Real-World Evidence for Utility of Serum sFlt-1/PlGF Test for Routine Clinical Evaluation of Hospitalized Women with Hypertensive Disorders of Pregnancy.

BACKGROUND: An imbalance of the anti-angiogenic factor, soluble fms-like tyrosine kinase-1 (sFlt-1), and pro-angiogenic factor, placental growth factor (PlGF) in the circulation is a reliable predictor for development of preeclampsia with severe features and related adverse outcomes. In 2023, the United States (US) Food and Drug Administration approved a serum sFlt-1/PlGF test at a cut-off of 40 to aid in the risk assessment of women hospitalized for hypertensive disorders of pregnancy (HDP) for the progression to preeclampsia with severe features between 23 and 35 weeks. OBJECTIVE: The purpose of this study was to generate real-world evidence for clinical utility for serum sFlt-1/PlGF test when made available to clinicians in a timely fashion as an aid in risk stratification of development of preeclampsia with severe features within two weeks of testing among hospitalized patients with HDP. STUDY DESIGN: Hospitalized patients with HDP between 23 weeks to 34 weeks and 6 days of gestation were prospectively studied from June 2023 to Jan 2024 following implementation of serum sFlt-1/PlGF testing into routine clinical practice. Serum samples were obtained from patients via venipuncture and analyzed on an automated immunoassay platform (PlGF and sFlt-1 assays; Thermo Fisher Scientific). Before implementation, physicians were educated on appropriate use and management guidelines based on biomarkers but made pragmatic management decisions independently. Results of sFlt-1/PlGF tests were available to clinicians within 24 hours of venipuncture. The association between sFlt-1/PlGF ≥ 40 and progression to preeclampsia with severe features and adverse maternal/perinatal outcomes were assessed. RESULTS: Of the 65 patient encounters, 36 had a sFlt-1/PlGF < 40 (55.4%). The rate of delivery for indications related to HDP within two weeks was significantly lower among encounters with a low ratio versus high ratio (2/36 [5.6%] vs 21/29 [72.4%]) even after controlling for relevant confounders (adjusted HR 7.52, 95% CI: 3.05, 18.54; p < 0.001). A diagnosis of preeclampsia with severe features within two weeks of testing was also less likely among the encounters with sFlt-1/PlGF ratio < 40 when compared to sFlt-1/PlGF ratio ≥ 40 (2/36 [5.6%] versus 23/29 [79.3%], p<0.001; PPV 79% [95% CI: 0.65, 0.94] and NPV 0.94 [95% CI: 0.87, 1.00]). The positive and negative likelihood ratios for the development of preeclampsia with severe features within two weeks of testing were 6.13 and 0.09 respectively. Encounters with an sFlt-1/PlGF ratio <40 were less likely to experience a maternal or fetal adverse event as compared to encounters with sFlt-1/PlGF ratio ≥40 (3/36 [8.3%] vs 10/29 [34.5%], p=0.01). Among 36 encounters involving low sFlt-1/PlGF values, 22 had had equivocal clinical or laboratory criteria resembling preeclampsia at presentation but were expectantly managed based on biomarkers and none developed preeclampsia with severe features or adverse outcomes at two weeks. The median latency defined as days between biomarker measurement and delivery in patients with low biomarker ratio was 33 (IQR 23, 47) versus 7 (IQR 4, 14) days among patients with a high ratio (p<0.001). Corticosteroid use within two weeks was also significantly reduced in the low biomarker group when compared to high biomarker group (8/35 [22.9%] vs 24/29 [82.8%], p<0.001). CONCLUSION: In this study, incorporation of sFlt-1/PlGF ratio into clinical practice serves as a dependable supplement in assessing risk for progression to preeclampsia with severe features and adverse outcomes in patients with HDP in the US. Among patients with a low ratio, pregnancy may be prolonged which resulted in better neonatal outcomes without harm to the mother.

Pearls and Pitfalls of Interpretation of Automated Breast US.

