Patterns and Predictors of Referral for Screening Breast MRI: A Mixed-Methods Study.

Introduction: Women with ≥20% lifetime breast cancer risk can receive supplemental breast cancer screening with MRI. We examined factors associated with recommendation for screening breast MRI among primary care providers (PCPs), gynecologists (GYNs), and radiologists. Methods: We conducted a sequential mixed-methods study. Quantitative: Participants (N = 72) reported recommendations for mammogram and breast MRI via clinical vignettes describing hypothetical patients with moderate, high, and very high breast cancer risk. Logistic regressions assessed the relationships of clinician-level factors (gender, specialty, years practicing) and practice-level factors (practice type, imaging facilities available) with screening recommendations. Qualitative: We interviewed a subset of survey participants (n = 17, 17/72 = 24%) regarding their decision-making about breast cancer screening recommendations. Interviews were audio-recorded, transcribed, and analyzed with directed content analysis. Results: Compared with PCPs, GYNs and radiologists were significantly more likely to recommend breast MRI for high-risk (ORs = 4.09 and 4.09, respectively) and very-high-risk patients (ORs = 8.56 and 18.33, respectively). Qualitative analysis identified two key phases along the clinical pathway for high-risk women. Phase 1 was "identifying high-risk women," which included three subthemes (systems for risk assessment, barriers to risk assessment, scope of practice issues). Phase 2 was "referral for screening," which included three subthemes (conflicting guidelines, scope of practice issues, legal implications). Frequency of themes differed between specialties, potentially explaining findings from the quantitative phase. Conclusions: There are significant differences between specialties in supplemental breast cancer screening recommendations. Multilevel interventions are needed to support identification and management of women with high breast cancer risk, particularly for PCPs.

Patterns of Screening Mammography and Breast MRI During the COVID-19 Pandemic: A Retrospective, Chart-Review Study.

Objective: This study examined patterns of breast cancer screening during the COVID-19 pandemic. Methods: This retrospective study was approved by the Georgetown University IRB. Review of electronic medical records identified screening mammograms and breast MRIs between March 13, 2018 and December 31, 2020, for female patients aged 18 to 85 years. Descriptive statistics characterized patterns of breast cancer screening before and during the COVID-19 pandemic. Logistic regression analyses examined whether receipt of breast MRI differed over time and demographic and clinical factors associated with receipt of breast MRI in 2020. Results: Data included 47 956 mammography visits in 32 778 patients and 407 screening breast MRI visits in 340 patients. After an initial decrease following the declaration of the COVID-19 pandemic, both screening mammograms and screening breast MRI demonstrated early recovery. Although the mammography receipt remained sustained, the receipt of screening breast MRI decreased in late 2020. Odds of having a breast MRI did not differ between 2018 and 2019 (OR = 1.07; 95% CI = 0.92%-1.25%; P = 0.384) but were significantly lower in 2020 versus 2019 (OR = 0.76; 95% CI = 0.61%-0.94%; P = 0.011). No demographic or clinical factors were associated with receipt of breast MRI during the COVID-19 pandemic (all P-values ≥0.225). Conclusion: Breast cancer screening decreased following the declaration of the COVID-19 pandemic. Although both procedures demonstrated early recovery, the rebound in screening breast MRI was not sustained. Interventions promoting return to screening breast MRI may be needed for high-risk women.

Palpable Lumps after Mastectomy: Radiologic-Pathologic Review of Benign and Malignant Masses.

Patients who have undergone mastectomy, with or without reconstruction, are not universally screened with mammography or US. Therefore, clinical breast examination by the physician and patient-detected palpable abnormalities are crucial for detecting breast cancer or recurrence. Diagnostic US is the first-line modality for evaluation of postmastectomy palpable masses, with occasional adjunct use of diagnostic mammography for confirming certain benign masses. In the setting of a negative initial imaging evaluation with continued clinical concern, diagnostic MRI may aid in improving sensitivity. Knowledge of the typical multimodality imaging appearances and locations of malignant palpable abnormalities-such as invasive carcinoma recurrence, cancer in residual breast tissue, radiation-induced sarcoma, and metastatic disease-is crucial in diagnosis and treatment of these entities. In addition, familiarity with the range of benign palpable postmastectomy processes-including fat necrosis, fat graft, seroma, granuloma, neuroma, fibrosis, and infection-may help avoid unnecessary biopsies and reassure patients. The authors review common and rare benign and malignant palpable masses in mastectomy patients, describe multimodality diagnostic imaging evaluation of each entity, review radiologic and pathologic correlation, and acquaint the radiologist with management when these findings are encountered. ©RSNA, 2021.

Transitioning from trainee to breast radiologist: A guide for a successful first year.

The transition from trainee to newly minted breast radiologist is exciting and daunting in equal measure. The early years in practice are pivotal to long-term success in breast imaging whether entering academic or nonacademic practice. Yet a paucity of literature exists to guide junior radiologists in their early career transition. New breast radiologists can successfully navigate the start of a prosperous and enriching career by implementing strategies adapted from the business world and collective wisdom from the radiology world. This article provides an outline of tips and habits for new radiologists to incorporate in their work lives as attendings to ensure that they will thrive in breast imaging for years to come.

Training to improve hearing speech in noise: biological mechanisms.

