MRI-visualized T2 hyperintense breast lesions: identifying clinical and imaging factors linked to malignant biopsy outcomes.

PURPOSE: To determine the malignancy rate for MRI-guided breast biopsies performed for T2 hyperintense breast lesions and to assess additional clinical and MRI characteristics that can predict benign and malignant outcomes. METHODS: A retrospective chart review of consecutive MRI-guided breast biopsies performed in two tertiary hospitals was conducted over two years. Biopsies performed for T2 hyperintense lesions were selected, and further lesion imaging characteristics and patient risk factors were collected. Univariate and multivariate modeling regression were used to determine additional imaging and patient factors associated with malignant outcomes for biopsies of T2 hyperintense lesions. RESULTS: Out of 369 MRI-guided breast biopsies, 100 (27%) were performed for T2 hyperintense lesions. Two biopsy-proven benign lesions were excluded as the patient was lost on follow-up. With a study cohort of 98 lesions, the final pathology results were benign for 80 (80%) of these lesions, while 18 (18%) were malignant. Using multivariate logistic modeling, patient age > 50 (OR 5.99 (1.49, 24.08 95% CI), p < 0.05) and lesion size > 3 cm (OR 5.54 (1.54-18.7), p < 0.01) were found to be important predictors of malignant outcomes for MRI biopsies performed for T2 hyperintense lesions. CONCLUSION: Our study observed a high malignancy rate, challenging the assumption that T2 hyperintensity can be considered a benign imaging characteristic for otherwise suspicious MRI-detected lesions. Decision-making regarding tissue sampling should be made based on a thorough evaluation of more reliable additional demographic and imaging factors, including patient age and lesion size.

Projecting the Future Pediatric Subspecialty Workforce: Summary and Recommendations.

This article summarizes the findings of a Pediatrics supplement addressing the United States workforce for 15 pediatric subspecialties. It includes results from a microsimulation model projecting supply through 2040; growth is forecasted to be uneven across the subspecialties with worsening geographic maldistribution. Although each subspecialty has unique characteristics, commonalities include (1) the changing demographics and healthcare needs of children, including mental health; (2) poor outcomes for children experiencing adverse social drivers of health, including racism; and (3) dependence on other subspecialties. Common healthcare delivery challenges include (1) physician shortages for some subspecialties; (2) misalignment between locations of training programs and subspecialists and areas of projected child population growth; (3) tension between increasing subsubspecialization to address rare diseases and general subspecialty care; (4) the need to expand clinical reach through collaboration with other physicians and advanced practice providers; (5) the lack of parity between Medicare, which funds much of adult care, and Medicaid, which funds over half of pediatric subspecialty care; and (6) low compensation of pediatric subspecialists compared with adult subspecialists. Overall, subspecialists identified the lack of a central authority to monitor and inform child healthcare provided by pediatric subspecialists as a challenge. Future research on the pediatric subspecialty workforce and the children it serves will be necessary to ensure these children's needs are met. Together, these articles provide overarching and subspecialty-specific recommendations to improve training, recruitment, and retention of a diverse workforce, implement innovative models of care, drive policy changes, and advise future research.

Effectiveness of a 12-Month Emergency Radiology Curriculum for Improving Self-Confidence and Competence of Postgraduate Year 1 Radiology Residents-A Canadian Study.

PURPOSE: Limited radiology curriculum during postgraduate year 1 of radiology residency combined with increasing workloads during emergency radiology call have contributed to heightened anxiety and responsibilities for junior residents. This study aimed to evaluate the effectiveness of a 12-month emergency radiology curriculum on self-rated confidence and general competence of Canadian postgraduate year 1 radiology residents. METHODS: A cohort of Canadian postgraduate year 1 Diagnostic Radiology residents voluntarily enrolled in a 12-month self-directed online emergency radiology curriculum (9 modules). Participants completed pretest and posttest surveys and examinations to gauge their self-rated competence on module material and knowledge acquisition, respectively. Average pretest and posttest scores were compared using Student 2-tailed unpaired t test, and Likert data from self-reported confidence were compared using a Mann Whitney U test. Statistical significance was defined as P < .05. RESULTS: Sixty-six trainees completed at least 1 module, and 15 trainees completed all 9 modules. Both self-rated confidence and posttest scores were statistically higher after module completion (P < .001) for all 9 learning modules. The greatest improvement in test scores was seen in the female genitourinary module (28.12 ± 3.018; difference between pretest and posttest means ± SEM). CONCLUSIONS: Our study demonstrates learning benefits for junior radiology trainees who participated in a self-directed online emergency radiology curriculum during postgraduate year 1. In the face of ever-increasing demands for imaging in on-call settings across Canada, inclusion of a self-directed online curriculum may become more important for upcoming competency-based medical education as it encourages a learner-driven and non-time-based method of education.