Dense breast tissue is an independent risk factor for breast cancer and reduces the sensitivity of mammography. Patients with dense breast tissue are more likely to present with interval cancers and higher-stage disease. Successful breast cancer screening outcomes rely on detection of early-stage breast cancers; therefore, several supplemental screening modalities have been developed to improve cancer detection in dense breast tissue. US is the most widely used supplemental screening modality worldwide and has been proven to demonstrate additional mammographically occult cancers that are predominantly invasive and node negative. According to the American College of Radiology, intermediate-risk women with dense breast tissue may benefit from adjunctive screening US due to the limitations of mammography. Several studies have demonstrated handheld US (HHUS) and automated breast US (AUS) to be comparable in the screening setting. The advantages of AUS over HHUS include lack of operator dependence and a formal training requirement, image reproducibility, and ability for temporal comparison. However, AUS exhibits unique features that can result in high false-positive rates and long interpretation times for new users. Familiarity with the common appearance of benign mammographic findings and artifacts, technical challenges, and unique AUS features is essential for fast, efficient, and accurate interpretation. The goals of this article are to (a) examine the role of AUS as a supplemental screening modality and (b) review the pearls and pitfalls of AUS interpretation. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Intra-Sonographer Correlation Between Transabdominal and Transvaginal Cervical Length Measurements and Associated Patient Demographics.

OBJECTIVES: To assess transvaginal (TV) and transabdominal (TA) cervical length (CL) measurements' variability and patient factors associated with TA CL accuracy. We hypothesized that patient factors would affect the accuracy of TA CL. METHODS: This was a prospective cohort study. During anatomy ultrasound, TA and TV CL measurements were obtained, distance from placental edge to internal cervical os assessed, and demographic questionnaires completed. Patients between 18 to 22 weeks and 6 days were included and those <18 year old or with a twin gestation were excluded. TA CL >0.5 cm different from TV length was considered inaccurate. RESULTS: A total of 530 patients were included. Exactly 18.7% had a prior cesarean, 9.8% a preterm birth, and 2.2% a cervical procedure. Mean age and BMI were 31.1 years and 27.8 kg/m2 . Median number of living children was one. Median TA and TV CL were 3.42 and 3.53 cm. Exactly 36% (95% CI: 32-40%) of TA CL measurements were inaccurate. CL of 3.4 cm corresponded to a mean difference of zero between TA and TV CL. TA ultrasound had a sensitivity of 25% and a specificity of 98.5% to detect TV CL <2.5 cm. On multivariable analyses, Hispanic ethnicity was associated with inaccurate TA measurement (OR 0.48, 95% CI: 0.24-0.96, P = .04). CONCLUSIONS: On average, TA CL underestimates TV CL when TV CL >3.40 cm and overestimates TV CL when TV CL <3.40 cm. Additional co-variates did not impact accuracy. TA ultrasound has low sensitivity to predict short cervix. Relying solely on TA CL to identify those who need intervention may miss diagnoses. It may be reasonable to develop protocols in which TV CL is used for TA CL <3.4 cm.

Self-reported pain and fatigue are associated with physical and cognitive function in middle to older-aged adults.

Persistent fatigue is often reported in those with chronic musculoskeletal pain. Separately, both chronic pain and chronic fatigue contribute to physical and cognitive decline in older adults. Concurrent pain and fatigue symptoms may increase disability and diminish quality of life, though little data exist to show this. The purpose of this study was to examine associations between self-reported pain and fatigue, both independently and combined, with cognitive and physical function in middle-older-aged adults with chronic knee pain. Using a cross-sectional study design participants (n = 206, age 58.0 ± 8.3) completed questionnaires on pain and fatigue, a physical performance battery to assess physical function, and the Montreal Cognitive Assessment. Hierarchical regressions and moderation analyses were used to assess the relationship between the variables of interest. Pain and fatigue both predicted physical function (ß = -0.305, p < 0.001; ß = -0.219, p = 0.003, respectively), however only pain significantly predicted cognitive function (ß = -0.295, p <0.001). A centered pain*fatigue interaction was a significant predictor of both cognitive function (ß = -0.137, p = 0.049) and physical function (ß = -0.146, p = 0.048). These findings indicate that self-reported fatigue may contribute primarily to decline in physical function among individuals with chronic pain, and less so to decline in cognitive function. Future studies should examine the impact of both cognitive and physical function decline together on overall disability and health.

Brain predicted age difference mediates pain impact on physical performance in community dwelling middle to older aged adults.