We investigated training-related improvements in listening in noise and the biological mechanisms mediating these improvements. Training-related malleability was examined using a program that incorporates cognitively based listening exercises to improve speech-in-noise perception. Before and after training, auditory brainstem responses to a speech syllable were recorded in quiet and multitalker noise from adults who ranged in their speech-in-noise perceptual ability. Controls did not undergo training but were tested at intervals equivalent to the trained subjects. Trained subjects exhibited significant improvements in speech-in-noise perception that were retained 6 months later. Subcortical responses in noise demonstrated training-related enhancements in the encoding of pitch-related cues (the fundamental frequency and the second harmonic), particularly for the time-varying portion of the syllable that is most vulnerable to perceptual disruption (the formant transition region). Subjects with the largest strength of pitch encoding at pretest showed the greatest perceptual improvement. Controls exhibited neither neurophysiological nor perceptual changes. We provide the first demonstration that short-term training can improve the neural representation of cues important for speech-in-noise perception. These results implicate and delineate biological mechanisms contributing to learning success, and they provide a conceptual advance to our understanding of the kind of training experiences that can influence sensory processing in adulthood.

Test-retest reliability of the speech-evoked auditory brainstem response.

OBJECTIVE: The speech-evoked auditory brainstem response (ABR) provides an objective measure of subcortical encoding of complex acoustic features. However, the intrasubject reliability of this response in both optimal and challenging listening conditions has not yet been systematically documented. This study aimed to evaluate test-retest reliability of the speech-evoked ABR in young adults. METHODS: In each of two sessions, ABRs were obtained with: (1) a 170 ms /da/ syllable presented in quiet as well as 2-talker and 6-talker babble background noise conditions and (2) a 40 ms /da/ syllable presented in quiet. Test-retest reliability of the responses was analyzed in the frequency and time domains. RESULTS: The speech-evoked ABR does not vary significantly across sessions within individuals on measures of temporal encoding (i.e., peak latencies, stimulus-to-response and response-to-response measures), frequency representation and response magnitude. CONCLUSIONS: The subcortical auditory pathway produces a response to a complex sound that is stable and replicable from session to session. SIGNIFICANCE: By demonstrating the high degree of replicability in optimal and challenging listening conditions, the applicability of the speech-evoked ABR may be increased to examining a range of auditory processing abilities in clinical and research settings.

Perception of speech in noise: neural correlates.

The presence of irrelevant auditory information (other talkers, environmental noises) presents a major challenge to listening to speech. The fundamental frequency (F(0)) of the target speaker is thought to provide an important cue for the extraction of the speaker's voice from background noise, but little is known about the relationship between speech-in-noise (SIN) perceptual ability and neural encoding of the F(0). Motivated by recent findings that music and language experience enhance brainstem representation of sound, we examined the hypothesis that brainstem encoding of the F(0) is diminished to a greater degree by background noise in people with poorer perceptual abilities in noise. To this end, we measured speech-evoked auditory brainstem responses to /da/ in quiet and two multitalker babble conditions (two-talker and six-talker) in native English-speaking young adults who ranged in their ability to perceive and recall SIN. Listeners who were poorer performers on a standardized SIN measure demonstrated greater susceptibility to the degradative effects of noise on the neural encoding of the F(0). Particularly diminished was their phase-locked activity to the fundamental frequency in the portion of the syllable known to be most vulnerable to perceptual disruption (i.e., the formant transition period). Our findings suggest that the subcortical representation of the F(0) in noise contributes to the perception of speech in noisy conditions.

Brainstem timing deficits in children with learning impairment may result from corticofugal origins.

A substantial proportion of children with language-based learning problems [learning disabilities (LD)] display abnormal encoding of speech at rostral levels of the auditory brainstem (i.e. midbrain) as measured by the auditory brainstem response (ABR). Of interest here is whether these timing deficits originate at the rostral brainstem or whether they reflect deficient sensory encoding at lower levels of the auditory pathway. We describe the early brainstem response to speech (waves I and III) in typically developing 8- to 12-year-old children and children with LD. We then focus on the early brainstem responses in children with LD found to show abnormal components of the rostral speech-evoked ABR (waves V and A). We found that wave I was not reliably evoked using our speech stimulus and recording parameters in either typically developing children or those with LD. Wave III was reliably evoked in the large majority of subjects in both groups and its timing did not differ between them. These data are consistent with the view that the auditory deficits in the majority of LD children with abnormal speech-evoked ABR originate from corticofugal modulation of subcortical activity.

Plasticity in the adult human auditory brainstem following short-term linguistic training.

Peripheral and central structures along the auditory pathway contribute to speech processing and learning. However, because speech requires the use of functionally and acoustically complex sounds which necessitates high sensory and cognitive demands, long-term exposure and experience using these sounds is often attributed to the neocortex with little emphasis placed on subcortical structures. The present study examines changes in the auditory brainstem, specifically the frequency following response (FFR), as native English-speaking adults learn to incorporate foreign speech sounds (lexical pitch patterns) in word identification. The FFR presumably originates from the auditory midbrain and can be elicited preattentively. We measured FFRs to the trained pitch patterns before and after training. Measures of pitch tracking were then derived from the FFR signals. We found increased accuracy in pitch tracking after training, including a decrease in the number of pitch-tracking errors and a refinement in the energy devoted to encoding pitch. Most interestingly, this change in pitch-tracking accuracy only occurred in the most acoustically complex pitch contour (dipping contour), which is also the least familiar to our English-speaking subjects. These results not only demonstrate the contribution of the brainstem in language learning and its plasticity in adulthood but also demonstrate the specificity of this contribution (i.e., changes in encoding only occur in specific, least familiar stimuli, not all stimuli). Our findings complement existing data showing cortical changes after second-language learning, and are consistent with models suggesting that brainstem changes resulting from perceptual learning are most apparent when acuity in encoding is most needed.