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BACKGROUND: Digital breast tomosynthesis (DBT) has been shown to improve screening outcomes compared with digital mammography (DM) alone. However, little is known about differences in breast cancer conspicuity between DM and DBT or by mammographic view. PURPOSE: To compare conspicuity of breast cancers at DM versus DBT and by mammographic view, craniocaudal (CC) versus mediolateral oblique (MLO). MATERIALS AND METHODS: Lesion conspicuity was graded by three readers by using a 0–5 numerical scale on both DM and DBT images from combined DM and DBT studies for 197 consecutive screening-detected cancers in women (mean age, 60.4 years ± 11.1 [standard deviation]) from October 1, 2011, through December 31, 2014. Intermodality (ie, DM vs DBT) and intramodality (ie, CC vs MLO) analyses were performed. For intramodality analyses, conspicuity was analyzed by view, CC versus MLO, within the same modality. Conspicuity grades were dichotomized into low (scores 0–3) and high (scores 4 and 5) conspicuity. This binary result was assessed by using a generalized linear mixed-effects model with logit link function, random-effect intercept for reader, and compound symmetry covariance structure for lesion. RESULTS: Cancers were more likely to be high conspicuity at DBT than at DM (odds ratio [OR], 2.4; 95% confidence interval [CI]: 1.9, 3.0; P < .01). At both DM and DBT, cancers were more likely to be high conspicuity at the CC than the MLO view (DM vs DBT OR, 1.6 [95% CI: 1.3, 1.9] vs 1.7 [95% CI: 1.3, 2.1], respectively; P < .01 for both). Cancers seen at one view only were more often detected at CC than MLO for both DM and DBT (DM vs DBT OR, 1.6 [95% CI: 1.2, 2.0] vs 3.6 [95% CI: 1.9, 7.0], respectively; P < .01.). CONCLUSION: Cancers were more conspicuous at digital breast tomosynthesis than at digital mammography. Cancers may only be detected at one of two views, and they are more likely to be seen at the craniocaudal view. © RSNA, 2019

Breast density (BD), an important risk factor for breast cancer, can change over time in some women, but the underlying mechanism is unclear. Very little is known about the impact of surgical weight loss on BD. Our hypothesis is that weight loss after bariatric surgery is associated with a significant and favorable change in mammographic BD. We identified 1097 women 40 years of age or older who underwent gastric bypass or sleeve gastrectomy at our institution from 2010 to 2014. Women who did not have either pre- and post-bariatric surgery mammograms performed at our institution were excluded; 110 had both mammograms and comprised the cohort. Breast density was determined both qualitatively, using reported BI-RADS density, and quantitatively, using the Laboratory for Individualized Breast Radiodensity Assessment. Qualitative BI-RADS density, quantitative breast area, and percent BD significantly decreased in post-bariatric surgery mammograms (p = 0.009

BACKGROUND: Breast Imaging Reporting and Data System (BI-RADS) breast density categories assigned by interpreting radiologists often influence decisions surrounding supplemental breast cancer screening and risk assessment. The landscape of mammographic screening continuously evolves, and different mammographic screening modalities may result in different perception of density, reflected in different assignment of BI-RADS density categories. PURPOSE: To investigate the effect of screening mammography modality on BI-RADS breast density assessments. MATERIALS AND METHODS: Data were retrospectively analyzed from 24 736 individual women (42.3% [10 455 of 24 736] white women, 57.7% [14 281 of 24 736] black women; mean age, 56.3 years; age range, 40.0–74.9 years) who underwent from one to seven mammographic screening examinations from September 2010 through February 2017 (60 766 examinations). Three screening modalities were used: digital mammography alone (8935 examinations); digital mammography with digital breast tomosynthesis (DBT; 30 779 examinations); and synthetic mammography with DBT (21 052 examinations). Random-effects logistic regression analysis was performed to estimate the likelihood of assignment to high versus low BI-RADS density category according to each modality, adjusted for ethnicity, age, body mass index (BMI), and radiologist. The interactions of modality with ethnicity and BMI on density categorization were also tested with the model. RESULTS: Women screened with DBT versus digital mammography alone had lower likelihood regarding categorization of high density breasts (digital mammography and DBT vs digital mammography: odds ratio, 0.69 [95% confidence interval: 0.61, 0.80], P < .001; synthetic mammography and DBT vs digital mammography: odds ratio, 0.43 [95% confidence interval: 0.37, 0.50], P < .001). Lower likelihood of high density was also observed at synthetic mammography and DBT compared with digital mammography and DBT (odds ratio, 0.62; 95% confidence interval: 0.56, 0.69; P < .001). There were interactions of modality with ethnicity (P = .007) and BMI (P = .003) on breast density assessment, with greater differences in density categorization according to modality observed for black women than for white women and groups with higher BMI. CONCLUSION: Breast density categorization may vary by screening mammographic modality, and this effect appears to vary by ethnicity and body mass index. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Philpotts in this issue.

