Use of ankle magnetic resonance imaging in the active duty military population: the results of a process improvement project.

BACKGROUND: Preventing overuse of magnetic resonance imaging (MRI) for diagnosing ankle pathology was the goal of a process improvement project at a military treatment facility. METHODS: Ordering patterns for MRI of nonorthopaedic providers and orthopaedic surgeons were evaluated over 2 separate periods. An educational initiative on appropriate use of MRI in evaluating ankle complaints was conducted between the 2 periods. RESULTS: Between October 2009 and March 2010, 230 ankle MRIs were performed at our institution, compared to 347 ankle MRIs performed between December 2012 and August 2013. A lower number of patients underwent operative procedures after the education process than before (17% versus 25%). Fellowship-trained foot and ankle surgeons produced the highest number of operative patients with their MRI ordering practices (P=.003 and P=.0001 for Phases 1 and 2 respectively). There was no change in the number of ankle MRI studies ordered each month following the educational initiative (38.3 and 38.5 for Phases 1 and 2 respectively). CONCLUSIONS: The majority of patients undergoing ankle MRI did not undergo operative intervention. Foot and ankle surgeons produce the highest number of operative patients with their MRI ordering practices. Education alone was ineffective in altering ankle MRI ordering patterns.

Heat-induced Epitope Retrieval for Immunohistochemistry at High Altitude: A Quality Assurance Study.

INTRODUCTION: Heat-induced epitope retrieval (HIER) of formalin-fixed paraffin-embedded tissues is now a standard practice in immunohistochemistry (IHC). In this study, we aimed to test the effect of altering HIER temperature on IHC staining quality at high altitude, the hypothesis being that lower HIER temperatures would result in improved staining patterns. MATERIALS AND METHODS: In a laboratory at high altitude (Aurora, CO), we used a platform with automated onboard epitope retrieval, and systematically tested 3 different HIER temperatures (100°C, 95°C, 90°C) with 4 IHC stains that are commonly used in routine practice: CD3, Ki67, CK20, and Melan A (n=10 for each antibody/epitope retrieval temperature combination). A scoring system was devised, the slides were scored in a blinded manner, and statistical analysis was performed. For comparison, the same study was performed in a laboratory near sea level (Atlanta, GA). RESULTS: At high altitude, lower HIER temperatures resulted in improved staining patterns, as quantified by stronger staining intensity and greater area of the slides stained. The scores obtained with HIER temperatures of 95°C and 90°C were higher than those obtained with HIER of 100°C, and the difference was found to be statistically significantly for some antibody/epitope retrieval temperature combinations (P<0.05). This effect was not seen in the laboratory near sea level. CONCLUSIONS: We show that alternate epitope retrieval recommendations are warranted for laboratories at high altitude. Furthermore, we suggest that manufactures should consider how their instruments will perform at high altitude as they further automate the process of IHC.

Enhancing Self-Efficacy to Achieve Competence.

A primary goal of cognitive therapy supervision is to help the supervisee achieve greater competence in cognitive therapy. However, helping supervisees achieve competence rests in part on their judgments that they can use the skills they learned to help their clients feel and get better. Bandura referred to these judgments as self-efficacy, which he defined as an individual's perception that he is capable of accomplishing a certain level of performance (Bandura, 1977). Although it is understandable that most supervisees enter supervision with low self-efficacy, it can become an impediment to achieving competence if it persists. In this article, I define self-efficacy and describe four sources of information that influence self-efficacy: performance accomplishments, vicarious experiences, persuasion, and physiological states. I then describe how supervisors can use these sources to enhance the self-efficacy of supervisees to assist them in achieving actual competence.

Working with families of people who hoard: a harm reduction approach.

Approximately, 3%-5% of the U.S. population suffers from compulsive hoarding but others suffer as well, in particular, the family members who care about them. This article describes the manifold ways family members suffer because of their loved one's hoarding behavior, including the frustration and hopelessness many family members experience in the face of their loved one's steadfast refusal to accept help for their hoarding problem. The article presents harm reduction as a way for family members to help a loved one who is unwilling to accept treatment of the hoarding problem. The article then presents two clinical examples-a private hoarding situation and a public hoarding situation-to illustrate the application of harm reduction to hoarding.

Guidelines for enhancing homework compliance.

The ability to enhance compliance with therapeutic tasks such as homework may be a crucial therapeutic skill that determines the success of psychotherapy in real-world clinical settings. This article presents guidelines for enhancing homework compliance through careful attention to: features of homework assignments, such as whether they are meaningful and doable and include a clear rationale and backup plan; and the therapist's manner when developing and reviewing homework assignments, such as whether that therapist is curious, collaborative, and reinforces all behavior that supports the homework's purposes. Clinical examples are used to illustrate the application of the guidelines.