The purpose of the study was to examine associations between physical performance and brain aging in individuals with knee pain and whether the association between pain and physical performance is mediated by brain aging. Participants (n=202) with low impact knee pain (n=111), high impact knee pain (n=60) and pain-free controls (n=31) completed self-reported pain, magnetic resonance imaging (MRI), and a Short Physical Performance Battery (SPPB) that included balance, walking, and sit to stand tasks. Brain predicted age difference, calculated using machine learning from MRI images, significantly mediated the relationships between walking and knee pain impact (CI: -0.124; -0.013), walking and pain-severity (CI: -0.008; -0.001), total SPPB score and knee pain impact (CI: -0.232; -0.025), and total SPPB scores and pain-severity (CI: -0.019; -0.001). Brain-aging begins to explain the association between pain and physical performance, especially walking. This study supports the idea that a brain aging prediction can be calculated from shorter duration MRI sequences and possibly implemented in a clinical setting to be used to identify individuals with pain who are at risk for accelerated brain atrophy and increased likelihood of disability.

Decreased cognitive function is associated with impaired spatiotemporal gait performance in community dwelling older adults with chronic musculoskeletal pain.

OBJECTIVE: Older adults with chronic musculoskeletal pain often suffer from cognitive impairments and diminished lower extremity physical function. Prior work suggests that these impairments may be interrelated, however, the relationship between cognition and spatiotemporal gait performance in this population is understudied. Therefore, the purpose of this study was to examine the association between cognition and spatiotemporal gait performance and determine if cognition mediates the relationship between pain severity and spatiotemporal gait performance in older adults with chronic musculoskeletal pain without cognitive impairment. METHODS: Older adults with chronic musculoskeletal pain (n = 36) completed the Montreal Cognitive Assessment (MoCA) to assess global cognitive function. Spatiotemporal gait analysis was completed using an automated gait mat. Hierarchical regressions and mediation analyses were used to assess the relationship between chronic musculoskeletal pain, cognition, and spatiotemporal gait performance. RESULTS: MoCA scores were significantly associated with double support time, with lower MoCA scores relating with longer double support times (ß = -0.686, p = 0.039). After accounting for cognition, pain severity was also associated with slower gait speed (ß = -0.422, p = 0.019), and double support time (ß = 0.454, p = 0.008). Cognition, however, did not mediate the relationship between pain severity and double support time. CONCLUSIONS: Global cognition and pain severity were associated with spatiotemporal gait performance in older adults with chronic pain. Pain severity, but not cognition, however, primarily explained spatiotemporal gait performance in our sample. Future work is needed to elucidate the role of cognition in spatiotemporal gait performance in older adults with chronic musculoskeletal pain.

Medicare Incentive Payments to United States Ophthalmologists for Use of Electronic Health Records: 2011-2016.

PURPOSE: To investigate ophthalmologists' rate of attestation to meaningful use (MU) of their electronic health record (EHR) systems in the Medicare EHR Incentive Program and their continuity and success in receiving payments in comparison with other specialties. DESIGN: Administrative database study. PARTICIPANTS: Eligible professionals participating in the Medicare EHR Incentive Program. METHODS: Based on publicly available data sources, subsets of payment and attestation data were created for ophthalmologists and for other specialties. The number of eligible professionals attesting was determined using the attestation data for each year and stage of the program. The proportion of attestations by EHR vendor was calculated using all attestations for each vendor. MAIN OUTCOME MEASURES: Numbers of ophthalmologists attesting by year and stage of the Medicare EHR Incentive Program, incentive payments, and number of attestations by EHR vendor. RESULTS: In the peak year of participation, 51.6% of ophthalmologists successfully attested to MU, compared with 37.1% of optometrists, 50.2% of dermatologists, 54.5% of otolaryngologists, and 64.4% of urologists. Across the 6 years of the program, ophthalmologists received an average of $17 942 in incentive payments compared with $11 105 for optometrists, $16 617 for dermatologists, $20 203 for otolaryngologists, and $23 821 for urologists. Epic and Nextgen were the most frequently used EHRs for attestation by ophthalmologists. CONCLUSIONS: Ophthalmology as a specialty performed better than optometry and dermatology, but worse than otolaryngology and urology, in terms of the proportion of eligible professionals attesting to MU of EHRs. Ophthalmologists were more likely to remain in the program after their initial year of attestation compared with all eligible providers. The top 4 EHR vendors accounted for 50% of attestations by ophthalmologists.

Endogenous Pain Inhibitory Function: Endurance-Trained Athletes vs Active Controls.