Performance incentives for preventive care may encourage inappropriate testing, such as cancer screening for patients with short life expectancies. Defining screening colonoscopies for patients with a >50% 4-year mortality risk as inappropriate, the authors performed a pre-post analysis assessing the effect of introducing a cancer screening incentive on the proportion of screening colonoscopy orders that were inappropriate. Among 2078 orders placed by 23 attending physicians in 4 academic general internal medicine practices, only 0.6% (n = 6/1057) of screening colonoscopy orders in the preintervention period and 0.6% (n = 6/1021) of screening colonoscopy orders in the postintervention period were deemed “inappropriate.” This study found no evidence that the incentive led to an increase in inappropriate screening colonoscopy orders.

Purpose To evaluate the early implementation of synthesized two-dimensional (s2D) mammography in a population screened entirely with s2D and digital breast tomosynthesis (DBT) (referred to as s2D/DBT) and compare recall rates and cancer detection rates to historic outcomes of digital mammography combined with DBT (referred to as digital mammography/DBT) screening. Materials and Methods This was an institutional review board-approved and HIPAA-compliant retrospective interpretation of prospectively acquired data with waiver of informed consent. Compared were recall rates, biopsy rates, cancer detection rates, and radiation dose for 15 571 women screened with digital mammography/DBT from October 1, 2011, to February 28, 2013, and 5366 women screened with s2D/DBT from January 7, 2015, to June 30, 2015. Two-sample z tests of equal proportions were used to determine statistical significance. Results Recall rate for s2D/DBT versus digital mammography/DBT was 7.1% versus 8.8%, respectively (P < .001). Biopsy rate for s2D/DBT versus digital mammography/DBT decreased (1.3% vs 2.0%, respectively; P = .001). There was no significant difference in cancer detection rate for s2D/DBT versus digital mammography/DBT (5.03 of 1000 vs 5.45 of 1000, respectively; P = .72). The average glandular dose was 39% lower in s2D/DBT versus digital mammography/DBT (4.88 mGy vs 7.97 mGy, respectively; P < .001). Conclusion Screening with s2D/DBT in a large urban practice resulted in similar outcomes compared with digital mammography/DBT imaging. Screening with s2D/DBT allowed for the benefits of DBT with a decrease in radiation dose compared with digital mammography/DBT. © RSNA, 2016 An earlier incorrect version of this article appeared online. This article was corrected on August 11, 2016.

Aim To compare the utility of breast magnetic resonance imaging (MRI) in determining the extent of disease in patients with newly diagnosed breast cancer detected on combination digital breast tomosynthesis (DBT) versus digital screening mammography (DM). Materials and methods Review of 24,563 DBT-screened patients and 10,751 DM-screened patients was performed. Two hundred and thirty-five DBT patients underwent subsequent MRI examinations; 82 to determine extent of disease after newly diagnosed breast cancer. Eighty-three DM patients underwent subsequent MRI examinations; 23 to determine extent of disease. MRI examinations performed to assess disease extent were considered true positives if additional disease was discovered in the contralateral breast or >2 cm away from the index malignancy. Differences in cancer subtypes and MRI outcomes between the DM and DBT cohorts were compared using chi-squared tests and post-hoc Bonferroni-adjusted tests for equal proportions. Results No differences in cancer subtype findings were observed between the two cohorts; however, MRI outcomes were found to differ between the DBT and DM cohorts ( p= 0.024). Specifically, the DBT cohort had significantly ( p= 0.013) fewer true-positive findings (7/82, 8.5%) than did the DM cohort (7/23; 30%), whereas the false-positive rate was similar between the cohorts (not statistically significant). When stratifying by breast density, this difference in true-positive rates was primarily observed when evaluating women with non-dense breasts ( p= 0.001). Conclusion In both the DM- and DBT-screened populations with new cancer diagnoses, MRI is able to detect additional cancer; however, in those patients who have DBT screen-detected cancers the positive impact of preoperative MRI is diminished, particularly in those women with non-dense breasts.

