Improving the transgender patient experience in the breast imaging center.

PURPOSE: This review discusses how breast centers can optimize patient experience scores among transgender patients. FINDINGS: High patient experience scores impact patient care and compliance. Increased regulations have been enacted to ensure that health systems are effectively meeting the health concerns of sexual minorities. This will be reflected in the patient experience surveys. A leading patient survey will be assessed to help breast imaging centers optimize the transgender patient experience and question types will be provided. SUMMARY: Breast Centers can be equipped to enhance the transgender patient experience.

Stepwise Implementation of 2D Synthesized Screening Mammography and Its Effect on Stereotactic Biopsy of Microcalcifications.

RATIONALE AND OBJECTIVES: Information evaluating the efficacy of 2D synthesized mammography (2Ds) reconstructions in microcalcification detection is limited. This study used stereotactic biopsy data for microcalcifications to evaluate the stepwise implementation of 2Ds in screening mammography. The study aim was to identify whether 2Ds + digital breast tomosynthesis (DBT) is non-inferior to 2D digital mammography (2DM) + 2Ds + DBT, 2DM + DBT, and 2DM in identifying microcalcifications undergoing further diagnostic imaging and stereotactic biopsy. MATERIALS AND METHODS: Retrospective stereotactic biopsy data were extracted following 151,736 screening mammograms of healthy women (average age, 56.3 years; range, 30-89 years), performed between 2012 and 2019. The stereotactic biopsy data were separated into 2DM, 2DM + DBT, 2DM + 2Ds + DBT, and 2Ds + DBT arms and examined using Fisher's exact test to compare the detection rates of all cancers, invasive cancers, DCIS, and ADH between modalities for patients undergoing stereotactic biopsy of microcalcifications. RESULTS: No statistical significance in cancer detection was seen for 2Ds + DBT among those calcifications that underwent stereotactic biopsy when comparing the 2Ds + DBT to 2DM, 2DM + DBT, and 2DM + 2Ds + DBT imaging combinations. CONCLUSION: These data suggest that 2Ds + DBT is non-inferior to 2DM + DBT in detecting microcalcifications that will undergo stereotactic biopsy.

The disruptive radiologist.

Hospital and regulatory organizations recognize the downstream impact of interpersonal relationships on patient safety. There are many contributors to interpersonal dynamics, one of which includes disruptive physicians. This can stem from overt or passive behaviors and has been categorized in the literature by terms that include disruptive physicians, professionalism and burnout. The contributing factor factors to such behavior are varied and may include burnout, stress, skill deficiencies, and impairment. These behaviors can be impacted through personal and systemic influences that are difficult for administrators to elucidate due to physician and organizational confidentiality concerns. However, there are opportunities and tools where radiology practice leaders and organizations can intervene to assist the disruptive radiologist. These include during residency/fellowship training, clarifying employee expectations during the time of radiologist hiring, offering interventions during practice, providing resources such as employee assistance programs, and addressing systemic challenges. Utilizing these tool sets can improve healthcare team dynamics and increase both staff and physician retention.

Peer learning in breast imaging.

With the increasing focus on quality and safety in medicine, radiology practices are increasingly transitioning from traditional score-based peer review to peer learning. Participation in a peer learning program can increase learning, practice improvement, and cultivation of interpersonal relationships in a non-punitive environment. As breast imaging errors are the most cited in medical malpractice cases, learning and attention to and reduction of these errors in breast imaging are especially important. We describe the strengths of a peer learning program, implementation process in a breast imaging program, challenges to overcome, and strategies to support success.

Breast cancer screening in women with and without implants: retrospective study comparing digital mammography to digital mammography combined with digital breast tomosynthesis.