Retrospective Analysis of Emergency Computed Tomography Imaging Utilization at an Academic Centre: An Analysis of Clinical Indications and Outcomes.

PURPOSE: To explore resource utilization through evaluation of computed tomography (CT) imaging trends in the emergency department by examining common indications/outcomes for imaging in this setting. METHODS: A retrospective analysis of clinical indications/outcomes for all CT imaging in 3 emergency departments over a 1-year period was conducted. Scans were divided by body part and the most common indications for each type of scan were determined. Clinical outcomes from each study were extracted from final interpretations by the reporting radiologist. RESULTS: A total of 4556 CT scans were performed in the emergency department over a 1-year period. A total of 3.6% of all-comers to our emergency departments underwent CT scan as part of their investigation. There were 2107 head CTs (46%), 1296 (28%) abdominal CTs, 468 (10%) CTs of the chest, 408 (9%) CTs of the neck/spine, and 101 (2%) extremity CTs performed. The most common clinical indication for performing a CT head was focal neurological defect comprising 1534 (73%) of all CT heads. Twenty-four percent of abdominal CTs were for investigation of right lower quadrant pain, followed by flank pain (19%). Chest pain and shortness of breath were the most common indications for CTs of the chest (315 [75%]) with 10% of these examinations for this indication positive for pulmonary embolism. Trauma was the most common indication for neck CTs (296 [73%]) and extremities (70 [69%]). Nil acute was the most common final interpretation in all categories (79% CT heads, 75% neck CTs, 38% abdominal CTs, 43% chest CTs). CONCLUSIONS: Nil acute was the most common diagnosis; however, serious clinical outcomes were identified 40% of the time. Cross-sectional imaging remains an integral tool for triage and diagnosis in this environment as the cost of missing a diagnosis in this setting has a great impact on patient care.

The Lumbar Artery Perforator Flap: 3-Dimensional Anatomical Study and Clinical Applications.

BACKGROUND: The lumbar region is a potential donor site for perforator-based rotational or free flaps or as a recipient site for free flaps to obtain coverage for deficits in the sacral region. Because of the lack of consensus regarding the microvascular anatomy of this potential flap site, a robust investigation of the anatomy of this region is required. METHODS: Three-dimensional reconstructions (n = 6) of the microvasculature of the lumbar region were generated using MIMICS software (Materialise, Belgium) for each of the four paired lumbar vessels. Diameter, course, and pedicle length were recorded for all lumbar artery (LA) perforators. Statistical analysis was performed using SigmaStat 4.0 and graphs were generated using GraphPad Prism 6 Software. RESULTS: Perforators arising from the first pair of LAs are reliably detected along the inferior margin of the 12th rib, extending inferiorly and laterally from the midline while perforators arising from the fourth pair of LA perforate the fascia along a horizontal plane connecting the posterior iliac crests. There are significantly more cutaneous perforators arising from the first (L1) and fourth (L4) pairs of LA than from the second (L2) and third (L3) (mean ± SD: L1, 5.5 ± 1.2; L2, 1.4 ± 0.7; L3, 1.3 ± 0.7; L4, 4.8 ± 1.0; P < 0.05). The average perforator diameter arising from L1 is greater than those arising from L4 (diameter ± SD: L1, 1.2 mm ± 0.2 >L4, 0.8 mm ± 0.2; P < 0.0001). L1 and L4 perforators have longer pedicle lengths than those arising from L2 and L3 (length ± SD: L1, 98.2 mm ± 57.8; L4, 106.1 mm ± 23.3 >L2, 67.5 mm ± 27.4; L3, 78.5 mm ± 30.3; P < 0.05). CONCLUSIONS: Perforators arising from the first and fourth LAs arise in a predictable fashion, have adequate pedicle lengths, and are of suitable diameter to support a perforator flap. We present a case to support the potential use of this flap for microvascular breast reconstruction.

Anatomical Study of the Princeps Pollicis Artery Perforator Flap.