Pseudomonas aeruginosa is one of the most common gram-negative bacterial causes of health care–acquired infections (1–3). These infections result in high morbidity and mortality rates (4,5). When serious P. aeruginosa infections are suspected, early and appropriate antimicrobial drug therapy is crucial because inadequate drug selection has been associated with increased mortality rates (6,7). Complicating the empiric selection of adequate therapy is the increasing prevalence of antimicrobial drug resistance among P. aeruginosa (8–10). Even in initially susceptible strains, resistance can rapidly develop during treatment (11–13). Cefepime, a fourth-generation cephalosphorin, is one of the few agents remaining that has reliable activity against P. aeruginosa. However, increased prevalence of resistance to cefepime among these organisms has been noted (14–18). As such, elucidating the epidemiology of cefepime-resistant P. aeruginosa is crucial to ensure that this agent remains a viable therapeutic option. Our goals were to identify risk factors for cefepime-resistant P. aeruginosa infections in the hospital setting and to describe the clinical effects of these infections.

Study objective We assess hospital readmission and death within 60 days in older adults admitted from the emergency department (ED) and discharged by an inpatient service within 24 hours. Methods This was a retrospective review of ED patients aged 64 years or older, admitted from 2 hospitals (2004 to 2006), who were discharged home within 24 hours. Excluded were inhospital deaths, observation admissions, transfers to other facilities, patients who left against medical advice, and hospice patients. Outcomes were 72-hour and 30-day readmissions and postdischarge deaths that occurred within 60 days of ED admission. Logistic regression was used to assess for predictors of readmission. A chart review of deaths after discharge was performed to assess for potential contributors to adverse outcomes. Results A total of 1,470 admissions met inclusion criteria as 1-day admissions. Of those, 22 (1.5%) patients returned for hospital readmission within 72 hours and 156 (10.6%) within 30 days of discharge. In the multivariable analysis, previous admissions (odds ratio [OR] 1.3; 95% confidence interval [CI] 1.1 to 1.4) and an admission diagnosis of heart failure (OR 2.2; 95% CI 1.0 to 5.0) were associated with 30-day readmission. In 841 individual patients with greater than or equal to one 1-day admission, there were 15 deaths (1.8%) within 60 days. Of those, 11 (73%) patients had abnormal ED ECG results, 6 (40%) were ruled out for acute myocardial infarction while hospitalized, and 3 (20%) had definitive follow-up arranged at discharge. Conclusion One-day admissions in hospitalized older adults through the ED do not represent a group at low risk for postdischarge adverse outcomes.

Objectives: Serum lactate values in the emergency department (ED) have been associated with mortality in diverse populations of critically ill patients. This study investigates whether serum lactate values measured in the ED are associated with mortality in older patients admitted to the hospital, both with and without infections. Methods: This is a retrospective cohort study performed at two urban teaching hospitals. The study population includes 1,655 older ED patients (age ≥ 65 years) over a 3-year period (2004–2006) who had serum lactate measured prior to admission. The presence or absence of infection was determined by review of International Classification of Diseases Ninth Revision (ICD-9) admission diagnosis codes. Mortality during hospitalization was determined by review of inpatient records. Mortality at 30 and at 60 days was determined using a state death registry. Results: In patients with infections, increasing serum lactate values of ≥2.0 mmol/L were linearly associated with relative risk (RR) of mortality during hospitalization (RR = 1.9 to 3.6 with increasing lactate), at 30 days (RR = 1.7 to 2.6), and at 60 days (RR = 1.4 to 2.3) when compared to patients with serum lactate levels of