OBJECTIVE: Athletes are at risk for developing chronic pain conditions, but the role of exercise in the modulation of pain in athletes has not been well established. The aim of this study was to investigate conditioned pain modulation (CPM) and exercise-induced hypoalgesia (EIH) responses between 13 endurance-trained athletes and 13 normally active controls. METHODS: In a cross-sectional, nonrandomized study with two independent groups of college-aged males and females, pressure pain thresholds (PPTs) were assessed in the vastus lateralis (VL) and brachioradialis (BR) using a pressure algometer before and after a conditioning stimulus, an isometric hand grip exercise to failure, and a 30-minute run. RESULTS: PPTs increased following the conditioning stimulus, indicating a CPM response, to a similar degree in the BR (19.3% ± 26.5% vs 18.6% ± 16.2%, P = 0.93) and VL (18.9% ± 25.9% vs 28.7% ± 27.4%, P = 0.73) in the athletes and controls. PPTs increased following isometric exercise to a similar extent in athletes and controls in the BR (23.9% ± 22.8% vs 28.2% ± 24.0%, P = 0.75) and VL (15.8% ± 14.8% vs 15.5% ± 11.6%, P = 0.94). Following 30 minutes of running, EIH was similar between athletes and controls in the VL (21.2% ± 17.2% vs 13.8% ± 13.3%, P = 0.23) but was attenuated in the BR of the athletes (6.1% ± 16.9% vs 20.9% ± 20%, P = 0.047). CONCLUSIONS: Athletes and controls exhibited similar endogenous pain inhibitory function both locally and systemically following CPM and isometric, upper body exercise. After the 30-minute run, BR EIH was reduced in the athletes compared with controls, suggesting a reduced systemic response following familiar exercise-perhaps due to the exercise being perceived as less painful and/or effortful.

Developmental trajectories for young children with 16p11.2 copy number variation.

Copy number variation at 16p11.2 is associated with diverse phenotypes but little is known about the early developmental trajectories and emergence of the phenotype. This longitudinal study followed 56 children with the 16p11.2 BP4-BP5 deletion or duplication between the ages of 6 months and 8 years with diagnostic characterization and dimensional assessment across cognitive, adaptive, and behavioral domains. Linear mixed modeling revealed distinct developmental trajectories with deletions showing VIQ gains but declines in motor and social abilities while duplications showed VIQ gains and steady development across other domains. Nonparametric analyses suggest distinct trajectories and early cognitive abilities for deletion carriers who are ultimately diagnosed with intellectual disability and developmental coordination disorder as well as distinct trajectories and early social communication and cognitive abilities for duplication carriers diagnosed with ASD and intellectual disability. Findings provide predictions for patient developmental trajectories, insight into mean functioning of individuals with 16p11.2 at early ages, and highlight the need for ongoing monitoring of social and motor functioning and behavioral symptomatology to improve treatment planning. © 2017 Wiley Periodicals, Inc.

Ambivalence About Interpersonal Problems and Traits Predicts Cross-Situational Variability of Social Behavior.

Multiple theoretical perspectives suggest that maladjusted personality is characterized by not only distress, but also opposing or "ambivalent" self-perceptions and behavioral lability across social interactions. However, the degree to which ambivalence about oneself predicts cross-situational variability in social behavior has not been examined empirically. Using the interpersonal circumplex (IPC) as a nomological framework, the present study investigated the extent to which endorsing opposing or "ambivalent" tendencies on IPC measures predicted variability in social behavior across a range of hypothetical interpersonal scenarios (Part 1; N = 288) and naturalistic social interactions (Part 2; N = 192). Ambivalent responding for interpersonal problems and traits was associated with measures of distress, maladaptive interpersonal tendencies, and greater variability of social behavior across both hypothetical and daily social interactions, though more consistently for interpersonal problems. More conservative tests suggested that ambivalence predicted some indexes of behavioral variability even when accounting for mean levels and squared means of social behaviors, vector length, gender, and depressive symptoms. Results suggest that processes theorized as typifying personality disorder may apply more broadly to personality maladjustment occurring outside of clinical samples.

Production of the polysaccharide curdlan by an Agrobacterium strain grown on a plant biomass hydrolysate.

