Creative Solutions for a Condensed Anatomy Course.

ABSTRACT: There are many variations of anatomy courses taught in accredited physician assistant (PA) programs in the United States. Course directors and program leadership must choose how to effectively deliver content within their program constraints. Our anatomy course has faced challenges related to instructional time for didactic and laboratory sessions, course length, curricular placement and alignment, assessments, and faculty availability. These challenges are not specific to anatomy courses in PA curricula but exist in anatomy courses in various health care programs. In this article, we present major solutions to challenges in didactic delivery, laboratory sessions, course content, and assessments over a 5-year period. Through modifications and problem-solving, we identified the following 4 lessons learned during this process: course alignment to clinical relevance, intentional content delivery for different pedagogical approaches, structured laboratory sessions with appropriate staffing, and an appropriate weighting for assessments. These lessons and solutions will be useful to other anatomy and disciplines-based course directors facing similar challenges.

Update on Interstitial Pneumonias.

The American Thoracic Society/European Respiratory Society/Japanese Respiratory Society/Asociación Latinoamericana de Tórax 2018 clinical practice guideline and 2022 update provide recommendations to define and diagnose idiopathic pulmonary fibrosis (IPF) in patients with newly diagnosed interstitial lung disease. The guideline emphasizes recognition of usual interstitial pneumonia (UIP) and probable UIP patterns of fibrosis on high-resolution CT, which can obviate the need for surgical lung biopsy and allow timely initiation of antifibrotic pharmacotherapy citing a high correlation with UIP on histopathology. This article reviews the recent 2022 IPF clinical practice guideline with a focus on the imaging updates.

The clinical and financial impact of remote clinical oncology pharmacist engagement in community-based practices within The US Oncology Network.

INTRODUCTION: The integration of clinical oncology pharmacists into multidisciplinary healthcare teams is not well-described in the community practice setting. This study aims to analyze the clinical and financial impact of a remote-based clinical oncology pharmacist in four community oncology practices within The US Oncology Network. METHODS: Oncology-trained clinical pharmacists electronically reviewed chemotherapy orders for clinical optimization and financial stewardship within four community oncology practices. Each pharmacist was appointed at 0.5 full-time equivalents per practice. Financial, clinical, and workload metrics were tracked to monitor the impact of pharmacist engagement. RESULTS: Over 12 months, 5716 order reviews were completed with an intervention rate of 57%. The most common interventions identified by the pharmacists were interventions with clinical impact on the patient (36%), followed by dose rounding (35%) and therapeutic interchange (30%). Overall, interventions improved the cumulative practice margins by $1,455,033 and reduced total medication costs by $5,962,551. The average program return on investment was 415% (range 100-915%). CONCLUSION: Community oncology practices seek to provide high-value care in a lean, resource-constrained model. An oncology clinical pharmacist is a cost-effective and clinically invaluable care team member in community oncology practice. Pharmacists in this setting identified opportunities to improve medication safety and regimen optimization and demonstrated a significant tremendous financial impact on small-scale budgets in community oncology.

Impostor phenomenon and ambiguity tolerance in practicing physical therapists: an exploratory correlational study.

Objectives: Investigate the prevalence and contextualize the relationship of impostor phenomenon (IP) and ambiguity tolerance (AT) in practicing physical therapists (PTs). Methods: Online survey including demographic questions, Clance Impostor Phenomenon Scale (CIPS), and Tolerance of Ambiguity Scale (TAS).  Descriptive analyses assessed (N = 422) demographic data, CIPS, and TAS scores. Chi-square tests determined distribution across demographic variables.  Kruskal-Wallis tests assessed differences between CIPS and TAS.  Age was a proxy for career stage in Pearson product-moment correlations to assess relationships between CIPS and TAS. Results: In practicing PTs (M age = 42.12, SD = 12.34), moderate (48.6%; n = 205) to frequent (26.8%; n = 113) IP feelings were prevalent, but only 31.5% (n = 133) were true impostors.  Significant differences exist in clinical experience for CIPS, H(7, n = 422) = 67.82, p <.001 and TAS, H(7, n = 422) = 21.79, p= .003. Most PTs tolerate ambiguity (M = 54.93, SD = 8.19).  A moderate negative correlation between age and CIPS, r = -.36, p <.001 and a small negative correlation between age and TAS, r=-.19, p <.001 exists. Age accounts for 13% of the variance per IP and 3.6% variance per TAS score.  A small positive relationship exists between CIPS and TAS, r = .10, p <.05. Conclusions: Practicing PTs experience moderate to frequent IP and are ambiguity tolerant.  Clinical experience is inversely related to IP and AT.  Almost half of early-career PTs feel like impostors, which can lead to decreased job satisfaction, burnout, psychological distress, feelings of self-doubt, and depression.

