Search

Congenital diaphragmatic hernia (CDH) results in varying degrees of pulmonary hypoplasia. Volume targeted ventilation (VTV) is a lung protective strategy but the optimal target tidal volume in CDH infants has not previously been studied. The aim of this study was to test the hypothesis that low targeted volumes would be better in CDH infants as determined by measuring the work of breathing (WOB) in CDH infants, at three different targeted tidal volumes. A randomised cross-over study was undertaken. Infants were eligible for inclusion in the study after surgical repair of their diaphragmatic defect. Targeted tidal volumes of 4, 5, and 6 ml/kg were each delivered in random order for 20-min periods with 20-min periods of baseline ventilation between. WOB was assessed and measured by using the pressure–time product of the diaphragm (PTPdi). Nine infants with a median gestational age at birth of 38 + 4 (range 36 + 4–40 + 6) weeks and median birth weight 3202 (range 2855–3800) g were studied. The PTPdi was higher at 4 ml/kg than at both 5, p = 0.008, and 6 ml/kg, p = 0.012.Conclusion: VTV of 4 ml/kg demonstrated an increased PTPdi compared to other VTV levels studied and should be avoided in post-surgical CDH infants. What is Known:• Lung injury secondary to mechanical ventilation increases the mortality and morbidity of infants with CDH.• Volume targeted ventilation (VTV) reduces ‘volutrauma’ and ventilator-induced lung injury in other neonatal intensive care populations. What is New:• A randomised cross-over trial was carried out investigating the response to different VTV levels in infants with CDH.• Despite pulmonary hypoplasia being a common finding in CDH, a VTV of 5ml/kg significantly reduced the work of breathing in infants with CDH compared to a lower VTV level.

To facilitate the delivery of accurate and timely care to patients in complex environments, process improvement methodologies such as Lean can be very effective. Lean is a quality improvement methodology that seeks to add value for patients and employees by continuously improving processes and eliminating waste. At our institution, Lean principles were applied to improve efficiency and minimize waste in the diagnostic breast imaging reading room. This paper describes how we applied Lean principles, including plan-do-study-act testing, level-loading (heijunka), and visual management, to level the workload of the diagnostic radiologists in our practice. Implementation of these principles to improve the diagnostic workflow in breast imaging is described along with examples from our practice, including challenges and future opportunities.

Molecular breast imaging (MBI) is a nuclear medicine technique that has evolved considerably over the past two decades. Technical advances have allowed reductions in administered doses to the point that they are now acceptable for screening. The most common radiotracer used in MBI, 99mTc-sestamibi, has a long history of safe use. Biopsy capability has become available in recent years, with early clinical experience demonstrating technically successful biopsies of MBI-detected lesions. MBI has been shown to be an effective supplemental screening tool in women with dense breasts and is also utilized for breast cancer staging, assessment of response to neoadjuvant chemotherapy, problem solving, and as an alternative to breast MRI in women who have a contraindication to MRI. The degree of background parenchymal uptake on MBI shows promise as a tool for breast cancer risk stratification. Radiologist interpretation is guided by a validated MBI lexicon that mirrors the BI-RADS lexicon. With short interpretation times, a fast learning curve for radiologists, and a substantially lower cost than breast MRI, MBI provides many benefits in the practices in which it is utilized. This review will discuss the current state of MBI technology, clinical applications of MBI, MBI interpretation, radiation dose associated with MBI, and the future of MBI.

Insomnia emerged for the first time in the Romantic period as a disorder with its own unique pathology and psychology, and was newly considered a separate state of consciousness, situated liminally...

Background Volumetric capnography allows for continuous monitoring of expired tidal volume and carbon dioxide. The slope of the alveolar plateau of the capnogram (SIII) could provide information regarding ventilation homogeneity. We aimed to assess the feasibility of measuring SIII during newborn resuscitation and determine if SIII decreased after surfactant indicating ventilation inhomogeneity improvement. Methods Respiratory function traces of preterm infants resuscitated at birth were analysed. Ten capnograms were constructed for each infant: five pre- and post-surfactant. If a plateau was present SIII was calculated by regression analysis. Results Thirty-six infants were included, median gestational age of 28.7 weeks and birth weight of 1055 g. Average time between pre- and post-surfactant was 3.2 min. Three hundred and sixty capnograms (180 pre and post) were evaluated. There was adequate slope in 134 (74.4%) capnograms pre and in 100 (55.6%) capnograms post-surfactant (p = 0.004). Normalised for tidal volume SIII pre-surfactant was 18.89 mmHg and post-surfactant was 24.86 mmHg (p = 0.006). An increase in SIII produced an up-slanting appearance to the plateau indicating regional obstruction. Conclusion It was feasible to evaluate the alveolar plateau pre-surfactant in preterm infants. Ventilation inhomogeneity increased post-surfactant likely due to airway obstruction caused by liquid surfactant present in the airways. Impact Volumetric capnography can be used to assess homogeneity of ventilation by SIII analysis. Ventilation inhomogeneity increased immediately post-surfactant administration during the resuscitation of preterm infants, producing a characteristic up-slanting appearance to the alveolar plateau. The best determinant of alveolar plateau presence in preterm infants was the expired tidal volume.