BACKGROUND: The volar aspect of the thumb often requires local flaps for reconstruction. This study characterizes perforators of the princeps pollicis artery (PPA) and evaluates the potential of a local propeller-type flap raised using these perforators for reconstruction of these defects. METHODS: Cadavers underwent whole-body lead-oxide injection and were then imaged using a 64-slice spiral computed tomographic scanner. The DICOM images were imported into Materialise's Interactive Medical Imaging Control System (Materialise, Belgium) for 3-dimensional reconstruction of the microvasculature. The number, length, caliber, and location of perforators arising from the PPA were determined and a plot was generated illustrating the relative distribution of perforators. RESULTS: A total of 16 PPA perforators were identified in the 8 specimen hands. Perforators had a mean (SD) diameter of 1.2 (0.4) mm and mean (SD) length of 8.9 (4.8) mm. The PPA perforators were consistently identified along the radial aspect of the thenar region. Seventy percent of all PPA perforators can be found over the distal 50% of the MC [20%-54%; mean (1SD)]. CONCLUSIONS: Perforators of the PPA were found in all hands and the average caliber and length of the perforators identified is sufficient for the creation of a local perforator flap. This, coupled with the mean location of these perforators, arising near the base of the thumb, confirms that a cutaneous flap from the thenar region can be raised based on this perforator as a propeller flap to obtain coverage of distal cutaneous defects of the thumb.

Accuracy of identifying the cricothyroid membrane by anesthesia trainees and staff in a Canadian institution.

PURPOSE: We sought to determine the rate of successful identification of the cricothyroid membrane by anesthesia residents and staff at a Canadian institution. METHODS: In this prospective study, healthy adult volunteer subjects were positioned supine with their necks placed in neutral position. There were 12 subjects, half of whom were non-obese (body mass index < 30.0 kg·m(2)) and half of whom were obese. There were equal numbers of male and female subjects in each of the obese and non-obese groups. Anesthesia staff and resident participants were allowed to palpate multiple subjects but with only one attempt per subject. For each subject, ultrasonography was used to identify the superior and inferior borders of the cricothyroid membrane, which were then marked with "invisible" ink that could be made visible with ultraviolet light. The midline was also marked with invisible ink. Identification of the cricothyroid membrane was considered correct if the mark was between the superior and inferior borders and within 0.5 cm of the midline. RESULTS: Altogether, 61 participants palpated 12 subjects, resulting in 186 identifications. The success rates for the subgroups were as follows: non-obese men 72% (95% confidence interval [CI] 59 to 85%); obese men 39% (95% CI 26 to 54%); non-obese women 24% (95% CI 12 to 36%); obese women 35% (95% CI 21 to 49%). CONCLUSION: Success rates for correct identification of the cricothyroid membrane were poor in this Canadian institution.

The use of retrograde limb of internal mammary vein in autologous breast reconstruction with DIEAP flap: anatomical and clinical study.

BACKGROUND: It has been postulated that the abdominal skin may have either predominantly deep or superficial venous drainage. This may account for complications arising from autologous breast reconstruction using the deep inferior epigastric artery perforator (DIEAP) flap. In this study, we evaluate the use of the retrograde limb of the internal mammary vein (IMV) as a second recipient vein in reconstructions with the DIEAP flap. METHODS: In Part A, 10 IMVs were harvested from 5 fresh cadavers and the flow of methylene blue through the retrograde limb and the presence of valves were evaluated under a stereoscopic microscope.In Part B, the clinical outcomes of 38 patients who underwent single or bilateral autologous breast reconstruction using the DIEAP flap technique between January 2007 and March 2011 were reviewed. A total of 48 flaps were evaluated: 31 with single vein anastomosis and 17 with 2-vein anastomosis. RESULTS: In Part A, no valves were identified in the IMVs. In all 10 cadaver IMVs, there was free flow of methylene blue in both antegrade (superior) and retrograde (inferior) directions.In Part B, a retrospective analysis of the 2 patient outcomes was performed. Outcomes assessed included total flap loss, partial flap necrosis, fat necrosis, wound infection, wound dehiscence, and hematoma. Results were compared using a 2-tailed Fisher exact test with a critical P value of 0.05. No statistically significant differences between groups were identified. CONCLUSIONS: The retrograde limb of the IMV seems to be a safe alternate recipient vein in DIEAP and muscle sparing free TRAM autologous breast reconstruction. This study does not identify a significant reduction in overall fat necrosis or overall complications when using the 2 venous repair techniques versus the simple venous repair technique.