Background.Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae is an emerging pathogen with serious clinical and infection control implications. To our knowledge, no study has specifically examined risk factors for KPC-producing K. pneumoniae or its impact on mortality.Methods.To identify risk factors for infection or colonization with KPC-producing K. pneumoniae, a case-control study was performed. Case patients with KPC-producing K. pneumoniae were compared with control subjects with carbapenem-susceptible K. pneumoniae. A cohort study evaluated the association between KPC-producing K. pneumoniae and in-hospital mortality.Results.Fifty-six case patients and 863 control subjects were identified. In multivariable analysis, independent risk factors for KPC-producing K. pneumoniae were (1) severe illness (adjusted odds ratio [AOR], 4.31; 95% confidence interval [CI], 2.25–8.25), (2) prior fluoroquinolone use (AOR, 3.39; 95% CI, 1.50, 7.66), and (3) prior extended-spectrum cephalosporin use (AOR, 2.55; 95% CI, 1.18, 5.52). Compared with samples from other anatomic locations, K. pneumoniae isolates from blood samples were less likely to harbor KPC (AOR, 0.33; 95% CI, 0.12, 0.86). KPC-producing K. pneumoniae was independently associated with in-hospital mortality (AOR, 3.60; 95% CI, 1.87–6.91).Conclusions.KPC-producing K. pneumoniae is an emerging pathogen associated with significant mortality. Our findings highlight the urgent need to develop strategies for prevention and infection control. Limiting use of certain antimicrobials, specifically fluoroquinolones and cephalosporins, use may be effective strategies.

To determine the validity of self-reported hepatitis B virus (HBV) and hepatitis C virus (HCV) in HIV-infected injection drug users (IDUs) vs. nonIDUs.A cross-sectional study was performed among HIV-infected IDUs and nonIDUs in the Penn Center for AIDS Research (CFAR) Database. Self-reported past HBV, HCV, and serostatus were obtained from the CFAR Database.Among 970 subjects (798 nonIDUs; 172 IDUs), there was no difference in sensitivity of self-reported HBV between nonIDUs (27% [95/346]; 95% CI, 23%-32%) and IDUs (26% [31/117]; 95% CI, 19%-35%; P0.5), but specificity was greater among nonIDUs (96% [360/374; 95% CI, 94%-98%] vs. 78% [28/36; 95% CI, 61%-90%]; P0.001). Sensitivity of self-reported HCV was greater among IDUs (78% [101/130; 95% CI, 70%-85%] vs. 62% [47/76; 95% CI, 50%-73%]; P=0.02), but there was no difference in specificity (97% [626/643]; 95% CI, 96%-98% for nonIDUs vs. 93% [26/28]; 95% CI, 76%-99%] for IDUs; P=0.2).The sensitivity of self-reported HBV and HCV compared to actual serostatus are not sufficiently high enough to warrant their use to estimate the prevalence and incidence of these infections.

Baseline mammography studies have significantly higher recall rates than mammography studies with available comparison examinations. Digital breast tomosynthesis reduces recalls when compared with digital mammographic screening alone, but many sites operate in a hybrid environment. To maximize the effect of screening digital breast tomosynthesis with limited resources, choosing which patient populations will benefit most is critical. This study evaluates digital breast tomosynthesis in the baseline screening population.Outcomes were compared for 10,728 women who underwent digital mammography screening, including 1204 (11.2%) baseline studies, and 15,571 women who underwent digital breast tomosynthesis screening, including 1859 (11.9%) baseline studies. Recall rates, cancer detection rates, and positive predictive values were calculated. Logistic regression estimated the odds ratios of recall for digital mammography versus digital breast tomosynthesis for patients undergoing baseline screening and previously screened patients, adjusted for age, race, and breast density.In the baseline subgroup, recall rates for digital mammography and digital breast tomosynthesis screening were 20.5% and 16.0%, respectively (p = 0.002); digital breast tomosynthesis screening in the baseline subgroup resulted in a 22% reduction in recall compared with digital mammography, or 45 fewer patients recalled per 1000 patients screened. Digital breast tomosynthesis screening in the previously screened patients resulted in recall reduction of 14.3% (p0.001; p for interaction = 0.21). The recall rate reduction for baseline screening was especially pronounced in women younger than 50 years (p = 0.005). DBT implementation resulted in an increase in cancer detection in the baseline subgroup of 40.5% versus an increase in the previously screened subgroup of 17.4%. DBT implementation resulted in an increase in PPV1 in the baseline subgroup of 85% versus 35.3% in the previously screened subgroup, although the p-interaction was not significant.If resources are limited, women younger than 50 years who are undergoing baseline screening or do not have prior available mammograms may benefit more from digital breast tomosynthesis than from digital mammography alone.