Clinically, acute mastitis presents as a red, swollen, and painful breast. Targeted ultrasound can be performed to evaluate the extent of infection and for an underlying abscess. Noncomplicated mastitis or a small fluid collection may respond to oral antibiotics without further intervention, but a larger or more complex abscess may require single or serial percutaneous aspiration. Breast infections, particularly those complicated by an abscess, can have a prolonged clinical course, and close follow-up is required. Since the clinical presentation and imaging features of acute infectious mastitis can overlap with other etiologies, such as inflammatory breast cancer and idiopathic granulomatous mastitis, a percutaneous biopsy may be indicated to accurately diagnose patients.

Purpose We analyzed multi-institutional data to understand the relationship of ACR Diagnostic Radiology In-Training Examination (DXIT) scores to ABR Core examination performance. Methods We collected DXIT rank scores and ABR Core examination outcomes and scores for anonymized residents from 12 different diagnostic radiology residency programs taking the ABR Core examination between 2013 and 2019. DXIT scores were grouped into quintiles based on rank score for residency year 1 (R1), residency year 2 (R2), and residency year 3 (R3) residents. Core outcome was scored as fail when conditionally passed or failed. Core performance was grouped using SD from the mean and measured by the percent of residents with scores below the mean. Differences between DXIT score quintiles for Core outcome and Core performance were statistically evaluated. Results DXIT and Core outcome data were available for 446 residents. The Core examination failure rate for the lowest quintile R1, R2, and R3 DXIT scores was 20.3%, 34.2%, and 38.0%, respectively. Core performance improved with higher R3 DXIT quintiles. Only 2 of 229 residents with R3 DXIT score ≥ 50th percentile failed the Core examination, with both failing residents having R2 DXIT scores in the lowest quintile. Conclusions DXIT scores are useful evaluation metrics to identify a subgroup of residents at significantly higher risk for Core examination failure and another subgroup of residents at significantly lower risk for Core examination failure, with increasing predictive power with advancing residency year. These scores enable identification of approximately one-half of R3 residents whose risk of Core examination failure is negligible.

Objectives Extubation failure is common in infants and associated with complications. Methods A prospective study was undertaken of preterm and term born infants. Diaphragm electromyogram (EMG) was measured transcutaneously for 15–60 min prior to extubation. The EMG results were related to tidal volume (Tve) to calculate the neuroventilatory efficiency (NVE). Receiver operating characteristic curves (ROC) were constructed and areas under the ROCs (AUROC) calculated. Results Seventy-two infants, median gestational age 28 (range 23–42) weeks were included; 15 (21%) failed extubation. Infants successfully extubated were more mature at birth (p=0.001), of greater corrected gestational age (CGA) at extubation (p29.6 weeks had the highest combined sensitivity (86%) and specificity (80%) in predicting extubation success. Conclusions Although NVE differed significantly between those who did and did not successfully extubate, CGA was the best predictor of extubation success.

Both proportional assist ventilation (PAV) and neurally adjusted ventilatory assist (NAVA) provide pressure support synchronised throughout the respiratory cycle proportional to the patient’s respiratory demand. Our aim was to compare the effect of these two modes on oxygenation in infants with evolving or established bronchopulmonary dysplasia. Two-hour periods of PAV and NAVA were delivered in random order to 18 infants born less than 32 weeks of gestation. Quasi oxygenation indices (“OI”) and alveolar-arterial (“A-a”) oxygen gradients at the end of each period on PAV, NAVA and baseline ventilation were calculated using capillary blood samples. The mean “OI” was not significantly different on PAV compared to NAVA (7.8 (standard deviation (SD) 3.2) versus 8.1 (SD 3.4), respectively, p = 0.70, but lower on both than on baseline ventilation (mean baseline “OI” 11.0 (SD 5.0)), p = 0.002, 0.004, respectively). The “A-a” oxygen gradient was higher on PAV and baseline ventilation than on NAVA (20.8 (SD 12.3) and 22.9 (SD 11.8) versus 18.5 (SD 10.8) kPa, p = 0.015, Conclusion: Both NAVA and PAV improved oxygenation compared to conventional ventilation. There was no significant difference in the mean “OI” between the two modes, but the mean “A-a” gradient was better on NAVA.What is Known:• Proportional assist ventilation (PAV) and neurally adjusted ventilatory assist (NAVA) can improve the oxygenation index (OI) in prematurely born infants.• Both PAV and NAVA can provide support proportional to respiratory drive or demand throughout the respiratory cycle.What is New:• In infants with evolving or established BPD, using capillary blood samples, both PAV and NAVA compared to baseline ventilation resulted in improvement in the “OI”, but there was no significant difference in the “OI” on PAV compared to NAVA.• The “alveolar-arterial” oxygen gradient was better on NAVA compared to PAV.

