Introduction
Mammography is one of the most technically demanding radiographic processes, and mammography quality assurance initiatives are priorities in the implementation of public health screening ...services. In the optimisation of image quality (IQ), radiographers play a major role. Between 1998 and 2009, the steering committee for mammography of a large population‐based screening service in northern Italy undertook several audit checks of the imaging facilities. In 2009, the target age range of the screening service was extended. The mammogram volume was projected to increase steeply but with no substantial increase in the radiographer workforce.
Methods
In view of the potential impact on mammographic IQ, the passive audit approach was abandoned in favour of an active radiographer‐oriented IQ review programme. Its technical basis consists of regularly repeated rounds of review of random samples of digital mammograms performed by each first‐level radiographer and by more experienced local reference radiographers, with IQ classification, followed by a training effort and a monitoring work.
Results
The mammogram volume grew from 140,822 in 2008 to 319,394 in 2014 (+127%) and then stabilised. In 2012, the proportion of mammograms with a poor IQ rose from 0.6% to 19.3%, paralleled by a substantial decrease of mammograms interpreted to have a moderate and perfect IQ. Conversely, a generalised improvement occurred in both rounds of 2016 and in the first round of 2018.
Conclusion
In the new challenging scenario, the programme proved to be effective. A successful IQ review initiative is one that encourages radiographers to participate with a positive and confident attitude.
A regional multicentre image quality review programme for mammography was developed consisting of a process of review of a sample of mammograms with image quality classification, independently performed by all first‐level radiographers and by more experienced local reference radiographers, followed by a training effort and a monitoring work. The programme places emphasis on motivating and training the radiographers and not on testing them. Its results demonstrate that a successful image quality review initiative for radiographers is one that encourages them to participate with a positive and confident attitude.
Background
Up to 10% of individuals with breast cancer (BC) belong to families with hereditary syndromes. The aim of this study was to develop an instrument to identify individuals/families at ...high‐hereditary risk for BC and offer dedicated surveillance programs according to different risks.
Methods
The instrument consisted of a primary questionnaire collecting history of BC and ovarian cancer (OC). This questionnaire was applied to women enrolled in the Emilia‐Romagna Breast Cancer Screening Program. General practitioners (GPs) and specialists could propose the same questionnaire too. Women with a score of ≥ 2, were invited to complete an oncogenetic counseling. According to the Tyrer‐Cuzick evaluation, women considered at high risk were invited to involve the most representative alive individual of the family affected with BC/OC for BRCA1/2 genetic testing.
Results
Since January 2012 and December 2016, 660 040 women were evaluated by the regional screening program, of which 22 289 (3.5%) were invited to the Spoke evaluation, but only 5615 accepted (25.2%). Totally, also considering women sent by GPs and specialists, 11 667 were assessed and 5554 were sent to the Hub evaluation. Finally, 2342 (42.8%) women fulfilled the criteria for genetic testing, and 544 (23.2%) resulted BRCA1/2 mutation carriers.
Conclusions
To our knowledge, this is the first regional population‐based multistep model that is aimed to identify individuals with BRCA1/2 mutations and to offer an intensive surveillance program for hereditary‐high risk women. This tool is feasible and effective, even if more efforts must be performed to increase the acceptance of multiple assessments by the study population.
This is, to our knowledge, the first multistep approach, including regional breast cancer screening program, general practitioners and specialists, aimed to identify individuals with BRCA1/2 mutations and to offer an intensive surveillance program for hereditary, high and intermediate risk women. Our results show that a regional population‐based model is feasible, even if more efforts have to be yielded to increase the acceptance of subsequent assessments from women at risk.
This position paper, issued by ICBR/SIRM and GISMa, summarizes the evidence on DBT and provides recommendations for its use. In the screening setting, DBT in adjunct to digital mammography (DM) ...increased detection rate by 0.5–2.7‰ and decreased false positives by 0.8–3.6% compared to DM alone in observational and double-testing experimental studies. The reduction in recall rate could be less prominent in those screening programs which already have low recall rates with DM. The increase in radiation exposure associated with DM/DBT protocols has been solved by the introduction of synthetic mammograms (sDM) reconstructed from DBT datasets. Thus, whenever possible, sDM/DBT should be preferred to DM/DBT. However, before introducing DBT as a routine screening tool for average-risk women, we should wait for the results of randomized controlled trials and for a statistically significant and clinically relevant reduction in the interval cancer rate, hopefully associated with a reduction in the advanced cancer rate. Otherwise, a potential for overdiagnosis and overtreatment cannot be excluded. Studies exploring this issue are ongoing. Screening of women at intermediate risk should follow the same recommendations, with particular protocols for women with previous BC history. In high-risk women, if mammography is performed as an adjunct to MRI or in the case of MRI contraindications, sDM/DBT protocols are suggested. Evidence exists in favor of DBT usage in women with clinical symptoms/signs and asymptomatic women with screen-detected findings recalled for work-up. The possibility to perform needle biopsy or localization under DBT guidance should be offered when DBT-only findings need characterization or surgery.
