). CONCLUSIONS: In twin pregnancies with a normal prepregnancy BMI, there is a significant association between SPTB <32 weeks and lower maternal weight gain, particularly prior to 16 weeks. Future studies are needed to test if prepregnancy or early nutritional interventions in twin pregnancies can reduce the risk of preterm birth and improve neonatal outcomes in this high-risk population.

Video conferencing technology in research on schizophrenia: a qualitative study of site research staff.

The objective of this study was to advance knowledge of the experience of multisite research staff with video conferencing mental health data collection among study participants with schizophrenia. An end-of-study focus group was conducted with all (N = 19) study coordinators of a multisite randomized trial of pharmacotherapy for schizophrenia to characterize the experiences of coordinators overseeing semistructured assessments via video conferencing technology (VCT). Researchers conducted an audiotaped voluntary focus group. Investigators independently coded a transcript of the focus group, followed by discussions to reach consensus on key themes. Three key themes emerged, involving issues associated with (a) the technology itself, (b) the technology in the context of clinical care and research, and (c) the feasibility of using VCT for study assessments, including coordinators' perceptions of participants' experience of VCT. Additional themes were that (a) interviewer skills appeared to moderate the impact of VCT, (b) research participants with serious psychiatric disorders who participated in VCT assessments appeared, overall, to be more amenable to the technology than research coordinators anticipated, and (c) because VCT will be adapted in a wide range of settings, staffing and resource needs should be considered in planning for and adopting VCT for psychiatric research or clinical assessment. This study adds contextual detail and emphasis to the existing literature on the use of VCT in research and factors regarding the effective deployment of the technology in research.

Type of congenital uterine anomaly and adverse pregnancy outcomes.

OBJECTIVE: To estimate whether the severity of uterine anomaly is associated with the risk of adverse pregnancy outcomes. METHODS: Retrospective cohort study of patients delivered by one maternal fetal medicine group from 2005 to 2012. We included 158 patients with a singleton pregnancy and a uterine anomaly, as well as an equal number of randomly selected unexposed singleton pregnancies delivered by the same group. Patients with uterine anomalies were subdivided into those with major fusion defects (unicornuate, bicornuate and didelphys) and minor fusion defects (arcuate, septate and t-shaped). RESULTS: The incidence of adverse pregnancy outcomes increased across unexposed patients, patients with minor fusion defects and patients with major fusion defects. These included preterm birth < 37 weeks, preterm birth < 35 weeks, birth weight < 10th percentile, birth weight < 5th percentile, preeclampsia, malpresentation and cesarean delivery. CONCLUSION: The incidence of adverse pregnancy outcomes and cesarean delivery is increased in patients with minor fusion defects and is further increased in patients with major fusion defects.

Development of a measure to inform return-to-duty decision making after mild traumatic brain injury.

Mild traumatic brain injury (mTBI), a principal injury of the wars in Iraq and Afghanistan, can result in significant morbidity. To make accurate return-to-duty decisions for soldiers with mTBI, military medical personnel require sensitive, objective, and duty-relevant data to characterize subtle cognitive and sensorimotor injury sequelae. A military-civilian research team reviewed existing literature and obtained input from stakeholders, end users, and experts to specify the concept and develop a preliminary assessment protocol to address this need. Results of the literature review suggested the potential utility of a test based on dual-task and multitask assessment methods. Thirty-three individuals representing a variety of military and civilian stakeholders/experts participated in interviews. Interview data suggested that reliability/validity, clinical feasibility, usability across treatment facilities, military face validity, and capacity to challenge mission-critical mTBI vulnerabilities were important to ultimate adoption. The research team developed the Assessment of Military Multitasking Performance, a tool composed of eight dual and multitasking test-tasks. A concept test session with 10 subjects indicated preliminary face validity and informed modifications to scoring and design. Further validation is needed. The Assessment of Military Multitasking Performance may fill a gap identified by stakeholders for complex cognitive/motor testing to assist return-to-duty decisions for service members with mTBI.

Driving-related anxiety in recently deployed service members: cues, mental health correlates, and help-seeking behavior.