Rasburicase dose optimization for tumor lysis syndrome management in a network of community oncology practices.

INTRODUCTION: Single, fixed-dose rasburicase administration has been evaluated as an effective strategy in the management of hyperuricemia in the hospital setting, but this has not yet been described within ambulatory community oncology practices. The objective of this study is to evaluate and optimize the dosing strategy for rasburicase in the management of tumor lysis syndrome (TLS)-associated hyperuricemia in The US Oncology Network (The Network). METHODS: A network-wide guideline was revised to standardize rasburicase dosing from a previous recommended fixed doses of 4.5 or 7.5 mg to either 3 or 6 mg for outpatient rasburicase use in management and prevention of TLS. The primary outcome evaluated mean dose of rasburicase among all patients before and after guideline revision. A retrospective chart review evaluated secondary endpoints. RESULTS: The primary analysis included 291 patients (128 pre-revised and 163 post-revised guideline implementation). The primary outcome, mean rasburicase dose, was reduced in the post-revision compared to the pre-revision population (mean 6.2 mg pre vs. 4.5 mg post, p < 0.00001) resulting in a reduced cost per rasburicase dose of $974. Fifty patients were included for the secondary analysis. Guideline concordance was identified in 12 (48%) and 16 patients (64%), and uric acid <8 mg/dL post-rasburicase administration occurred in 14 (56%) and 16 patients (64%) before and after guideline revision, respectively. CONCLUSIONS: Guideline revision and electronic health record modification resulted in a 27% reduction in the mean rasburicase dose and a 50% reduction in repeat rasburicase dosing without a negative impact on clinical efficacy.

CRISPR activation and interference as investigative tools in the cardiovascular system.

CRISPR activation and interference (CRISPRa/i) technology offers the unprecedented possibility of achieving regulated gene expression both in vitro and in vivo. The DNA pairing specificity of a nuclease dead Cas9 (dCas9) is exploited to precisely target a transcriptional activator or repressor in proximity to a gene promoter. This permits both the study of phenotypes arising from gene modulation for investigative purposes, and the development of potential therapeutics. As with virtually all other organ systems, the cardiovascular system can deeply benefit from a broader utilisation of CRISPRa/i. However, application of this technology is still in its infancy. Significant areas for improvement include the identification of novel and more effective transcriptional regulators that can be docked to dCas9, and the development of more efficient methods for their delivery and expression in vivo.

Scurvy: Rare Orthopaedic Complications Associated with Multinutritional Deficiencies.

Suboptimal nutrition can lead to deficiencies in micronutrients such as ascorbic acid (vitamin C), which can present with catastrophic neurological sequelae. Deficiencies of vitamin C, vitamin B3 (niacin) and zinc levels contribute to reduced bone density. Vitamin C associated vertebral fractures, although rare in adults, are still treatable if diagnosed early with a thorough clinical and nutritional history, and early supplementation. Radiological clues suggestive of scurvy-induced vertebral fractures can be diagnosed on plain X-ray and MRI spine imaging. LEARNING POINTS: Although nutritional deficits like scurvy, pellagra and zinc deficiency are rare, early recognition and prompt treatment can prevent critical neurological sequelae.Clinical history including nutritional intake and associated patient symptoms are vital to diagnose scurvy-related vertebral fractures, which are treatable.It is important to note that scurvy can also present in an adult population.

Mosaic Attenuation Pattern: A Guide to Analysis with HRCT.

Mosaic attenuation pattern is commonly encountered on high-resolution computed tomography and has myriad causes. These diseases may involve small airways, vessels, alveoli, or interstitium, with some involving compartmental combinations. Small airways disease is caused by cellular bronchiolitis, infiltrated by inflammatory cells or constrictive bronchiolitis, resulting in fibrosis of the small airways. Any acute or chronic cause of ground-glass opacity can result in a mosaic pattern. Vascular causes of mosaic attenuation include chronic thromboembolic pulmonary hypertension and rarely other causes of pulmonary arterial hypertension. Ancillary CT findings along with the clinical history help narrow the differential diangosis. Biopsy is uncommonly required for definitiive diagnosis.

Imaging of Occupational and Environmental Lung Disease.