Abnormal levels of end-tidal carbon dioxide (EtCO2) during resuscitation in the delivery suite are associated with intraventricular haemorrhage (IVH) development. Our aim was to determine whether carbon dioxide (CO2) levels in the first 3 days after birth reflected abnormal EtCO2 levels in the delivery suite, and hence, a prolonged rather than an early insult resulted in IVH. In addition, we determined if greater EtCO2level fluctuations during resuscitation occurred in infants who developed IVH. EtCO2 levels during delivery suite resuscitation and CO2 levels on the neonatal unit were evaluated in 58 infants (median gestational age 27.3 weeks). Delta EtCO2 was the difference between the highest and lowest level of EtCO2. Thirteen infants developed a grade 3–4 IVH (severe group). There were no significant differences in CO2 levels between those who did and did not develop an IVH (or severe IVH) on the NICU. The delta EtCO2 during resuscitation differed between infants with any IVH (6.2 (5.4–7.5) kPa) or no IVH (3.8 (2.7–4.3) kPA) (p < 0.001) after adjusting for differences in gestational age. Delta EtCO2 levels gave an area under the ROC curve of 0.940 for prediction of IVH.Conclusion: The results emphasize the importance of monitoring EtCO2 levels in the delivery suite. What is Known:• Abnormal levels of carbon dioxide (CO2) in the first few days after birth and abnormal end-tidal CO2levels (EtCO2) levels during resuscitation are associated in preterm infants with the risk of developing intraventricular haemorrhage (IVH). What is New:• There were no significant differences in NICU CO2levels between those who developed an IVH or no IVH.• There was a poor correlation between delivery suite ETCO2levels and NICU CO2levels.• Large fluctuations in EtCO2during resuscitation in the delivery suite were highly predictive of IVH development in preterm infants.

PURPOSE Background parenchymal uptake (BPU), which describes the level of radiotracer uptake in normal fibroglandular tissue on molecular breast imaging (MBI), has been identified as a breast cancer risk factor. Our objective was to develop and validate a deep learning model using image convolution to automatically categorize BPU on MBI. METHODS MBI examinations obtained for clinical and research purposes from 2004 to 2015 were reviewed to classify the BPU pattern using a standardized five-category scale. Two expert radiologists provided interpretations that were used as the reference standard for modeling. The modeling consisted of training and validating a convolutional neural network to predict BPU. Model performance was summarized in data reserved to test the performance of the algorithm at the per-image and per-breast levels. RESULTS Training was performed on 24,639 images from 3,133 unique patients. The model performance on the withheld testing data (6,172 images; 786 patients) was evaluated. Using direct matching on the predicted classification resulted in an accuracy of 69.4% (95% CI, 67.4% to 71.3%), and if prediction within one category was considered, accuracy increased to 96.0% (95% CI, 95.2% to 96.7%). When considering the breast-level prediction of BPU, the accuracy remained strong, with 70.3% (95% CI, 68.0% to 72.6%) and 96.2% (95% CI, 95.3% to 97.2%) for the direct match and allowance for one category, respectively. CONCLUSION BPU provided a robust target for training a convolutional neural network. A validated computer algorithm will allow for objective, reproducible encoding of BPU to foster its integration into risk-stratification algorithms.

This article does not include an abstract. Please see the accompanying Counterpoint by Sonya Bhole and Sarah M. Friedewald.

ObjectiveWe evaluated the accuracy of molecular breast imaging (MBI)—a nuclear medicine technique that employs dedicated dual-detector, cadmium zinc telluride gamma cameras to image the functional uptake of a radiopharmaceutical (typically Tc-99m sestamibi) in the breast—in patients with suspicious calcifications on mammography.MethodsWomen scheduled for stereotactic biopsy of calcifications detected on 2D digital mammography were prospectively enrolled to undergo MBI before biopsy. Molecular breast imaging was performed with injection of Tc-99m sestamibi and a dual-detector, cadmium zinc telluride gamma camera. Positive findings on either modality were biopsied. High-risk and malignant biopsy findings were excised.ResultsIn 71 participants, 76 areas of calcifications were recommended for biopsy after mammography, and 24 (32%) were malignant, including 20 cases of ductal carcinoma in situ (DCIS) and 4 cases of invasive ductal cancer. Prebiopsy MBI was positive in 17 of the 76 (22%) calcifications, including 10 of 20 (50%) DCISs and 2 of 4 (50%) invasive cancers. The median pathologic size for MBI–positive cancers was 1.5 cm (range 0.5–3.2 cm) compared with 0.9 cm (range 0.1–2.0 cm) for MBI–negative cancers (P = 0.09).Non-mass uptake on MBI led to additional biopsies of 6 sites in 6 patients, and 2 of 6 (33%) MBI–detected incidental lesions showed malignancy; both DCIS contralateral to the mammographically detected calcifications. The overall per-lesion positive and negative predictive values of MBI in this prebiopsy setting were 61% (14 of 23) and 80% (47 of 59), respectively.ConclusionMolecular breast imaging has insufficient negative predictive value to identify calcifications in which biopsy could be avoided. However, among women presenting for biopsy of suspicious calcifications, MBI revealed additional sites of mammographically occult breast cancer.To avoid biopsy of suspicious calcifications on mammography, negative findings on MBI should not be used.