BACKGROUND Incidence of cutaneous melanoma continues to increase in the Caucasian population worldwide. Approximately 5% of melanoma patients develop additional primary melanoma. This rate is significantly higher than the estimated lifetime risk of an individual for developing the disease (1.4%). These features suggest that a genetic predisposition may underlie multiple primary melanomas (MPMs). Prior studies had identified CDKN2A mutations in a few MPM individuals. The objectives of this study were to determine the frequency of family history of melanoma in MPM cases, to characterize other clinical features including history of other cancer, and to determine the association with functional CDKN2A mutations. METHODS This study used a case series design. All living patients who had been seen in the Pigmented Lesion Clinic at the University of Pennsylvania and who had more than one primary invasive malignant melanoma or an invasive primary followed by an in situ melanoma were eligible for participation. RESULTS Individuals with MPM frequently had a family history of melanoma, dysplastic nevi (DN), and/or another cancer including basal cell carcinoma (BCC), and squamous cell carcinoma breast cancer, and a personal history of DN, and basal cell carcinoma. Germline mutations in CDKN2A gene were identified in 8 of 96 MPM cases (8.3%, 95% confidence interval, 6.7–9.9%). CONCLUSIONS These data indicate that the presence of MPM is associated with a modest incidence of a family history of melanoma, DN, or BCC and a small association with CDKN2A mutations. Therefore, in addition to the MPM index case, other family members can benefit from screening and regular surveillance for melanoma, DN, and BCC. Cancer 2002;94:2248–55. © 2002 American Cancer Society. DOI 10.1002/cncr.10454

Purpose To assess indication for examination for four breast imaging modalities and describe the complexity and heterogeneity of data sources and ascertainment methods. Methods Indication was evaluated among the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) breast cancer research centers (PRCs). Indication data were reported overall and separately for four breast imaging modalities: digital mammography (DM), digital breast tomosynthesis (DBT), ultrasound (US), and magnetic resonance imaging (MRI). Results The breast PRCs contributed 236,262 women with 607,735 breast imaging records from 31 radiology facilities. We found a high degree of heterogeneity for indication within and across six data sources. Structured codes within a data source were used most often to identify indication for mammography (59% DM, 85% DBT) and text analytics for US (45%) and MRI (44%). Indication could not be identified for 17% of US and 26% of MRI compared with 2% of mammography examinations (1% DM, 3% DBT). Conclusions Multiple and diverse data sources, heterogeneity of ascertainment methods, and nonstandardization of codes within and across data systems for determining indication were found. Consideration of data sources and standardized methodology for determining indication is needed to assure accurate measurement of cancer screening rates and performance in clinical practice and research.

Screening mammography, despite ongoing controversy regarding its risk-benefit ratio, remains the mainstay of early breast cancer detection (1,2). Digital breast tomosynthesis (DBT), a relatively new x-ray technology (3,4) that images the breast in 3-D, has shown promise in addressing some limitations of conventional mammography by alleviating the effect of superimposed structures that can lead to erroneous interpretations (5–8). This new technology is increasingly implemented in breast clinics across the country, despite relatively little data on its clinical outcomes and effectiveness in specific patient populations (9). Early enthusiasm for DBT is based mostly on retrospective reader studies that compared DBT combined with digital mammography (DM) imaging vs DM alone. These studies demonstrated reductions of up to 30% to 40% in false-positives, with similar or slightly improved cancer detection (6,10–12). In the United States, Food and Drug Administration (FDA) approval was granted to a single vendor in 2011 (Hologic, Inc., Bedford, MA) based on a large multicenter retrospective reader study that demonstrated statistically significant improvement in performance when DBT was combined with DM (13,14). More recently, two prospective European trials have also shown improvements in screening outcomes with DBT. An interim analysis from the Oslo Screening Trial (n = 12631) and the final results from the Italian Screening with Tomosynthesis or Standard Mammography Trial (STORM, n = 7292) have demonstrated reductions in recalls of 15% to 17% and improvements in cancer detection of 33% to 53% (15,16). Furthermore, in the Oslo trial there was a 40% increase in the detection of invasive cancers with a stable rate of in situ cancer detection. However, in both of these trials subject compliance with screening invitations was less than 100%, and there were complex reading protocols requiring at least two readers per case, which is uncommon in clinical practices in the United States. More recently, two separate US centers have reported early results from DBT screening (17,18). These data again demonstrate improvements in outcomes with reductions in recalls up to 37% and increases in cancer detection up to 35%. At both sites, however, there was concurrent screening with DM alone and, therefore, a potential for bias in the selection of patients screened with DBT and potentially imaged with DBT at recall. In a recent report from a consortium of 13 US practices, a 15% reduction in recall rate and a 29% increase in cancer detection were seen with DBT screening compared with DM alone screening. However, no patient-level data was reported, and eleven of the thirteen sites had concurrent DM screening, leading to possible biases in selection of patients for DBT (19). Here we report the patient-level outcomes of implementing DBT screening for the entire screening population at our institution beginning October 2011. We compare outcomes for the cohort screened with DBT over a period of 17 months to the cohort screened with DM alone during the 12 months prior to DBT implementation. All women presenting for routine screening were imaged with DBT after its implementation, and radiologist readers remained the same over the DM and DBT cohorts, providing a “pre and post” comparison of DBT to DM-alone screening.