The respiratory tract is continuously exposed to and filters toxins from the home and work environments. Certain occupations and environmental exposures can cause unique injuries to the upper and lower respiratory system. Despite increasing federal regulations in the workplace, occupation-associated lung disease is still a major cause of lung disease and disability and continues to evolve with changes in industry, regulation, and new emerging exposures and toxins. Establishing a diagnosis can be difficult, often due to long latency between exposure and clinical disease, insufficient patient history, and nonspecific or varying imaging appearance. Identifying key imaging features of occupational lung disease along with a multidisciplinary approach can aid in accurate and timely diagnosis. In this review, we will discuss the importance of a comprehensive patient history, multidisciplinary approach to diagnosis, and key imaging features of occupation-related lung injuries. Radiographic and computed tomographic findings will be described and illustrated.

Racism, structural racism, and the American Association for Anatomy: Initial report from a task force.

In 2021, the American Association for Anatomy (AAA) Board of Directors appointed a Task Force on Structural Racism to understand how the laws, rules, and practices in which the Association formed, developed and continues to exist affect membership and participation. This commentary is the first public report from the Task Force. We focus on African Americans with some comments on Jews and women, noting that all marginalized groups deserve study. Through much of its 130 year history, some members were an essential part of perpetuating racist ideas, the Association largely ignored racism and had some practices that prevented participation. The Task Force concluded that individual and structural racism within the AAA, combined with the broader social context in which the Association developed, contributed to the current underrepresentation of African Americans who constitute 4.1% of the membership even though 13.4% of the U.S. population is Black. Intentional efforts within the AAA to reckon with racism and other forms of bias have only begun in the last 10-20 years. These actions have led to more diverse leadership within the Association, and it is hoped that these changes will positively affect the recruitment and retention of marginalized people to science in general and anatomy in particular. The Task Force recommends that the AAA Board issue a statement of responsibility to acknowledge its history. Furthermore, the Task Force advocates that the Board commit to (a) sustaining ongoing projects to improve diversity, equity, and inclusion and (b) dedicating additional resources to facilitate novel initiatives.

Movement System Theory and Anatomical Competence: Threshold Concepts for Physical Therapist Anatomy Education.

This viewpoint proposes eight anatomy threshold concepts related to physical therapist education, considering both movement system theory and anatomical competence. Movement system theory provides classifications and terminology that succinctly identifies and describes physical therapy practice from a theoretical and philosophical framework. The cardiovascular, pulmonary, endocrine, integumentary, nervous, and musculoskeletal systems are all included within this schema as the movement system theory encompasses all body systems interacting to create movement across the lifespan. Implementing movement system theory requires an ability to use human anatomy in physical therapist education and practice. Understanding the human body is a mandatory prerequisite for effective diagnosis, assessment, treatment, and patient evaluation. Anatomical competence refers to the ability to apply anatomic knowledge within the appropriate professional and clinical contexts. Exploring the required anatomical concepts for competent entry-level physical therapist education and clinical practice is warranted. The recommended threshold concepts (fluency, dimensionality, adaptability, connectivity, complexity, stability or homeostasis, progression or development, and humanity) could serve as an integral and long-awaited tool for guiding anatomy educators in physical therapy education.

The imperative for scientific societies to change the face of academia: Recommendations for immediate action.

As organizations that facilitate collaboration and communication, scientific societies have an opportunity, and a responsibility, to drive inclusion, diversity, equity, and accessibility in science in academia. The American Association for Anatomy (AAA), with its expressed and practiced culture of engagement, can serve as a model of best practice for other professional associations working to become more inclusive of individuals from historically underrepresented groups. In this publication, we acknowledge anatomy's exclusionary past, describe the present face of science in academia, and provide recommendations for societies, including the AAA, to accelerate change in academia. We are advocating for scientific societies to investigate inequities and revise practices for inclusivity; develop and empower underrepresented minority leadership; and commit resources in a sustained manner as an investment in underrepresented scientists who bring diverse perspectives and lived experiences to science in academia.

Pearls and Pitfalls in Lung Cancer Imaging.

Imaging plays an essential role in the diagnosis and staging of pulmonary malignancy. Familiarity of less common manifestations of lung cancer including subsolid nodule, consolidation, and cyst associated lung cancer is important to avoid delayed diagnosis and improve patient outcomes. In this article, we review the staging of multifocal lung cancer, PET negative lung cancers (carcinoid and indolent lung adenocarcinoma), and false positive lymph nodes on PET due to infectious and inflammatory etiologies. Knowledge of these potential pitfalls and pearls in lung cancer imaging and correlation with patients' clinical history are essential to prevent misinterpretation.

Call for Consistency: the Need to Establish Gross Anatomy Learning Objectives for the Entry-Level Physical Therapist.