OBJECTIVE. The purpose of this study is to prospectively compare the size of invasive breast cancer before and after neoadjuvant chemotherapy (NAC) at breast MRI and molecular breast imaging (MBI) and to assess the accuracy of post-NAC MBI and MRI relative to pathologic analysis. SUBJECTS AND METHODS. Women with invasive breast cancer greater than or equal to 1.5 cm were enrolled to compare the longest dimension before and after NAC at MRI and MBI. MBI was performed on a dual-detector cadmium zinc telluride system after administration of 6.5 mCi (240 MBq) 99mTc-sestamibi. The accuracy of MRI and MBI in assessing residual disease (invasive disease or ductal carcinoma in situ) was determined relative to pathologic examination. RESULTS. The longest dimension at MRI was within 1.0 cm of that at MBI in 72.3% of cases before NAC and 70.1% of cases after NAC. The difference between the longest dimension at imaging after NAC and pathologic tumor size was within 1 cm for 58.7% of breast MRI cases and 59.6% of MBI cases. Ninety patients underwent both MRI and MBI after NAC. In the 56 patients with invasive residual disease, 10 (17.9%) cases were negative at MRI and 23 (41.1%) cases were negative at MBI. In the 34 patients with breast pathologic complete response, there was enhancement in 10 cases (29.4%) at MRI and uptake in six cases (17.6%) at MBI. Sensitivity, specificity, positive predictive value, and negative predictive value after NAC were 82.8%, 69.4%, 81.4%, and 71.4%, respectively, for MRI and 58.9%, 82.4%, 84.6%, and 54.9%, respectively, for MBI. CONCLUSION. Breast MRI and MBI showed similar disease extent before NAC. MBI may be an alternative to breast MRI in patients with a contraindication to breast MRI. Neither modality showed sufficient accuracy after NAC in predicting breast pathologic complete response to obviate tissue diagnosis to assess for residual invasive disease. Defining the extent of residual disease compared with pathologic evaluation was also limited after NAC for both breast MRI and MBI.

Heated, humidified, high-flow nasal cannula (HHHFNC) is increasingly being used, but there is a paucity of evidence as to the optimum flow rates in prematurely born infants. We have determined the impact of three flow rates on the work of breathing (WOB) assessed by transcutaneous diaphragm electromyography (EMG) amplitude in infants with respiratory distress or bronchopulmonary dysplasia (BPD). Flow rates of 4, 6 and 8 L/min were delivered in random order. The mean amplitude of the EMG trace and mean area under the EMG curve (AEMGC) were calculated and the occurrence of bradycardias and desaturations recorded. Eighteen infants were studied with a median gestational age of 27.8 (range 23.9–33.5) weeks and postnatal age of 54 (range 3–122) days. The median flow rate prior to the study was 5 (range 3–8) L/min and the fraction of inspired oxygen (FiO2) was 0.29 (range 0.21–0.50). There were no significant differences between the mean amplitude of the diaphragm EMG and the AEGMC and the number of bradycardias or desaturations between the three flow rates. Conclusions: In infants with respiratory distress or BPD, there was no advantage of using high (8 L/min) compared with lower flow rates (4 or 6 L/min) during support by HHHFNC. What is known: • Humidified high flow nasal cannulae (HHHFNC) is increasingly being used as a non-invasive form of respiratory support for prematurely born infants. • There is a paucity of evidence regarding the optimum flow rate with 1 to 8 L/min being used. What is new: • We have assessed the work of breathing using the amplitude of the electromyogram of the diaphragm at three HHHFNC flow rates in infants with respiratory distress or BPD. • No significant differences were found in the EMG amplitude results or the numbers of bradycardias or desaturations at 4, 6 and 8 L/min.

Background Sustained inflations at initial stabilisation in the delivery suite may reduce the need for intubation and result in a shorter duration of initial ventilation, but have not been compared to routine UK practice. Aims To compare the early efficacy of sustained inflation during stabilisation after delivery to UK practice. Study design A randomised trial was performed of a fifteen second sustained inflation compared to five inflations lasting 2 to 3 s, each intervention could be repeated once if no chest rise was apparent. Respiratory function monitoring was undertaken. Subjects Infants born prior to 34 weeks of gestation. Outcome measures The minute volume and maximum end-tidal carbon dioxide level in the first minute after the interventions, the time to the first spontaneous breath after the beginning of stabilisation and the duration of ventilation in the first 48 h. Results There were no significant differences in the minute volume or maximum end tidal carbon dioxide level between the groups. Infants in the sustained inflation group made a respiratory effort sooner (median 3.5 (range 0.2–59) versus median 12.8 (range 0.4–119) s, p = 0.001). The sustained inflation group were ventilated for a shorter duration in the first 48 h (median 17 (range 0–48) versus median 32.5 (range 0–48) h, p = 0.025). Conclusions A sustained inflation of 15 s compared to five two to three second inflations during initial stabilisation was associated with a shorter duration of mechanical ventilation in the first 48 h after birth.

An amendment to this paper has been published and can be accessed via the original article.

Purpose: Patient-derived xenografts (PDX) are a research tool for studying cancer biology and drug response phenotypes. While engraftment rates are higher for tumors with more aggressive characteristics, it is uncertain whether engraftment is prognostic for cancer recurrence. Patients and Methods: In a prospective study of patients with breast cancer treated with neoadjuvant chemotherapy (NAC) with taxane ± trastuzumab followed by anthracycline-based chemotherapy, we report the association between breast cancer events and PDX engraftment using tumors derived from treatment naïve (pre-NAC biopsies from 113 patients) and treatment resistant (post-NAC at surgery from 34 patients). Gray test was used to assess whether the cumulative incidence of a breast cancer event differs with respect to either pre-NAC PDX engraftment or post-NAC PDX engraftment. Results: With a median follow-up of 5.7 years, the cumulative incidence of breast cancer relapse did not differ significantly according to pre-NAC PDX engraftment (5-year rate: 13.6% vs. 13.4%; P = 0.89). However, the incidence of a breast event was greater for patients with post-NAC PDX engraftment (5-year rate: 50.0% vs. 19.6%), but this did not achieve significance (P = 0.11). Conclusions: In treatment-naïve breast cancer receiving standard NAC, PDX engraftment was not prognostic for breast cancer recurrence. Further study is needed to establish whether PDX engraftment in the treatment-resistant setting is prognostic for cancer recurrence.