OBJECTIVES: Compare four groups being screened: women without breast implants undergoing digital mammography (DM), women without breast implants undergoing DM with digital breast tomosynthesis (DM/DBT), women with implants undergoing DM, and women with implants undergoing DM/DBT. METHODS: Mammograms from February 2011 to March 2017 were retrospectively reviewed after 13,201 were excluded for a unilateral implant or prior breast cancer. Patients had been allowed to choose between DM and DM/DBT screening. Mammography performance metrics were compared using chi-square tests. RESULTS: Six thousand forty-one women with implants and 91,550 women without implants were included. In mammograms without implants, DM (n = 113,973) and DM/DBT (n = 61,896) yielded recall rates (RRs) of 8.53% and 6.79% (9726/113,973 and 4204/61,896, respectively, p < .001), cancer detection rates per 1000 exams (CDRs) of 3.96 and 5.12 (451/113,973 and 317/61,896, respectively, p = .003), and positive predictive values for recall (PPV1s) of 4.64% and 7.54% (451/9726 and 317/4204, respectively, p < .001), respectively. In mammograms with implants, DM (n = 6815) and DM/DBT (n = 5138) yielded RRs of 5.81% and 4.87% (396/6815 and 250/5138, respectively, p = .158), CDRs of 2.49 and 2.92 (17/6815 and 15/5138, respectively, p > 0.999), and PPV1s of 4.29% and 6.0% (17/396 and 15/250, respectively, p > 0.999), respectively. CONCLUSIONS: DM/DBT significantly improved recall rates, cancer detection rates, and positive predictive values for recall compared to DM alone in women without implants. DM/DBT performance in women with implants trended towards similar improvements, though no metric was statistically significant. KEY POINTS: • Digital mammography with tomosynthesis improved recall rates, cancer detection rates, and positive predictive values for recall compared to digital mammography alone for women without implants. • Digital mammography with tomosynthesis trended towards improving recall rates, cancer detection rates, and positive predictive values for recall compared to digital mammography alone for women with implants, but these trends were not statistically significant - likely related to sample size.

Community outreach and integration of breast radiologists.

With the increased emphasis on patient experience and shift toward patient- and family-centered care in health care, balancing the daily practice of radiology and devoting time to community outreach and engagement can seem challenging. We describe various methods of community outreach and integration attainable by breast imagers and how these can be used to develop relations with patients and providers, improve patient access, and inspire future breast imagers. Engagement in community outreach by the breast imager can positively impact breast radiologists, their radiology groups, and patients.

Optimizing patient experience scores in outpatient breast centers.

High patient experience scores in outpatient radiology is a goal that impacts patient care and compliance. There are secondary positive effects on employee engagement and retention as well as reimbursement and increased market share. Effective administrative and physician leadership is critical in obtaining employee buy-in to the importance of customer experience. Training for employees at all levels in understanding the patient psyche empowers them to offer personalized care to a diverse patient population. Given the multiple benefits of high patient experience scores, a leading patient experience survey was assessed in detail to assist radiologists in breast imaging and other subspecialties, to understand and implement steps to optimize their own patient experience scores.

Enhancing Quality Using the Inspection Program (EQUIP): A Primer for Radiologists.

The new Enhancing Quality Using the Inspection Program (EQUIP) law places more responsibility for quality assurance on the interpreting radiologists and the lead interpreting physician (LIP). Compliance with the law will require addressing three specific questions related to quality assurance and clinical image corrective action, continued compliance, and ensuring LIP oversight. This process enables the radiologist to exemplify added value through physician leadership, team integration, and improved patient care.

The nexus of opioids, pain, and addiction: Challenges and solutions.

Pain and addiction are complex disorders with many commonalities. Beneficial outcomes for both disorders can be achieved through similar principles such as individualized medication selection and dosing, comprehensive multi-modal therapies, and judicious modification of treatment as indicated by the patient's status. This is implicit in the term "medication assisted treatment" (MAT) for opioid use disorders (OUD), and is equally important in pain management; however, for many OUD and pain patients, medication is central to the treatment plan and should neither be denied nor withdrawn if critical to patient well-being. Most patients prescribed opioids for pain do not develop OUD, and most people with OUD do not develop it as a result of appropriately prescribed opioids. Nonetheless, concerns about undertreatment of pain in the late 20th century likely contributed to inappropriate prescribing of opioids. This, coupled with a shortfall in OUD treatment capacity and the unfettered flood of inexpensive heroin and fentanyl, behavioral economics and other factors facilitated the 21st century opioid epidemic. Presently, injudicious reductions in opioid prescriptions for pain are contributing to increased suffering and suicides by pain patients as well as worsening disparities in pain management for ethnic minority and low-income people. Many of these people are turning to illicit opioids, and no evidence shows that the reduction in opioid prescriptions is reducing OUD or overdose deaths. Comprehensive, science-based policies that increase access to addiction treatment for all in need and better serve people with pain are vital to addressing both pain and addiction.