Recent military operations have involved repeated trauma exposure while driving vehicles. Combat deployment and post-traumatic stress disorder (PTSD) have been associated with risky driving practices, increasing the likelihood of fatalities and problems adjusting to civilian life. However, no studies have specifically examined the role of driving-related anxiety, including common cues and mental health correlates. This study conducted structured interviews with 46 recently deployed service members. Interviews assessed the prevalence of driving-related anxiety or hyperarousal (anger or irritation) in relation to civilian driving scenarios, combat exposure, post-traumatic stress symptoms, depression symptoms, and help-seeking behavior. The majority of participants reported high driving anxiety or hyperarousal in response to scenarios involving close proximity to other cars. Driving-related anxiety was positively correlated with PTSD and depression. Although PTSD and driving anxiety were positively associated with help seeking, only one-third of soldiers sought help for driving anxiety and most sought help from informal sources (i.e., friend and battle buddy). The findings underscore the need to address driving-related anxiety in combat-exposed service members with mental health symptoms, with a particular focus on specific anxiety-provoking situations. Furthermore, interventions that reduce stigma and improve access to formal care could improve help seeking and treatment for these problems.

Going to the source: creating a citizenship outcome measure by community-based participatory research methods.

OBJECTIVE: This study used participatory methods and concept-mapping techniques to develop a greater understanding of the construct of citizenship and an instrument to assess the degree to which individuals, particularly those with psychiatric disorders, perceive themselves to be citizens in a multifaceted sense (that is, not in a simply legal sense). METHODS: Participants were persons with recent experience of receiving public mental health services, having criminal justice charges, having a serious general medical illness, or having more than one of these "life disruptions," along with persons who had not experienced any of these disruptions. Community-based participatory methods, including a co-researcher team of persons with experiences of mental illness and other life disruptions, were employed. Procedures included conducting focus groups with each life disruption (or no disruption) group to generate statements about the meaning of citizenship (N = 75 participants); reducing the generated statements to 100 items and holding concept-mapping sessions with participants from the five stakeholder groups (N = 66 participants) to categorize and rate each item in terms of importance and access; analyzing concept-mapping data to produce citizenship domains; and developing a pilot instrument of citizenship. RESULTS: Multidimensional scaling and hierarchical cluster analysis revealed seven primary domains of citizenship: personal responsibilities, government and infrastructure, caring for self and others, civil rights, legal rights, choices, and world stewardship. Forty-six items were identified for inclusion in the citizenship measure. CONCLUSIONS: Citizenship is a multidimensional construct encompassing the degree to which individuals with different life experiences perceive inclusion or involvement across a variety of activities and concepts.

Readability of patient education materials: a comparison of rural and urban cardiac rehabilitation sites in Minnesota.

PURPOSE: Printed materials play a major role in cardiac rehabilitation (CR) patient education. Past studies have demonstrated a marked disparity between the average American reading ability (8th grade) and the readability levels of printed CR patient materials. This study compares the readability of facility-developed patient education materials used by rural and urban CR sites in Minnesota. METHODS: By random selection, 30 rural and 30 urban CR sites were invited to submit printed education materials addressing home programs, exercise and activity guidelines, and leisure and recreation. Materials from 7 rural and 10 urban sites were submitted and assessed using the SMOG and SMOG-C readability formulas. RESULTS: On the average, the materials from both urban and rural CR sites were written at a 10th-grade level. More than 87% of the sites required reading skills above the eighth-grade level. An independent t test showed no significant difference in the readability levels between the urban and rural sites. This study primarily compared readability across sites. However, the distribution of the 36 pieces of written material also was examined. Only 9% of the urban materials and 14% of the rural materials were written at or below the targeted eighth-grade level. CONCLUSIONS: There was no significant difference in mean readability levels between urban and rural CR sites in Minnesota. On the average, the readability levels were two grades higher than recommended, with 87.5% of the CR sites expecting patients to learn information from materials too difficult for average American adults. The large number of polysyllabic words appears to be the main culprit for difficult readability levels.