Breast cancer screening with digital breast tomosynthesis (DBT) combined with digital mammography (DM) decreases false-positive examinations and increases cancer detection compared with screening with DM alone. However, the longitudinal performance of DBT screening is unknown.To determine whether the improved outcomes observed after initial implementation of DBT screening are sustainable over time at a population level and to evaluate the effect of more than 1 DBT screening at the individual level.Retrospective analysis of screening mammography metrics was performed for all patients presenting for screening mammography in an urban, academic breast center during 4 consecutive years (DM, year 0; DBT, years, 1-3). The study was conducted from September 1, 2010, to September 30, 2014 (excluding September 2011, which was the transition period from DM to DBT), for a total of 44 468 screening events attributable to a total of 23 958 unique women. Differences in screening outcomes between each DBT year and the DM year, as well as between groups of women with only 1, 2, or 3 DBT screenings, were assessed, and the odds of recall adjusted for age, race/ethnicity, breast density, and prior mammograms were estimated. Data analysis was performed between February 16 and October 26, 2015.Digital mammography screening supplemented with DBT.Recall rates, cancer cases per recalled patients, and biopsy and interval cancer rates were determined.Screening outcome metrics were evaluated for a total of 44 468 examinations attributable to 23 958 unique women (mean [SD] age, 56.8 [11.0] years) over a 4-year period: year 0 cohort (DM0), 10 728 women; year 1 cohort (DBT1), 11 007; year 2 cohort (DBT2), 11 157; and year 3 cohort (DBT3), 11 576. Recall rates rose slightly for years 1 to 3 of DBT (88, 90, and 92 per 1000 screened, respectively) but remained significantly reduced compared with the DM0 rate of 104 per 1000 screened. Reported as odds ratios (95% CIs), the findings were DM vs DBT1, 0.83 (0.76-0.91, P .001); DM vs DBT2, 0.85 (0.78-0.93, P .001); and DM vs DBT3, 0.87 (0.80-0.95, P = .003). The cancer cases per recalled patients continued to rise from DM0 rate of 4.4% to 6.2% (P = .06), 6.5% (P = .03), and 6.7% (P = .02) for years 1 to 3 of DBT, respectively. Outcomes assessed for the most recent screening for individual women undergoing only 1, 2, or 3 DBT screenings during the study period demonstrated decreasing recall rates of 130, 78, and 59 per 1000 screened, respectively (P .001). Interval cancer rates, determined using available follow-up data, decreased from 0.7 per 1000 women screened with the use of DM to 0.5 per 1000 screened with the use of DBT1.Digital breast tomosynthesis screening outcomes are sustainable, with significant recall reduction, increasing cancer cases per recalled patients, and a decline in interval cancers.

Background: Increased breast density is a strong risk factor for breast cancer and also decreases the sensitivity of mammographic screening. The purpose of our study was to compare breast density for black and white women using quantitative measures. Methods: Breast density was assessed among 5282 black and 4216 white women screened using digital mammography. Breast Imaging-Reporting and Data System (BI-RADS) density was obtained from radiologists’ reports. Quantitative measures for dense area, area percent density (PD), dense volume, and volume percent density were estimated using validated, automated software. Breast density was categorized as dense or nondense based on BI-RADS categories or based on values above and below the median for quantitative measures. Logistic regression was used to estimate the odds of having dense breasts by race, adjusted for age, body mass index (BMI), age at menarche, menopause status, family history of breast or ovarian cancer, parity and age at first birth, and current hormone replacement therapy (HRT) use. All statistical tests were two-sided. Results: There was a statistically significant interaction of race and BMI on breast density. After accounting for age, BMI, and breast cancer risk factors, black women had statistically significantly greater odds of high breast density across all quantitative measures (eg, PD nonobese odds ratio [OR] = 1.18, 95% confidence interval [CI] = 1.02 to 1.37, P = .03, PD obese OR = 1.26, 95% CI = 1.04 to 1.53, P = .02). There was no statistically significant difference in BI-RADS density by race. Conclusions: After accounting for age, BMI, and other risk factors, black women had higher breast density than white women across all quantitative measures previously associated with breast cancer risk. These results may have implications for risk assessment and screening.