Production of the commercially available polysaccharide curdlan by Agrobacterium sp. strain ECP-1, isolated as a mutant strain from ATCC 31749, on a medium containing a hydrolysate of the plant prairie cordgrass with selected ammonium phosphate concentrations was investigated for a period of 144 h. Although several ammonium phosphate concentrations supported curdlan production by the strain, the optimal concentration after 120 or 144 h was 3.3 mmol·L⁻¹. Only ammonium phosphate concentrations of 1.1 or 8.7 mmol·L⁻¹ failed to support curdlan production by the strain after 120 or 144 h. Biomass production by strain ECP-1 on the hydrolysate-containing medium after 120 or 144 h was comparable, independent of the ammonium phosphate concentration present. The curdlan yield from the cordgrass hydrolysate indicated that the grass was an effective plant biomass substrate for polysaccharide production.

Elevated 3-hydroxypropionaldehyde production from glycerol using a Citrobacter freundii mutant.

A mutant strain of Citrobacter freundii capable of elevated 3-hydroxypropionaldehyde production from glycerol was isolated using chemical mutagenesis and a screening protocol. The protocol involved screening mutagenized bacterial cells on solid minimal medium containing 5 % (v/v) glycerol. Colonies were picked onto duplicate solid minimal medium plates and one plate was stained with 1 % (w/v) phloroglucinol. Those colonies staining red were further screened and a mutant, HPAO-1, was identified. The mutant strain produced a several-fold higher 3-hydroxypropionaldehyde concentration than did the parent strain when grown on 5 % (v/v) glycerol. The ratio of culture volume to flask volume influenced 3-hydroxypropionaldehyde production by the mutant cells compared to the parent cells. Aldehyde production was highest when the mutant strain was grown on 5 % (v/v) glycerol at a ratio of culture volume to flask volume of 1:3 or 1:12.5.

Waiting and watching: Nurse migration trends before a change to the National Council Licensure Examination as entry to practice for Canada's nurses.

BACKGROUND: A number of factors in the health care environment, including a change in regulatory policy, may affect a country's nursing workforce and nurse migration and mobility. PURPOSE: This study compared the characteristics of Canadian-educated nurses who had migrated to the United States to work with their colleagues in the United States and Canada in anticipation of a change in Canada's RN entry to practice requirements in 2015. METHODS: We conducted a retrospective comparative study of nurses in Canada and the U.S. using 2008 data from the US National Sample Survey of Registered Nurses and the Canadian Institute of Health Information. DISCUSSION: There was little change in the number of Canadian-educated nurses working in the United States in 2008 compared with 2004. We found differences between U.S. nurses and Canadian-educated nurses working in the United States in educational level, work status, work location, and age. No differences were found between Canadian-educated nurses working in the United States and those working in Canada. CONCLUSIONS: This research highlights the value of international comparisons of the nursing workforce, especially in the context of anticipated regulatory changes, which may affect a country's nursing health human resources.

Anesthesia information management systems: imperatives for nurse anesthetists.

Informatics is a new science within healthcare and anesthesia that leverages computer technology to improve patient safety, the quality of care provided, and workload efficiency. In clinical anesthesia practice, appropriate application of informatics promotes data standardization and integrity, and supports clinical decision-making. This article describes current issues in anesthesia information management to support the critical need for Certified Registered Nurse Anesthetists (CRNAs) to influence functionality, adoption, and use of an anesthesia information management system. The use of informatics tools and concepts should enable CRNAs to enhance their bedside vigilance, align their practice with evidence-based clinical guidelines, and provide cost-effective care for patients and healthcare systems.

Delayed-Onset Muscle Soreness Alters Mechanical Sensitivity, but Not Thermal Sensitivity or Pain Modulatory Function.

Introduction: Many clinical musculoskeletal pain conditions are characterized by chronic inflammation that sensitizes nociceptors. An unresolved issue is whether inflammation affects all nociceptors in a similar manner. Exercise-induced muscle damage (EIMD) has been proposed as a model for simulating clinical inflammatory pain in healthy samples. We sought to test the effect of EIMD on various painful stimuli (pressure and thermal), central pain processing (via the nociceptive flexion reflex) and endogenous pain modulation via conditioned pain modulation and exercise-induced hypoalgesia. Methods: Eighteen participants (9F, age: 24.6 ± 3.3) were recruited for repeated measures testing and each completed pain sensitivity testing prior to and 48 hours after an eccentric exercise protocol. The participants performed a minimum of 6 rounds of 10 eccentric knee extension exercises to induce muscle damage and localized inflammation in the right quadriceps. Force decrements, knee range-of-motion, and delayed onset muscle soreness (DOMS) were used to quantify EIMD. Results: There was a significant main effect of time for pressure pain (%diff; -58.9 ± 23.1; p = 0.02, ηp2 = 0.28) but no significant main effect was observed for limb (%diff; -15.5 ± 23.9; p = 0.53, ηp2 = 0.02). In contrast, there was a significant interaction between time and limb (p < 0.001, ηp2 = 0.47) whereby participants had lower pressure pain sensitivity in the right leg only after the damage protocol (%diff; -105.9 ± 29.2; p = 0.002). Discussion: Individuals with chronic inflammatory pain usually have an increased sensitivity to pressure, thermal, and electrical stimuli, however, our sample, following muscle damage to induce acute inflammation only had sensitivity to mechanical pain. Exercise induced inflammation may reflect a peripheral sensitivity localized to the damaged muscle rather than a global sensitivity like those with chronic pain display.