Women who were previously treated for breast cancer (BC) are an important particular subgroup of women at intermediate BC risk. Their breast follow-up should be planned taking in consideration a ...1.0–1.5 % annual rate of loco-regional recurrences and new ipsilateral or contralateral BCs during 15–20 years, and be based on a regional/district invitation system. This activity should be carried out by a Department of Radiology integrating screening and diagnostics in the context of a Breast Unit. We recommend the adoption of protocols dedicated to women previously treated for BC, with a clear definition of responsibilities, methods for invitation, site(s) of visits, methods for clinical and radiological evaluation, follow-up duration, role and function of family doctors and specialists. These women will be invited to get a mammogram in dedicated sessions starting from the year after the end of treatment. The planned follow-up duration will be at least 10 years and will be defined on the basis of patient’s age and preferences, taking into consideration organizational matters. Special agreements can be defined in the case of women who have their follow-up planned at other qualified centers. Dedicated screening sessions should include: evaluation of familial/personal history (if previously not done) for identifying high-risk conditions which could indicate a different screening strategy; immediate evaluation of mammograms by one or, when possible, two breast radiologists with possible addition of supplemental mammographic views, digital breast tomosynthesis, clinical breast examination, breast ultrasound; and prompt planning of possible further workup. Results of these screening sessions should be set apart from those of general female population screening and presented in dedicated reports. The following research issues are suggested: further risk stratification and effectiveness of follow-up protocols differentiated also for BC pathologic subtype and molecular classification, and evaluation of different models of survivorship care, also in terms of cost-effectiveness.
We analyzed the temporal (dry and rainy periods) and spatial (zones) phytoplankton biomass variation (FGs—functional groups) in a tropical reservoir, and determined the main drivers. We hypothesized ...that water flow negatively affects the FG–environment relationship because high flow promotes dispersal stochasticity. Our results indicated that the FG–environment relationship was affected mainly by the rainfall regime. Periods with intermediate precipitation showed greater predictability than periods with extreme precipitation. This suggests that the effect of stochastic processes on the phytoplankton community is more important in both the highest and lowest water flow, and deterministic processes are more important at intermediate flow. The longitudinal gradient of nutrients, light, and water-column mixing influenced the distribution of the FG biomass. The riverine zone showed high nutrient concentrations, low light availability, and a high biomass of organisms related to highly enriched systems (FG
J
—chlorophyceans) and shade-adapted taxa (FG
S1
—cyanobacteria). The lacustrine zone showed high light availability and a high biomass of heterocytous cyanobacteria (FGs
S
N
and
H1
) and meroplanktonic diatoms (FG
MP
). The functional approach can be applied to understand the processes responsible for species coexistence and for the organization of aquatic ecosystems.
•Chlorogenic acids extract-rich can be produced with coproduct of ilex paraguariensis.•Optimized anti-solvent precipitation results in 94 % encapsulation.•Thermal stability increased at 47 ºC after ...extract encapsulation.
Five tons, per hectare, of thick stems of Ilex paraguariensis are generated each harvest the external part of these (IPC) has a high concentration of chlorogenic acids but is not yet commercially exploited. Thus, it is hypothesized that the coproduct of I. paraguariensis when submitted to optimized extraction conditions will result in extracts rich in chlorogenic acids. Furthermore, optimized encapsulation by anti-solvent precipitation with zein ensures improved thermal stability. Multivariate strategies were successfully employed to obtain extraction of 10.16 g chlorogenic acids per 100 g IPC in 75 % ethanol. The mixture of IPC extract (15 mL) and zein (1.36 g) dripped (18.14 mL h−1) on the water under stirring (4 rpm) results in encapsulated with 94 % efficiency and thermal stability of up to 357.5 C. We show that it is possible to optimize the extraction of chlorogenic acids and encapsulate them in a fast and efficient way for easy industrial expansion. The high amount of chlorogenic acids and the thermal resistance of the encapsulates indicate that applications in foods exposed to heat are highly promising for the valorization of this natural resource not commercially exploited, in line with the concepts of the circular economy.
Background: Potentially inappropriate medication (PIM) use in the elderly is associated with increased risk of adverse drug reactions (ADRs), but there is limited information regarding PIM use in the ...intensive care unit (ICU) setting. Objective: The aim of the study is to describe the prevalence and factors associated with the use of PIM and the occurrence of PIM-related adverse reactions in the critically ill elderly. Methods: This study enrolled all critically ill older adults (60 years or more) admitted to medical or cardiovascular ICUs between January and December 2013, in a large tertiary teaching hospital. For all patients, clinical pharmacists listed the medications given during the ICU stay and data on drugs were analyzed using 2012 Beers Criteria, to identify the prevalence of PIM. For each identified PIM the medical records were analyzed to evaluate factors associated with its use. The frequency of ADRs and, the causal relationship between PIM and the ADRs identified were also evaluated through review of medical records. Results: According to 2012 Beers Criteria, 98.2% of elderly patients used at least one PIM (n=599), of which 24.8% were newly started in the ICUs. In 29.6% of PIMs, there was a clinical circumstance that justified their prescription. The number of PIMs was associated with ICU length of stay and total number of medications. There was at least one ADR identified in 17.8% of patients; more than 40% were attributed to PIM, but there was no statistical association. Conclusions: There is a high prevalence of PIM used in acutely ill older people, but they do not seem to be the major cause of adverse drug reactions in this population. Although many PIMs had a clinical circumstance that led to their prescription during the course of ICU hospitalization, many were still present upon hospital discharge. Therefore, prescription of PIMs should be minimized to improve the safety of elderly patients.
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