Computed tomographic angiography for localization of the cutaneous perforators of the leg.

BACKGROUND: Results of vascular anatomical studies of the lower limb in the past have been primarily descriptive in nature and are therefore less useful in directing the design of local perforator-based flaps. The purpose of this study was to document the three-dimensional anatomy of the cutaneous perforators arising from the anterior tibial, posterior tibial, and peroneal arteries and provide a statistically verified method for predicting perforator location for use in the clinical setting. METHODS: Computed tomographic angiography and three-dimensional reconstructions of the lower limb using Mimics software were completed for five lead oxide-injected cadavers. The cutaneous perforators of the vessels of the tibial trunk were identified, and perforator diameter, course, and location relative to leg length were determined. Cluster analysis was performed to evaluate the consistency of perforator locations across individuals. RESULTS: The anterior tibial artery had the greatest number of perforator vessels, which clustered into three groups centered at 83 ± 6 percent (percent of tibial height ± SD), 59 ± 7 percent, and 28 ± 9 percent. Peroneal artery perforators were clustered in two groups centered at 61 ± 9 percent and 27 ± 11 percent. The posterior tibial artery perforators could also be divided into two groups; however, a larger SD in the two groups suggests that perforators arising from this vessel are more evenly spaced. CONCLUSIONS: Statistical analysis demonstrated that the major perforator vessels of the tibial trunk are conserved across individuals and can be reliably dissected using the cluster's statistical distribution. Results of this study will allow for better preoperative planning of local flaps.

The natriuretic peptides BNP and CNP increase heart rate and electrical conduction by stimulating ionic currents in the sinoatrial node and atrial myocardium following activation of guanylyl cyclase-linked natriuretic peptide receptors.

Natriuretic peptides (NPs) are best known for their ability to regulate blood vessel tone and kidney function whereas their electrophysiological effects on the heart are less clear. Here, we measured the effects of BNP and CNP on sinoatrial node (SAN) and atrial electrophysiology in isolated hearts as well as isolated SAN and right atrial myocytes from mice. BNP and CNP dose-dependently increased heart rate and conduction through the heart as indicated by reductions in R-R interval, P wave duration and P-R interval on ECGs. In conjunction with these ECG changes BNP and CNP (100 nM) increased spontaneous action potential frequency in isolated SAN myocytes by increasing L-type Ca(2+) current (I(Ca,L)) and the hyperpolarization-activated current (I(f)). BNP had no effect on right atrial myocyte APs in basal conditions; however, in the presence of isoproterenol (10nM), BNP increased atrial AP duration and I(Ca,L). Quantitative gene expression and immunocytochemistry data show that all three NP receptors (NPR-A, NPR-B and NPR-C) are expressed in the SAN and atrium. The effects of BNP and CNP on SAN and right atrial myocytes were maintained in mutant mice lacking functional NPR-C receptors and blocked by the NPR-A antagonist A71915 indicating that BNP and CNP function through their guanylyl cyclase-linked receptors. Our data also show that the effects of BNP and CNP are completely absent in the presence of the phosphodiesterase 3 inhibitor milrinone. Based on these data we conclude that NPs can increase heart rate and electrical conduction by activating the guanylyl cyclase-linked NPR-A and NPR-B receptors and inhibiting PDE3 activity.

Safety and stability for foster children: the policy context.

Even though federal laws have had a major influence on foster care and child welfare policy for more than 40 years, additional reforms are needed to ensure safe and stable families for children in care. This article describes the complex array of policies that shape federal foster care and observes: A number of federal policies addressing issues such as housing, health care, welfare, social security benefits, taxes, and foster care reimbursement to the states, form the federal foster care policy framework. The Adoption and Safe Families Act significantly altered federal foster care policy by instituting key changes such as defining when it is reasonable to pursue family reunification, expediting timelines for making permanency decisions, recognizing kinship care as a permanency option, and providing incentives to the state for increasing the number of adoptions. Courts play a key and often overlooked role in achieving safety and permanency for children in foster care. Efforts to improve court performance have focused on increasing the responsiveness and capacity of courts. The article concludes with policy recommendations that are needed to improve the lives of children in foster care, such as increasing investments in children and families, redirecting funding incentives, addressing service gaps, and enhancing accountability.