Body composition and body mass index are independently associated with widespread pain and experimental pain sensitivity in older adults: a pilot investigation.

Introduction: Chronic musculoskeletal (MSK) pain is prevalent in older adults and confers significant risk for loss of independence and low quality of life. While obesity is considered a risk factor for developing chronic MSK pain, both high and low body mass index (BMI) have been associated with greater pain reporting in older adults. Measures of body composition that distinguish between fat mass and lean mass may help to clarify the seemingly contradictory associations between BMI and MSK pain in this at-risk group. Methods: Twenty-four older adults (mean age: 78.08 ± 5.1 years) completed dual-energy x-ray absorptiometry (DEXA), and pain measures (Graded Chronic Pain Scale, number of anatomical pain sites, pressure pain threshold, mechanical temporal summation). Pearson correlations and multiple liner regression examined associations between body mass index (BMI), body composition indices, and pain. Results: Significant positive associations were found between number of pain sites and BMI (b = 0.37) and total fat mass (b = 0.42), accounting for age and sex. Total body lean mass was associated with pressure pain sensitivity (b = 0.65), suggesting greater lean mass is associated with less mechanical pain sensitivity. Discussion: The results from this exploratory pilot study indicate lean mass may provide additional resilience to maladaptive changes in pain processing in older adults, and highlights the importance of distinguishing body composition indices from overall body mass index to better understand the complex relationship between obesity and MSK pain in older adults.

Socioeconomic Status, Knee Pain, and Epigenetic Aging in Community-Dwelling Middle-to-Older Age Adults.

Chronic musculoskeletal pain is often associated with lower socioeconomic status (SES). SES correlates with psychological and environmental conditions that could contribute to the disproportionate burden of chronic stress. Chronic stress can induce changes in global DNA methylation and gene expression, which increases risk of chronic pain. We aimed to explore the association of epigenetic aging and SES in middle-to-older age individuals with varying degrees of knee pain. Participants completed self-reported pain, a blood draw, and answered demographic questions pertaining to SES. We used an epigenetic clock previously associated with knee pain (DNAmGrimAge) and the subsequent difference of predicted epigenetic age (DNAmGrimAge-Diff). Overall, the mean DNAmGrimAge was 60.3 (±7.6), and the average DNAmGrimAge-diff was 2.4 years (±5.6 years). Those experiencing high-impact pain earned less income and had lower education levels compared to both low-impact and no pain groups. Differences in DNAmGrimAge-diff across pain groups were found, whereby individuals with high-impact pain had accelerated epigenetic aging (∼5 years) compared to low-impact pain and no pain control groups (both ∼1 year). Our main finding was that epigenetic aging mediated the associations of income and education with pain impact, as such the relationship between SES and pain outcomes may occur through potential interactions with the epigenome reflective of accelerated cellular aging. PERSPECTIVE: Socioeconomic status (SES) has previously been implicated in the pain experience. The present manuscript aims to present a potential social-biological link between SES and pain via accelerated epigenetic aging.

The Impact of Closed-Loop Imaging on Actionable CT-Detected Breast Findings.