Objective Document occurrence of breast cancer in females after liver, kidney, or pancreas transplantation seen at a tertiary medical center. Methods Medical records of adult female patients with liver, kidney, or pancreas transplants from 1/1/1995 to 4/4/2014 were retrospectively reviewed. Patients with a history of breast cancer, no mammogram post-transplant, or no research authorization were excluded. Mammogram findings and pathology results were reviewed and recorded. Cancer rates could not be measured in patients followed up outside the institution. Descriptive statistics summarized the cohort. Occurrence rates were estimated using Poisson regression. Results 1095 women were included and 33 were diagnosed with breast cancer post-transplant. Median age at diagnosis was 58 years. Average interval from transplant to cancer diagnosis was 82.6 months. Observed occurrence of invasive and in-situ breast cancer (reported as per 100,000 person-years [95% confidence interval]) was 353 [243–496]. Liver transplant patients showed the lowest rate (181 [95% CI 73–372]), vs. kidney (476 [305–708]) or pancreas (467 [57–1688]). Patients with the highest breast density showed increased occurrence despite younger age (1001 [367–2178]) compared to those with lower breast density (range 239 [109–454] to 372 [186–666]). Conclusions Female patients after organ transplant experienced increased breast cancer occurrence in this observational study. Those who developed breast cancer also had increased breast density. The findings underscore the importance of breast cancer screening in this population.

OBJECTIVE. The purpose of this article is to review clinical uses and image interpretation of molecular breast imaging (MBI) and clarify radiation risks. CONCLUSION. MBI detects additional cancers compared with conventional imaging in women with dense breasts and those with elevated risk of breast cancer. Its role as an imaging biomarker of cancer risk and in assessing neoadjuvant chemotherapy response is growing. Radiation risk is minimal; benefit-to-risk ratio is similar to that of mammography. MBI is low cost, well tolerated, and easily adapted into clinical practice.

Intraventricular haemorrhage (IVH) and bronchopulmonary dysplasia (BPD) are major complications of premature birth. We tested the hypotheses that prematurely born infants who developed an IVH or BPD would have high expiratory tidal volumes (VTE) (VTE > 6 ml/kg) and/or low-end tidal carbon dioxide (ETCO2) levels (ETCO2 levels < 4.5 kPa) as recorded by respiratory function monitoring or hyperoxia (oxygen saturation (SaO2) > 95%) during resuscitation in the delivery suite. Seventy infants, median gestational age 27 weeks (range 23–33), were assessed; 31 developed an IVH and 43 developed BPD. Analysis was undertaken of 31,548 inflations. The duration of resuscitation did not differ significantly between the groups. Those who developed an IVH compared to those who did not had a greater number of inflations with a high VTE and a low ETCO2, which remained significant after correcting for differences in gestational age and birth weight between groups (p = 0.019). Differences between infants who did and did not develop BPD were not significant after correcting for differences in gestational age and birth weight. There were no significant differences in the duration of hyperoxia between the groups. Conclusions: Avoidance of high tidal volumes and hypocarbia in the delivery suite might reduce IVH development.What is known• Hypocarbia on the neonatal unit is associated with the development of intraventricular haemorrhage (IVH) and bronchopulmonary dysplasia (BPD).What is new• Infants who developed an IVH compared to those who did not had significantly more inflations with high expiratory tidal volumes and low ETCO2s.

ObjectivesEnd tidal carbon dioxide (ETCO2) monitoring can facilitate identification of successful intubation. The aims of this study were to determine the time to detect ETCO2following intubation during resuscitation of infants born prematurely and whether it differed according to maturity at birth or the Apgar scores (as a measure of the infant’s condition after birth).DesignAnalysis of recordings of respiratory function monitoring.SettingTwo tertiary perinatal centres.PatientsSixty-four infants, with median gestational age of 27 (range 23–34)weeks.InterventionsRespiratory function monitoring during resuscitation in the delivery suite.Main outcome measuresThe time following intubation for ETCO2levels to be initially detected and to reach 4 mm Hg and 15 mm Hg.ResultsThe median time for initial detection of ETCO2following intubation was 3.7 (range 0–44) s, which was significantly shorter than the median time for ETCO2to reach 4 mm Hg (5.3 (range 0–727) s) and to reach 15 mm Hg (8.1 (range 0–827) s) (both P2to reach 4 mm Hg (r=−0.44, P>0.001) and 15 mm Hg (r=−0.48, PConclusionsThe time for ETCO2to be detected following intubation in the delivery suite is variable emphasising the importance of using clinical indicators to assess correct endotracheal tube position in addition to ETCO2monitoring. Capnography is likely to detect ETCO2faster than colorimetric devices.

Molecular breast imaging (MBI) technologists are required to possess a combination of nuclear medicine skills and mammographic positioning techniques. Currently, no formal programs offer this type of hybrid technologist training. The purpose of this perspective is to provide a best practices guide for technologists performing MBI. Familiarity with best practices may aid in obtaining high-quality MBI examinations by decreasing the likelihood of image artifacts, positioning problems and other factors that contribute to false negative or false positive findings.