Assessing likelihood of product use for snus with modified-risk information among adult current cigarette smokers, former tobacco users, and never tobacco users.

INTRODUCTION: Switching from cigarettes to snus by smokers unlikely to quit would be expected to benefit overall population health, with any potential benefit needing to be weighed against potential harms from snus use by tobacco non-users and smokers likely to quit. This study evaluates likelihood of snus use among tobacco users and non-users provided modified-risk information. METHODS: An online sample of 11,302 U.S. adults was randomized to view advertisements for snus that either provided modified-risk information or only described snus. Intent to purchase ratings were converted to projected purchase (use) rates using an empirically derived algorithm. RESULTS: Projected product use for snus was significantly higher among current smokers than former or never tobacco users (p < 0.0001) for both the modified-risk and control information. A significant interaction effect between information and tobacco user group (p < 0.0001) indicated the modified-risk information differentially increased projected use among smokers (8.2% vs. 6.9%), with much lower projections for both the test and control information among former (1.2%) and never tobacco users (0.4%). Among never users, projected use was highest among those susceptible to smoking. These findings were generally similar for young adults, ages 18-24. Smokers expecting to quit who viewed modified-risk information had lower projected use (4.2%) than those not expecting to quit (8.7%). CONCLUSIONS: Results suggest that providing modified-risk information for snus is unlikely to increase use among those not using tobacco. Interest in snus was greatest among current smokers who would benefit by switching to snus as communicated in the modified-risk advertisement.

Kratom as a substitute for opioids: Results from an online survey.

BACKGROUND: Kratom is a South Eastern Asian tree whose leaves are used to make tea-like brews or swallowed in powdered form for various health and well-being reasons including to relieve pain and opioid withdrawal. It is important to learn more about the potential public health impact of kratom in the context of the opioid epidemic. METHODS: An anonymous online survey of kratom users (2867 current users and 157 former users) was conducted in September 2017 through the American Kratom Association and associated social media sites. RESULTS: Kratom was used primarily to relieve pain (endorsed by 48% of respondents), for anxiety, PTSD, or depression (22%), to increase energy or focus (10%) and to help cut down on opioid use and/or relieve withdrawal (10%). Over 90% of respondents who used it in place of opioids indicated that it was helpful to relieve pain, reduce opioid use, and relieve withdrawal. The reported incidence of bad adverse reactions was 13%, and reactions were overwhelmingly mild and self-managed. CONCLUSIONS: Respondents reported using kratom for conditions which often require use of opioids, including pain and reduction of opioid use. The high self-reported efficacy and low incidence of adverse reactions associated with kratom use suggest that it may provide a potential alternative to opioids for some persons even though it has not been evaluated in multi-center clinical trials or approved for any therapeutic purpose. Further study of kratom, including systematic characterization of its safety and efficacy for various conditions is warranted.

Overutilization of Health Care Resources for Breast Pain.

OBJECTIVE: The objective of this study is to analyze the incidence of women with breast pain who present to an imaging center and assess the imaging findings, outcomes, and workup costs at breast imaging centers affiliated with one institution. MATERIALS AND METHODS: Demographic characteristics of and imaging findings for female patients presenting with breast pain at three community breast imaging centers between January 1, 2014, and December 31, 2014, were reviewed. Patients who were pregnant, were lactating, had a history of breast cancer, or presented with palpable nipple or skin findings were excluded. RESULTS: A total of 799 patients met the study criteria. Pain was diffuse in 30%, was focal in 30%, and was not localized in 40%. Of the 799 patients with breast pain, 790 (99%) presented for a diagnostic evaluation; 759 (95%) of these evaluated patients had negative findings. A benign sonographic correlate was detected in the area of pain in 5% of patients (39/799). One patient had a single cancer detected in the contralateral asymptomatic breast. When correlations between breast pain and the presence of cancer in the study patients were compared with the concurrent cancer detection rate in the screening population (5.5 cases per 1000 examinations performed), breast pain was not found to be a sign of breast cancer (p = 0.027). Patients younger than 40 years (316/799) underwent a total of 454 workup studies for breast pain; all findings were benign, and the cost of these studies was $87,322. Patients 40 years or older (483/799) underwent 745 workup studies, for a cost of $152,732. CONCLUSION: Breast pain represents an area of overutilization of health care resources. For female patients who present with pure breast pain, breast imaging centers should consider the following imaging protocols and education for referring physicians: an annual screening mammogram should be recommended for women 40 years or older, and reassurance without imaging should be offered to patients younger than 40 years.