A need currently exists for the establishment of anatomy learning objectives for physical therapist education programs. Developing recommended anatomy objectives to serve as a curricular guide may foster more consistent student outcomes while preserving instructional autonomy. These objectives could serve as a vital resource when making decisions during curricular reform or prioritizing and emphasizing the curriculum's anatomic content. We advocate for collaboration amongst anatomy faculty and clinicians to create specific and measurable anatomy learning objectives for the entry-level physical therapist. It is essential that the objectives be peer-reviewed and that they reflect a global consensus.

Performance and Operational Evaluation of the Access Bio CareStart Rapid Antigen Test in a High-Throughput Drive-Through Community Testing Site in Massachusetts.

BACKGROUND: To facilitate deployment of point-of-care testing for severe acute respiratory syndrome coronavirus 2, we evaluated the Access Bio CareStart COVID-19 Antigen test in a high-throughput, drive-through, free community testing site using anterior nasal (AN) swab reverse-transcription polymerase chain reaction (RT-PCR) for clinical testing. METHODS: Consenting symptomatic and asymptomatic children (≤18 years) and adults received dual AN swabs. CareStart testing was performed with temperature/humidity monitoring. All tests had 2 independent reads to assess interoperator agreement. Patients with positive CareStart results were called and instructed to isolate pending RT-PCR results. The paired RT-PCR result was the reference for sensitivity and specificity calculations. RESULTS: Of 1603 participants, 1245 adults and 253 children had paired RT-PCR/CareStart results and complete symptom data. Eighty-three percent of adults and 87% of children were asymptomatic. CareStart sensitivity/specificity were 84.8% (95% confidence interval [CI], 71.1-93.7)/97.2% (95% CI, 92.0-99.4) and 85.7% (95% CI, 42.1-99.6)/89.5% (95% CI, 66.9-98.7) in adults and children, respectively, within 5 days of symptoms. Sensitivity/specificity were 50.0% (95% CI, 41.0-59.0)/99.1% (95% CI, 98.3-99.6) in asymptomatic adults and 51.4% (95% CI, 34.4-68.1)/97.8% (95% CI, 94.5-99.4) in asymptomatic children. Sensitivity in all 234 RT-PCR-positive people was 96.3% with cycle threshold (Ct) ≤25, 79.6% with Ct ≤30, and 61.4% with Ct ≤35. All 21 false-positive CareStart tests had faint but normal bands. Interoperator agreement was 99.5%. Operational challenges included identification of faint test bands and inconsistent swab elution volumes. CONCLUSIONS: CareStart had high sensitivity in people with Ct ≤25 and moderate sensitivity in symptomatic people overall. Specificity was unexpectedly lower in symptomatic versus asymptomatic people. Excellent interoperator agreement was observed, but operational challenges indicate that operator training is warranted.

Performance and Implementation Evaluation of the Abbott BinaxNOW Rapid Antigen Test in a High-Throughput Drive-Through Community Testing Site in Massachusetts.

Rapid diagnostic tests (RDTs) for SARS-CoV-2 antigens (Ag) that can be performed at point of care (POC) can supplement molecular testing and help mitigate the COVID-19 pandemic. Deployment of an Ag RDT requires an understanding of its operational and performance characteristics under real-world conditions and in relevant subpopulations. We evaluated the Abbott BinaxNOW COVID-19 Ag card in a high-throughput, drive-through, free community testing site in Massachusetts using anterior nasal (AN) swab reverse transcriptase PCR (RT-PCR) for clinical testing. Individuals presenting for molecular testing in two of seven lanes were offered the opportunity to also receive BinaxNOW testing. Dual AN swabs were collected from symptomatic and asymptomatic children (≤18 years of age) and adults. BinaxNOW testing was performed in a testing pod with temperature/humidity monitoring. One individual performed testing and official result reporting for each test, but most tests had a second independent reading to assess interoperator agreement. Positive BinaxNOW results were scored as faint, medium, or strong. Positive BinaxNOW results were reported to patients by phone, and they were instructed to isolate pending RT-PCR results. The paired RT-PCR result was the reference for sensitivity and specificity calculations. Of 2,482 participants, 1,380 adults and 928 children had paired RT-PCR/BinaxNOW results and complete symptom data. In this study, 974/1,380 (71%) adults and 829/928 (89%) children were asymptomatic. BinaxNOW had 96.5% (95% confidence interval [CI], 90.0 to 99.3) sensitivity and 100% (95% CI, 98.6 to 100.0) specificity in adults within 7 days of symptoms and 84.6% (95% CI, 65.1 to 95.6) sensitivity and 100% (95% CI, 94.5 to 100.0) specificity in children within 7 days of symptoms. Sensitivity and specificity in asymptomatic adults were 70.2% (95% CI, 56.6 to 81.6) and 99.6% (95% CI, 98.9 to 99.9), respectively, and in asymptomatic children, they were 65.4% (95% CI, 55.6 to 74.4) and 99.0% (95% CI, 98.0 to 99.6), respectively. By cycle threshold (CT ) value cutoff, sensitivity in all subgroups combined (n = 292 RT-PCR-positive individuals) was 99.3% with CT values of ≤25, 95.8% with CT values of ≤30, and 81.2% with CT values of ≤35. Twelve false-positive BinaxNOW results (out of 2,308 tests) were observed; in all 12, the test bands were faint but otherwise normal and were noted by both readers. One invalid BinaxNOW result was identified. Interoperator agreement (positive versus negative BinaxNOW result) was 100% (n = 2,230/2,230 double reads). Each operator was able to process 20 RDTs per hour. In a separate set of 30 specimens (from individuals with symptoms ≤7 days) run at temperatures below the manufacturer's recommended range (46 to 58.5°F), sensitivity was 66.7% and specificity 95.2%. BinaxNOW had very high specificity in both adults and children and very high sensitivity in newly symptomatic adults. Overall, 95.8% sensitivity was observed with CT values of ≤30. These data support public health recommendations for use of the BinaxNOW test in adults with symptoms for ≤7 days without RT-PCR confirmation. Excellent interoperator agreement indicates that an individual can perform and read the BinaxNOW test alone. A skilled laboratorian can perform and read 20 tests per hour. Careful attention to temperature is critical.