Objectives This article reviews our experience and describes the literature findings of granulomatous diseases of the breast and axilla. Methods After approval of the Institutional Review Board was obtained, the surgical pathological records from January 2000 to January 2017 were searched for the keyword granulomatous. Clinical, imaging and histology findings were reviewed by both a fellowship-trained radiologist and a breast-imaging consultant radiologist, reviewing 127 patients (age range, 32–86 years; 126 women and 1 man). Results Most common causes of granulomatous lesions of the breast and axilla included silicone granulomas 33% (n = 42), fat necrosis 29% (n = 37) and suture granulomas 11% (n = 14). In 16% (n = 20), no cause could be found and clinical history was consistent with idiopathic granulomatous mastitis. Other granulomatous aetiologies included granulomatous infections, sarcoidosis and Sjögren’s syndrome. Causes of axillary granulomatous disease were similar to the breast; however, a case of cat-scratch disease was found that only involved the axillary lymph nodes. They can have a variable appearance on imaging and may mimic malignancy with irregular masses seen on mammography, ultrasound and magnetic resonance imaging. Fistulas to the skin and nipple retraction can suggest chronicity and a granulomatous aetiology. Combination of clinical history, laboratory and imaging findings can be diagnostic. Conclusions Granulomatous processes of the breast are rare. The diagnosis can, however, be made if there is relevant history (prior trauma, silicone breast implants, lactation), laboratory (systemic or infectious processes) and imaging findings (fistula, nipple retraction). Recognising these entities is important for establishing pathological concordance after biopsy and for preventing unnecessary treatment. Teaching points Breast granulomatous are rare but can mimic breast carcinoma on imaging Imaging with clinical and laboratory findings can correctly diagnosis specific granulomatous breast diseases Recognition of the imaging findings allows appropriate pathological concordance and treatment

ObjectivesTo assess the work of breathing at different levels of volume targeting in prematurely born infants with evolving or established bronchopulmonary dysplasia (BPD).DesignRandomised crossover study.SettingTertiary neonatal intensive care unit.PatientsEighteen infants born at InterventionsInfants received ventilation at volume targeting levels of 4, 5, 6 and 7 mL/kg each for 20 minutes, the levels were delivered in random order. Baseline ventilation (without volume targeting) was delivered for 20 minutes between each epoch of volume-targeting.Main outcome measuresPressure-time product of the diaphragm (PTPdi), a measure of the work of breathing, at different levels of volume targeting.ResultsThe 18 infants had a median gestational age of 26 (range 24–30) weeks and were studied at a median of 18 (range 7–60) days. The mean PTPdi was higher at 4 mL/kg than at baseline, 5 mL/kg, 6 mL/kg and 7 mL/kg (all P≤0.001). The mean PTPdi was higher at 5 mL/kg than at 6 mL/kg (P=0.008) and 7 mL/kg (PConclusionsOnly a tidal volume target of 7 mL/kg reduced the work of breathing below the baseline and may be more appropriate for infants with evolving or established BPD who remained ventilator dependent at or beyond 7 days of age.

Key Clinical Message This case highlights the role of molecular breast imaging (MBI) in evaluating persistent clinical concerns after a negative diagnostic mammogram and ultrasound. MBI is especially useful in the diagnosis of invasive lobular carcinoma due to its occult nature on conventional imaging modalities.

Purpose/Objectives: The optimal clinical target volume (CTV) for internal mammary node irradiation (IMNI) is uncertain in an era of increasingly conformal volume-based treatment planning for breast cancer. We mapped the location of gross internal mammary lymph node (IMN) metastases in order to identify areas at highest risk for harboring occult disease. Methods and Materials: Patients with axial imaging of IMN disease, including fluorodeoxyglucose F-18 (FDG18) positron emission tomography (PET-CT) and magnetic resonance imaging (MRI), were identified from a breast cancer registry. The IMN location was transferred by a radiation oncologist and breast radiologist onto the corresponding anatomic position on representative axial CT images of a patient in the treatment position. Distribution of lymph nodes, and their location was compared with consensus group guidelines of IMN target delineation. Results: Sixty-seven patients with 130 IMN metastases were mapped. The location was in the first three intercostal spaces in 102 of 130 (78%) nodal metastases. Eighteen of 130 (14%) IMN were located caudal to the third intercostal space, while 10 of 130 (8%) IMN were located cranial to the first intercostal space, including 3 patients with isolated IMN metastases at that location in the absence of distant disease. Of the 102 nodal metastases within the first three intercostal spaces, 54 (53%) were located within the RTOG consensus volume. Relative to the internal mammary (IM) vessels, 19 (19%) nodal metastases were located medially with a mean distance of 2.2 mm (SD 2.9 mm), while 29 (28%) were located laterally with a mean distance of 3.6 mm (SD 2.5 mm). Ninety and ninety-five percent of lymph nodes within the first three intercostal spaces would have been encompassed within a 4 mm and 6 mm medial and lateral expansion on the IM vessels, respectively. Conclusions: For women with indications for elective IMNI, a 4 mm medial and lateral expansion on the IM vessels within the first 3 intercostal spaces may be appropriate. In women with known IMN involvement, cranial extension to the confluence of the IM vein with the brachiocephalic vein +/- caudal extension to the 4th or 5th interspace with a 6 mm medial and lateral expansion may be considered, provided that normal tissue constraints are met. Citation Format: Jethwa KR, Kahila MM, Hunt KN, Brown LC, Corbin KS, Park SS, Yan ES, Boughey JC, Mutter RW. Delineation of internal mammary nodal target volumes in breast cancer radiotherapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-10-09.