Can Radiologists Predict the Presence of Ductal Carcinoma In Situ and Invasive Breast Cancer?

OBJECTIVE: We hypothesize that radiologists' estimated percentage likelihood assessments for the presence of ductal carcinoma in situ (DCIS) and invasive cancer may predict histologic outcomes. MATERIALS AND METHODS: Two hundred fifty cases categorized as BI-RADS category 4 or 5 at four University of California Medical Centers were retrospectively reviewed by 10 academic radiologists with a range of 1-39 years in practice. Readers assigned BI-RADS category (1, 2, 3, 4a, 4b, 4c, or 5), estimated percentage likelihood of DCIS or invasive cancer (0-100%), and confidence rating (1 = low, 5 = high) after reviewing screening and diagnostic mammograms and ultrasound images. ROC curves were generated. RESULTS: Sixty-two percent (156/250) of lesions were benign and 38% (94/250) were malignant. There were 26 (10%) DCIS, 20 (8%) invasive cancers, and 48 (19%) cases of DCIS and invasive cancer. AUC values were 0.830-0.907 for invasive cancer and 0.731-0.837 for DCIS alone. Sensitivity of 82% (56/68), specificity of 84% (153/182), positive predictive value (PPV) of 66% (56/85), negative predictive value (NPV) of 93% (153/165), and accuracy of 84% ([56 + 153]/250) were calculated using an estimated percentage likelihood of 20% or higher as the prediction threshold for invasive cancer for the radiologist with the highest AUC (0.907; 95% CI, 0.864-0.951). Every 20% increase in the estimated percentage likelihood of invasive cancer increased the odds of invasive cancer by approximately two times (odds ratio, 2.4). For DCIS, using a threshold of 40% or higher, sensitivity of 81% (21/26), specificity of 79% (178/224), PPV of 31% (21/67), NPV of 97% (178/183), and accuracy of 80% ([21 + 178]/250) were calculated. Similarly, these values were calculated at thresholds of 2% or higher (BI-RADS category 4) and 95% or higher (BI-RADS category 5) to predict the presence of malignancy. CONCLUSION: Using likelihood estimates, radiologists may predict the presence of invasive cancer with fairly high accuracy. Radiologist-assigned estimated percentage likelihood can predict the presence of DCIS, albeit with lower accuracy than that for invasive cancer.

The Impact of Flavor Descriptors on Nonsmoking Teens' and Adult Smokers' Interest in Electronic Cigarettes.

INTRODUCTION: Smokers switching completely from combustible cigarettes to electronic cigarettes (e-cigarettes) are likely to reduce health risk, suggesting that e-cigarettes should be made appealing to adult smokers. However, uptake of e-cigarettes by nonsmoking teens would add risk without benefit and should be avoided. Although e-cigarette flavors may appeal to adult smokers, the concern is that flavors might attract nonsmoking teens. METHODS: Nonsmoking teens (n = 216, ages 13-17, no tobacco in past 6 months) and adult smokers (n = 432, ages 19-80, smoking 3+ years; could have used e-cigarettes) were recruited from an Internet research panel. In assessments completed online (May 22, 2014 to June 13, 2014), participants indicated their interest (0-10 scale) in e-cigarettes paired with various flavor descriptors. These were mixed (order balanced) with similar flavor offerings for ice cream and bottled water to mask the focus on e-cigarettes and validate the assessment. Mixed models contrasted interest between teens and adults and among adults by e-cigarette history. RESULTS: Nonsmoking teens' interest in e-cigarettes was very low (mean = 0.41 ± 0.14 [SE] on 0-10 scale). Adult smokers' interest (1.73 ± 0.10), while modest, was significantly higher overall (p < .0001) and for each flavor (most p values < .0001). Teen interest did not vary by flavor (p = .75), but adult interest did (p < .0001). Past-30-day adult e-cigarette users had the greatest interest in e-cigarettes, and their interest was most affected by flavor. Adults who never tried e-cigarettes had the lowest interest, yet still higher than nonsmoking teens' interest (p < .0001). CONCLUSION: The e-cigarette flavors tested appealed more to adult smokers than to nonsmoking teens, but interest in flavors was low for both groups.