Background & Aims In the United States, the use of abdominopelvic computed tomography (APCT) by emergency departments for patients with abdominal pain has increased, despite stable admission rates and diagnosis requiring urgent intervention. We proposed that trends would be similar for patients with Crohn's disease (CD). Methods We conducted a retrospective study of data from 648 adults with CD who presented at 2 emergency departments (2001–2009; 1572 visits). Trends in APCT use were assessed with Spearman correlation coefficient. We compared patient characteristics and APCT findings during 2001–2003 and 2007–2009. Results APCT use increased from 2001 (used for 47% of encounters) to 2009 (used for 78% of encounters; P = .005), whereas admission rates were relatively stable at 68% in 2001 and 71% in 2009 ( P = .06). The overall proportion of APCTs with findings of intestinal perforation, obstruction, or abscess was 29.0%; 34.9% of APCTs were associated with urgent diagnoses, including those unrelated to CD. Between 2001–2003 and 2007–2009, the proportions of APCTs that detected intestinal perforation, obstruction, or abscess were similar (30% vs 29%, P = .92), as were the proportions used to detect any diagnosis requiring urgent intervention, including those unrelated to CD (36% vs 34%, P = .91). Conclusions Despite the increased use of APCT by emergency departments for patients with CD, there were no significant changes in admission rates between the periods of 2001–2003 and 2007–2009. The proportion of APCTs that detected intestinal perforation, obstruction, abscess, or other urgent conditions not related to CD remained high.

Background : Dysplastic nevi are markers of melanoma risk and potential precursors of melanoma. Few studies have addressed the natural history of dysplastic nevi. Objective : Our purpose was to describe the changes observed in nevi over time in a cohort of our patients with dysplastic nevi. Methods : We used a historical cohort design to study 153 patients with dysplastic nevi observed for a minimum of 5 years. Physical examination at completion of the study was compared with baseline overview and close-up photographs. Lesions excised during the study interval were assessed for history of change. Results : Fifty one percent of all evaluated nevi (297 of 593) showed clinical signs of change during an average follow-up of 89 months. New nevi were common in adulthood and continued to form in more than 20% of patients older than 50 years of age. Nevi were observed to become more clinically atypical, less clinically atypical, and disappear in all age groups. In this small cohort rates of nevus change were not correlated with personal or family history of melanoma, sex, or total number of nevi. Total nevus counts and rates of nevus change were correlated with age. Conclusion : Dysplastic nevi remain clinically dynamic in adulthood. Our data suggest that the decrease in counts of dysplastic nevi associated with increasing age is only partly explained by the disappearance of nevi over time and probably reflects a tendency to larger numbers of nevi among more recent birth cohorts.

A historical cohort of 153 patients with dysplastic nevi was studied for the development of melanoma. Each subject had a minimum follow-up of 5 years, with an average study follow-up of 94 months. Eleven new melanomas developed in 11 patients between 11 and 143 months (average 61 months) into the study period. Age-adjusted melanoma incidence in the cohort was 692/100,000 person years. Development of melanoma was strongly correlated with prior personal and/ or family history of melanoma. Even among the 89 patients with no personal or family history of melanoma, the age-adjusted incidence of melanoma was an alarming 154/100,000 person years. Within this small, non-randomly ascertained cohort no association could be discerned between melanoma incidence and total number of banal or dysplastic nevi. These findings support the public health significance of the recognition of dysplastic nevi and confirm the importance of family history in evaluating melanoma risk associated with dysplastic nevi.