Although in the preface to Prometheus Unbound Percy Shelley urges that “Didactic poetry is my abhorrence … My purpose has hitherto been simply to familiarize the highly refined imagination of the m...

OBJECTIVE. The purpose of this study was to determine whether application of a proprietary image-processing algorithm would allow a reduction in the necessary administered activity for molecular breast imaging (MBI) examinations. MATERIALS AND METHODS. Images from standard-dose MBI examinations (300 MBq 99mTc-sestamibi) of 50 subjects were analyzed. The images were acquired in dynamic mode and showed at least one breast lesion. Half-dose MBI examinations were simulated by summing one-half of the dynamic frames and were processed with the algorithm under study in both a default and a preferred filter mode. Two breast radiologists independently completed a set of two-alternative forced-choice tasks to compare lesion conspicuity on standard-dose images, half-dose images, and the algorithm-processed half-dose images in both modes. RESULTS. Relative to the standard-dose images, the half-dose images were preferred in 4, the default-filtered half-dose images in 50, and preferred-filtered half-dose images in 76 of 100 readings. Compared with standard-dose images, in terms of lesion conspicuity, the half-dose images were rated better in 2, equivalent in 6, and poorer in 92 of 100 readings. The default-filtered half-dose images were rated better, equivalent, or poorer in 13, 73, and 14 of 100 readings. The preferred-filtered half-dose images were rated as better, equivalent, or poorer in 55, 34, and 11 of 100 readings. CONCLUSION. Compared with that on standard-dose images, lesion conspicuity on images obtained with the algorithm and acquired at one-half the standard dose was equivalent or better without compromise of image quality. The algorithm can also be used to decrease imaging time with a resulting increase in patient comfort and throughput.

Introduction: Caffeine, a methylxanthine, is used to facilitate extubation from the ventilator and treat apnoea of prematurity. Caffeine increased the electrical activity of the diaphragm (Edi) in spontaneously breathing preterm infants. Aims: To determine whether caffeine influenced Edi or respiratory parameters of mechanically ventilated, preterm infants. Methods: Edi was measured using transcutaneous electromyography in infants Results: Sixteen infants were recruited with a gestational age of 29.1 (25.7–30.5) weeks and birthweight of 1.037(0.748–1.435) kg. Five minutes post administration the AUC of the Edi (2.48(1.69-3.17) versus baseline: 2.31(1.42-2.60) µV; p=0.011) was increased. Twenty-five minutes post administration both the amplitude of the Edi (1.59(0.92-2.52) versus baseline: 1.44(0.73-2.24) µV; p=0.022) and the AUC (2.42(1.70-2.93) µV; p=0.024) were higher than at baseline. HR increased at fifteen minutes (151.8(142.6-161.0) bpm; p=0.003) and at thirty minutes (147.9(135.3-166.9) bpm; p=0.021) compared to baseline (144.3(137.4-158.0) bpm). At 60- and 120-minutes, there were no significant changes. Conclusions: A loading dose of caffeine resulted in a temporary increase in the amplitude of Edi in ventilated, very preterm infants.

Aims: The diaphragm electromyogram (dEMG) recorded via oesophageal catheter has been used to predict extubation in adults and children. We sought to assess whether non-invasive transcutaneous measurement of dEMG could be used to predict extubation success in ventilated infants. Methods: Once the clinical team had decided the infants were ready to be extubated, the dEMG was recorded before extubation using three surface electrodes (H59P Cloth Electrodes, Kendall) and a physiological amplifier (Dipha-16, Inbiolab BV, Netherlands) transmitting to a bedside computer (PolyBench, Applied Biosignals, Germany). If infants remained extubated at 48 hours then extubation was deemed successful. Assuming a 25% failure rate, a sample size of 72 would allow detection of one standardised difference in dEMG amplitude between those who successfully extubated and those who did not. Results: 72 infants, 33 male (46%) were studied. They were born at a median gestational age (GA) of 28.4 (range 23.4 – 42.1) weeks, with birthweight (BW) 1118 (470 – 5000) grams and were studied at a postnatal age of 6 (1 – 213) days. The dEMG amplitude and area under the dEMG curve were not significantly different between those who were and were not successfully extubated. GA, BW, weight, tidal volume and the inspired oxygen concentration (FiO2) were better predictors than the amplitude or area under the dEMG curve (Table 1.) Conclusion: The surface diaphragm EMG was not a better predictor of successful extubation than readily collected clinical variables.