Epidemiology of stimulant misuse and abuse: implications for future epidemiologic and neuropharmacologic research.

Stimulants are a diverse array of drugs that range from everyday caffeine to prescription medications and illicitly manufactured street drugs. The surveillance of misuse and abuse of stimulants many times confounds prescription and illicit street drugs such that the data are not specific enough to guide mitigation efforts or assess their impact. This review highlights the surveillance efforts that are conducted in the United States (US) for stimulant misuse and abuse. These surveillance efforts include national level surveys as well as reporting systems such as Poison Centers and emergency departments. This epidemiologic analysis has implications for interpreting the current known neuropharmacology of stimulants and possibly informing future neuropharmacology research that may contribute to a better understanding of potential neuropharmacologic factors influencing differing patterns of use, abuse, and adverse consequences associated with various stimulants. This article is part of the Special Issue entitled 'CNS Stimulants'.

Consumer understanding of prescription drug information: an illustration using an antidepressant medication.

BACKGROUND: Patient education and warnings have emerged as prominent interventions for improving drug safety. As part of the provision of information and guidance on safe use of drugs, patients often receive multiple pieces of written information when they obtain a prescription medication, including a Food and Drug Administration (FDA)-mandated medication guide (MG), consumer medication information (CMI), and patient package insert (PPI). OBJECTIVE: To determine whether patients understand the materials providing drug information and whether the materials convey the intended information. METHODS: Fifty-two adults with a high school education or less were shown an actual (blinded) MG, CMI, and PPI for a marketed antidepressant medication. Comprehension was tested with methods used by the FDA to assess label comprehension for nonprescription products. RESULTS: The majority of participants (88.2%) looked at all 3 pieces of information provided. The mean (SD) time spent reviewing the CMI was 5.2 (4.8) minutes (range 0-21.9), 16.5 (13.3) minutes for the PPI (range 0-43.0), and 2.5 (1.6) minutes for the MG (range 0-7.6). Less than 20% of participants were able to identify the symptoms of a rare but potentially life-threatening situation that can occur with this medication and only 61.5% recalled the risk of teen suicide, which is the sole focus of the MG. Respondents with lower literacy scores performed more poorly than those with higher literacy scores. CONCLUSIONS: Information provided with at least some prescription drugs is not adequately understood by less-educated consumers and does not effectively communicate critical safety messages or directions.

Disparities by ethnicity and socioeconomic status in the use of weight loss treatments.

BACKGROUND: Prior research suggests that ethnic minorities and individuals of low socioeconomic status (SES) may be more likely to attempt weight loss using unproven methods. METHODS: Data were from a national, random-digit-dial telephone survey of weight loss practices. Seven modalities of weight loss were examined. Multivariable analysis controlled for clinical and sociodemographic variables (including race/ethnicity, SES, and body mass index), as well as self-perception of weight and weight loss attitudes. RESULTS: In multivariable analysis, African Americans (OR, 1.71; 95% CI, 1.05-2.78; p =.03) and Latinos (OR, 1.69; 95% CI, 1.11-2.60; p = .016) were more likely than Caucasians to report use of over-the-counter (OTC) weight loss supplements. African Americans (OR, 0.39; 95% CI, 0.21-0.71; p = .002) and Latinos (OR, 0.56; CI, 0.33-0.97; p = .038) also were less likely than Caucasians to report use of commercial weight loss programs. Higher-SES individuals were more likely than low-SES persons to report self-directed attempts at weight loss (OR, 1.39; CI, 1.00-1.93; p = .05) and commercial programs (OR, 2.12; CI, 1.51-2.97; p < .001) and less likely to report use of OTC supplements (OR, 0.64; CI, 0.47-0.88]; p = .006). African Americans were more likely than Caucasians to report use of medically supervised programs (OR, 1.74; CI, 1.06-2.86; p = .028). CONCLUSIONS: With the exception of medically supervised programs, ethnic minorities and low-SES individuals are generally more likely to report use of unproven methods for weight loss and less likely to report use of potentially beneficial treatments. These findings should be explored in more detail. Use of proven treatments for weight management should be encouraged.