PURPOSE: Closed-loop imaging programs (CLIPs) are designed to ensure that patients receive appropriate follow-up, but a review of incidental CT-detected breast findings in the setting of CLIPs has not been performed. METHODS: A retrospective review was conducted of CT reports at a single academic institution from July 1, 2020, to January 31, 2022, to identify reports with recommendations for breast imaging follow-up. Medical records were reviewed to evaluate patient adherence to follow-up, CLIP intervention, subsequent BI-RADS assessment, and diagnosis. Adherence was defined as diagnostic breast imaging performed within 6 months of the CT recommendation. RESULTS: Follow-up recommendations for breast imaging were included in CT report impressions for 311 patients. Almost half of patients (47.3% [147 of 311]) underwent follow-up breast imaging within 6 months, yielding breast cancer diagnoses in 12.9% (19 of 147) and a biopsy-proven positive predictive value of 65.5% (19 of 29). Most patients who returned for follow-up within 6 months did so without CLIP intervention. The majority of CT report impressions in the follow-up group (85.0% [125 of 147]) contained specific recommendations for "diagnostic breast imaging." For patients who did not receive follow-up, the CLIP team tracked all cases and intervened in 19.1% (28 of 147). The most common intervention was a phone call and/or fax to the primary care provider. Outpatient CT examination setting and specific recommendation for diagnostic breast imaging were significantly associated with higher follow-up adherence (P < .0001). CONCLUSIONS: Actionable CT-detected breast findings require follow-up diagnostic breast imaging because of a relevant cancer detection rate of 12.9%. Although many patients return for breast imaging without intervention, almost half of patients did not receive follow-up and may account for a significant number of missed cancer diagnoses. Specific CT recommendation verbiage is associated with higher follow-up adherence, which can be addressed across settings even without CLIPs.

Atypia Involving Fibroadenomas: Outcomes and Upgrade Rates.

OBJECTIVE: Fibroadenomas (FAs) involved by atypia are rare. Consensus guidelines for management of FAs involved by atypia when diagnosed on image-guided biopsy do not exist because of limited data reporting surgical upgrade rates to ductal carcinoma in situ (DCIS) or invasive malignancy. Therefore, these lesions commonly undergo surgical excision. METHODS: This single-institution retrospective study identified cases of FAs involved by atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and/or lobular carcinoma in situ (LCIS) diagnosed on image-guided biopsy between January 2014 and April 2023 to determine upgrade rates. Cases with incidental atypia adjacent to but not involving FAs were excluded. RESULTS: Among 1736 FAs diagnosed on image-guided biopsy, 32 cases (1.8%) were FAs involved by atypia including 43.8% (14/32) ALH, 28.1% (9/32) ADH, 18.8% (6/32) LCIS, 6.3% (2/32) LCIS + ALH, and 3.1% (1/32) unspecified atypia. The most common imaging finding was a mass. Most cases, 81.3% (26/32), underwent subsequent surgical excisional biopsy. A single case of ADH involving and adjacent to an FA was upgraded to FA involved by low-grade DCIS on excision for an overall surgical upgrade rate of 3.8%. There were no cases upgraded to invasive malignancy. For those omitting surgical excision, there was no subsequent malignancy diagnosis at the FA biopsy site over a mean follow-up of 73 months. CONCLUSION: Cases of radiologic-pathologic concordant FAs involved by atypia have a low upgrade rate of 3.8% and should undergo multidisciplinary review. Larger multi-institutional analysis is needed to determine whether guidelines for excision of atypia should apply to atypia involving FAs.

Comparison of Mepivacaine 2% and Isobaric Bupivacaine 0.5% Spinal Anesthetics for Total Knee Arthroplasty.

Spinal anesthesia is an option for patients during total knee arthroplasty (TKA) procedures. Spinal anesthesia can offer advantages and disadvantages to the patient's experience and outcomes. We conducted an evidence-based, quality improvement project comparing mepivacaine 2% and isobaric bupivacaine 0.5% and retrospectively assessed specific intraoperative and postoperative outcomes that were of interest to the staff at the hospital where the project was completed. Primary outcome measures of interest included intraoperative heart rate, blood pressure, vasopressor use, fluid resuscitation, postoperative pain scores, use of opioid analgesic medications, and time to ambulation after administration of the spinal anesthetic. Compared with patients receiving isobaric bupivacaine 0.5% (n = 30), patients receiving mepivacaine 2% (n = 30) had greater intraoperative hemodynamic stability (defined as heart rate and blood pressure maintained within 20% of baseline values) during the first 30 minutes after anesthetic administration (P < .05 for multiple time points). They also required less opioid medication for postoperative pain management (25 vs 50 mcg fentanyl) and were able to ambulate sooner after the procedure (mean [standard deviation], 452.2 [218.5] vs 681.0 [476.6] minutes; P = .006). In conclusion, mepivacaine 2% was the higher-performing local primary spinal anesthetic for patients undergoing TKA.