Administration of caffeine citrate can facilitate extubation. Our aim was to determine whether a loading dose of caffeine citrate given to ventilated, preterm infants affected the diaphragm electrical activity.Infants34 weeks of gestational age were recruited if requiring mechanical ventilation and prescribed a loading dose of caffeine citrate. Surface electrodes recorded the electrical activity of the diaphragm (dEMG) before and after administration of intravenous caffeine citrate. The mean amplitude of the EMG (dEMG) trace and the mean area under the EMG curve (aEMGc) were calculated.Thirty-two infants were assessed with a median gestational age of 29 (27-31) weeks. The dEMG amplitude increased, peaking at 25 min post administration (p = 0.006), and the increase in aEMGc (p = 0.004) peaked at 30 min; the differences were not significant after 60 min. At 20 min, there was an increase in minute volume (p = 0.034) and a reduction in the peak inspiratory pressure (p = 0.049).We have demonstrated a transient increase in both electrical activity of the diaphragm and respiratory function following an intravenous loading dose of caffeine citrate.

Aims There is increasing interest in using sustained inflations (SI) during resuscitation at delivery, particularly for prematurely-born infants. It is known that the five inflation breaths (IB) currently in use in the UK are often shorter than the recommended two to three seconds.1 The aim of the study was to determine how accurately IB and SI were delivered to a mannequin and prematurely-born infants. Methods Thirty-two doctors used a Neopuff device to deliver SIs lasting fifteen seconds and IBs to a mannequin. Sixty infants were randomised to receive SIs or IBs during stabilisation at delivery.2 An NM3 respiratory function monitor (Phillips Respironics) was used to record the duration of the SI and IB. An accurate IB was determined as between two and three seconds and an accurate SI between 14.5 and 15.5 s. Results There were no significant differences between the durations of SIs or IBs delivered to the mannequin or to infants during stabilisation at delivery or the percentage of ‘accurate’ IBs or SIs respectively (table 1). The proportion of accurate durations of IB or SI were not significantly different between ST2–3 doctors or ST6 +doctors delivered either to a mannequin or at delivery (table 2). Conclusion The accuracy of delivery of inflation breaths and sustained inflations was not significantly different when delivered to a low fidelity mannequin or during stabilisation at delivery. More experienced doctors did not outperform those with less experience. References Murthy, et al.Arch Dis Child Fetal Neonatal Ed 2012;97:F249–53. Hunt, et al. Trials 2017;18:569.

ObjectivesTo ascertain parental views regarding taking part in neonatal unit ward rounds.DesignA service evaluation project.SettingTertiary neonatal intensive care unit.PatientsParent(s) of infants receiving care on the neonatal unit.InterventionsStructured interviews conducted at the cot side.Main outcome measuresParents were asked if they knew when ward rounds occurred, whether they had attended ward rounds and if they had not what were the factors inhibiting them from doing so, their experience of attending ward rounds and whether they were concerned about issues of confidentiality.Results23 of 24 consecutive parents agreed to be interviewed. The median age of their infants was 14 (range 3 – 123) days when they were interviewed. Eighty-five per cent were able to identify when a nursing handover or doctor’s ward round occurred. Seventy-five per cent of parents had attended at least one ward round and the median score in terms of usefulness was 5 out of 5. Reasons for not attending included time and cost to travel to the unit, their partners were working and having other children. Parents volunteered that the nurses proactively updated them as soon as they arrived, hence making regular attendance less important. Regarding confidentiality, 85% were not concerned if other people overheard information about their baby, unless the news was bad.ConclusionsParents recognised the value of attending ward rounds and generally found it a positive experience, but emphasised limitations on their ability to attend.

In this article, the Group Chairs and early career members of the European Respiratory Society (ERS) Paediatric Assembly highlight some of the most interesting findings in the field of paediatrics which were presented at the 2018 international ERS Congress., The 2018 international #ERSCongress in Paris, France reflected the @ERSTalk's commitment to support the continuing professional and academic development of the 1500 members of the Paediatric Assembly. http://ow.ly/P2Ck50pDRy6

The purpose of this study is to compare the performance of dual-energy CT (DECT) with that of breast MRI for detection of silicone gel breast implant rupture and nodal spread of silicone.This prospective study enrolled consecutive patients with current or prior silicone gel implants and clinical suspicion of implant rupture or extra-capsular silicone. All patients underwent MRI followed by unenhanced DECT. A breast radiologist not participating in image evaluation established reference standards for implant rupture (intra- or extracapsular) and regional nodal silicone spread (to axillary nodes and internal mammary [IM] and mediastinal nodes) using MRI, surgical findings, and medical records. After undergoing reader training, two radiologists who were blinded to all medical records interpreted randomized images in two sessions, indicating confidence in diagnosis using a 100-point visual scale.A total of 46 patients who had a subpectoral silicone gel implant (n = 31), a subglandular silicone gel implant (n = 14), or a silicone gel implant that was removed (n = 1) underwent MRI and DECT (mean [± SD] volume CT dose index, 8.2 ± 2.0 mGy). Nineteen patients had implant rupture, and 13 of these patients had silicone within the IM or axillary nodes. Pooled data showed no significant difference between MRI and DECT interpretation of intra- or extracapsular rupture of implants (AUC value for intracapsular rupture, 0.958 [for MRI] vs 0.989 [for DECT]; p = 0.28; AUC value for extracapsular rupture, 0.864 [for MRI] vs 0.878 [for DECT]; p = 0.78). No difference was noted in the AUC value for silicone spread to regional lymph nodes: 0.823-0.866 [for MRI] vs 0.892-0.906 [for DECT]; p = 0.34-0.54).DECT performs similar to MRI for the detection of silicone gel implant rupture and the presence of silicone in regional lymph nodes, and it may be an alternative for patients who are unable or unwilling to undergo MRI.