Neurovascular axillary variations: superficial brachial artery and single-corded brachial plexus.

Variants of the axillary artery and brachial plexus were found bilaterally in the axilla of an 86-year-old Asian female. On the left, the cadaver donor had a high bifurcation of the second part of the axillary artery, creating a superficial brachial artery. Meanwhile, the right axilla presented with root, trunk, and cord variations in the formation of the brachial plexus, the most interesting feature being a single, unified cord. Presented in this case report are the structural relationships of the variants with considerations regarding anatomy, embryology, prevalence, and clinical importance.

Incidental Breast Cancer on Chest CT: Is the Radiology Report Enough?

OBJECTIVE: To determine the frequency of incidental breast findings reported on chest CT for which breast imaging follow-up is recommended, the follow-up adherence rate, and the breast malignancy rate. The relationship between strength of recommendation verbiage and follow-up was also explored. METHODS: A retrospective review was conducted of chest CT reports from July 1, 2018, to June 30, 2019, to identify those with recommendation for breast imaging follow-up. Patients with recently diagnosed or prior history of breast malignancy were excluded. Medical records were reviewed to evaluate patient adherence to follow-up, subsequent BI-RADS assessment, and diagnosis (if tissue sampling performed). Adherence was defined as diagnostic breast imaging performed within 6 months of CT recommendation. Chi-square and Mann-Whitney U tests were used to determine statistical significance of categorical and continuous variables, respectively. RESULTS: A follow-up recommendation for breast imaging was included in chest CT reports of 210 patients; 23% (48/210) returned for follow-up breast imaging. All patients assessed as BI-RADS 4 or 5 underwent image-guided biopsy. Incidental breast cancer was diagnosed in 15% (7/48) of patients who underwent follow-up breast imaging as a result of a CT report recommendation and 78% (7/9) of patients undergoing biopsy. There was no significant difference in follow-up adherence when comparing report verbiage strength. CONCLUSION: It is imperative that incidental breast findings detected on chest CT undergo follow-up breast imaging to establish accurate and timely diagnosis of breast malignancy. Outreach to referring providers and patients may have greater impact on the diagnosis of previously unsuspected breast cancer.

Chondroepitrochlearis and a supernumerary head of the biceps brachii.

Unique variants of the pectoralis major and biceps brachii were found during a routine student dissection of a 96-year-old Caucasian female's axilla and brachium. The donor cadaver had bilateral presentation of a muscle originating from the pectoralis major, near the lateral lip of the intertubercular groove, extending obliquely to insert on the medial intermuscular septum and medial epicondyle of the humerus. This muscle variant is currently described as a rare presentation of the chondroepitrochlearis, potentially a remnant of the panniculus carnosus in man. Often considered to be a thin, slender muscle taking origin from the true ribs, the right-side chondroepitrochlearis described in this report was notably larger-to the authors' knowledge-than all other published cases, measuring 38.1 mm at the widest point. Meanwhile, another small muscle originating on the posterior surface of the pectoralis major tendon was present. Due to its insertion, the muscle was identified as a supernumerary portion, or a third head, of the biceps brachii. The proximal attachment of both the chondroepitrochlearis and the third head of the biceps brachii could impose functional limitations on the pectoralis major.