By Y. Baldar. Goddard College.
What is the performance of percutaneous image-guided breast biopsy compared with standard surgical excisional biopsy? What type of imaging guidance is best suited for breast lesions manifest as masses or as microcalcifications? Special case: biopsy of breast lesions detected on breast mag- netic resonance imaging XII 20mg cialis sublingual amex. Key Points Mammography Prospective randomized controlled trials have demonstrated reduced breast cancer mortality of approximately 30% associated with mam- mography screening (strong evidence). Women aged 40 to 54 should be screened at intervals of 12 to 18 months in order to achieve similar mortality reductions compared with women 55 years of age and older due to faster tumor growth in younger women (moderate evidence). Ultrasound Data from single center studies of screening ultrasound suggest that it has a detection benefit as a supplement to screening mammogra- phy in patients with dense (at least 50% of the breast is not fatty) breast parenchyma (moderate evidence). Reports from single-institution studies found a high percentage (91%) of breast cancers identified on supplemental screening sonography are stage I invasive cancers. Detecting this subset of breast cancers is most likely to reduce breast cancer mortality (moderate evidence). In patients with dense breast parenchyma, mammography and sonography appear complementary in that ductal carcinoma in situ (DCIS) is better depicted by mammography and small, <1cm, inva- sive breast cancers are better detected sonographically (moderate evidence). Women with dense breast parenchyma on mammography, contem- plating a supplemental sonographic screening examination, should consider the risk of a false-positive sonogram, possibly resulting in the recommendation for a breast biopsy (moderate evidence). Sonography is appropriate in the evaluation of palpable breast masses (moderate evidence). Sonography is appropriate in the evaluation of mammographically circumscribed, obscured, or indistinctly marginated masses and focal asymmetries (moderate evidence). The combination of mammography and sonography depicts 96% to 97% of palpable breast cancer and 92% of nonpalpable breast cancer (moderate evidence). Sonography can help identify the invasive component of mixed inva- sive and intraductal carcinoma and guide optimal percutaneous biopsy (limited evidence).
The rate of hippocampal volume loss measured with serial MRI exams in patients with MCI and normal elderly individu- als correlates with cognitive decline buy cialis sublingual 20mg with amex, as these individuals progress in the cognitive continuum from normal to MCI and to AD (105) (moderate evi- dence). Similarly, the decrease in whole brain volumes (106) and cerebral metabolism on PET (107) is associated with cognitive decline in patients under the genetic risk of developing AD, although the outcome of these risk groups is not known at this time (moderate evidence). Clinical rating scales and neuropsychological tests are regarded as the gold standard for assessing disease progression and therapeutic efficacy in AD. However, imaging markers may be more accurate in measuring patho- logic progression. Estimated sample sizes required to power an effective therapeutic trial (25% to 50% reduction in rate of deterioration over 1 year) in MCI indicate that the required sample sizes are substantially smaller for MRI volumetry than commonly used cognitive tests or clinical rating scales at the early stages of disease progression (108). These data support the use of MRI along with clinical and psychometric measures as surrogate markers of disease progression in AD therapeutic trials (Moderate evidence). S e n s i t i v i t y a n d s p e c i fi c i t y o f n e u r o i m a g i n g t e c h n i q u e s i n d i s t i n g u i s h i n g A l z h e i m e r d i s e a s e ( A D ) f r o m n o r m a l e l d e r l y N o. Suggested diagnostic evaluation for suspected dementia or mild cognitive impairment (MCI) Detailed clinical evaluation Structural imaging with CT or MRI PET and SPECT if the diagnosis is still uncertain Suggested Protocols Computed Tomography Imaging • CT without contrast: Axial 5- to 10-mm images should be used to assess for cerebral hemorrhage, mass effect, normal pressure hydrocephalus or calcifications. Magnetic Resonance Imaging • A scout image is acquired to ensure symmetric positioning of the brain within the field of view. Fluorodeoxyglucose–Positron Emission Tomography and Single Photon Emission Computed Tomography Imaging • Standard brain fluorodeoxyglucose (FDG)-PET and SPECT protocols can be used. Future Research Areas • Validating the clinical criteria for AD by clinicians with different levels of expertise and at different clinical settings. Chapter 8 Neuroimaging in Alzheimer Disease 157 • Determining the choice of either CT or MRI for the initial evaluation of dementia in large-scale clinical trials. Advisory Panel on Alzheimer Disease and Related Dementias: Acute and Long-Term Care Services.
There is in fact much evidence from research into medical communication showing that the following behaviours result in the effective transmission of information from doctor to patient best 20mg cialis sublingual. Adopting these behaviours means that, as a doctor, you are doing your best to ensure that your patient both hears and understands what has been said. What can we take from these two sets of principles that is directly relevant to giving presentations at meetings? Preparation Know your audience Decide what it is about your topic that you want your audience to understand. The presenter is usually in the situation of knowing a lot more about the subject than many of the people in the audience. Is the language in which you are giving your presentation your audience’s first language? Regardless of first language, will your audience have a feel for the technical/medical/scientific terminology with which you are so familiar? Above all, avoid the temptation to try to impart more information than your audience can possibly assimilate. Don’t let yourself get too anxious Anxiety on the part of either the giver or receiver can act as a barrier to effective communication. Most experienced presenters will tell you that they are always anxious before starting their talk and this does not necessarily get better over time. It is normal and can be advantageous – a certain amount of adrenaline actually 2 PRINCIPLES OF COMMUNICATION makes for a more exciting presentation. On the other hand, too much anxiety is a problem not only for the speaker but also for the audience. An audience can feel embarrassed and show more concern for the state of mind of the speaker than for what is being communicated. Rehearse your presentation An important key to anxiety reduction is to know that you are properly prepared. Not only should you be sure about what you are going to say but how long it will take to say it. This means practising your presentation, preferably in front of colleagues whom you trust and who will give you constructive feedback.
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