Two-hundred and seven patients without evidence of disease following lymph node dissection (LND) were stratified into three groups: Group A, lymph node relapse within the site of prior LND; Group B, lymph node relapse in a different, but regional, lymph node group; Group C, no lymph node relapse. Decreased survival was noted in both Groups A and B versus Group C. Prognostic factors were identified as: (i) axial or subungal/volar (subvolar) location and the number of positive lymph nodes at initial LND for nodal relapse within the same lymph node group; (ii) male gender, axial/subvolar location, and the number of histologically positive lymph nodes at initial LND for nodal relapse in a different, but regional lymph node group; (iii) relapse within the initial LND site for a decreased survival. Six of 10 patients with both axial/subvolar primaries and four or more positive lymph nodes developed a relapse within the dissection site post-LND. These prognostic factors describe a subset of patients who would be candidates for postoperative adjuvant local/regional and systemic therapy trials.

Background.Pseudomonas aeruginosa is one of the most common gram-negative hospital-acquired pathogens. Resistance of this organism to imipenem complicates treatment.Objective.To elucidate the risk factors for imipenem-resistant P. aeruginosa (IRPA) infection or colonization and to identify the effect of resistance on clinical and economic outcomes.Methods.Longitudinal trends in prevalence of IRPA from 2 centers were characterized during the period from 1989 through 2006. For P. aeruginosa isolates obtained during the period from 2001 through 2006, a case-control study was conducted to investigate the association between prior carbapenem use and IRPA infection or colonization, and a cohort study was performed to identify the effect of IRPA infection or colonization on mortality, length of stay after culture, and hospital cost after culture.Results.From 1989 through 2006, the proportion of P. aeruginosa isolates demonstrating resistance to imipenem increased from 13% to 20% (P< .001, trend). During the period from 2001 through 2006, there were 2,542 unique patients with P. aeruginosa isolates, and 253 (10.0%) had IRPA isolates. Prior carbapenem use was independently associated with IRPA infection or colonization (adjusted odds ratio [OR], 7.92 [95% confidence interval {CI}, 4.78-13.11]). Patients with an IRPA isolate recovered had higher in-hospital mortality than did patients with an imipenem-susceptible P. aeruginosa isolate (17.4% vs 13.4%; P = .01). IRPA infection or colonization was an independent risk factor for mortality among patients with isolates recovered from blood (adjusted OR, 5.43 [95% CI, 1.72-17.10]; P = .004) but not among patients with isolates recovered from other anatomic sites (adjusted OR, 0.78 [95% CI, 0.51-1.21]; P = .27). Isolation of IRPA was associated with longer hospital stay after culture (PPP = .02) and greater hospital cost after culture (coefficient, 0.30 [95% CI, 0.06-0.54]; P = .02).Conclusions.The prevalence of IRPA infection or colonization has increased significantly, with important implications for both clinical and economic outcomes. Interventions to curb this continued increase and strategies to optimize therapy are urgently needed.

Background.Acinetobacter baumannii is an emerging gram-negative pathogen that can cause healthcare-acquired infections among patients. Treatment is complicated for cases of healthcare-acquired infection with A. baumannii resistant to imipenem.Objective.To elucidate the risk factors for imipenem-resistant A. baumannii (IRAB) infection or colonization and to identify the effect of resistance on clinical and economic outcomes.Methods.We analyzed data from 2 medical centers of the University of Pennsylvania. Longitudinal trends in the prevalence of IRAB clinical isolates were characterized during the period from 1989 through 2004. For A. baumannii isolates obtained from 2001 through 2006, a case-control study was conducted to investigate the association between prior carbapenem use and IRAB infection or colonization, and a cohort study was performed to identify the effect of IRAB infection or colonization on mortality, length of stay after culture, and hospital cost after culture.Results.From 1989 through 2004, the annual prevalence of IRAB isolates ranged from 0% to 21%. During the period from 2001 through 2006, there were 386 unique patients with A. baumannii isolates, and 89 (23.1%) had IRAB isolates. Prior carbapenem use was independently associated with IRAB infection or colonization (adjusted odds ratio, 3.04 [95% confidence interval, 1.07–8.65]). There was a borderline significant association between IRAB infection or colonization and mortality, although this association was limited to isolates recovered from blood samples (adjusted odds ratio, 5.30 [95% confidence interval, 0.81–34.59]). Compared with patients with imipenem-susceptible A. baumannii infection or colonization, patients with IRAB infection or colonization had a longer hospital stay after culture (median, 21 vs 16 days; P = .07) and greater hospital charges after culture (mean, $334,516 vs $276,059; P = .03). After controlling for patient location in an intensive care unit, transfer from another facility, and length of hospital stay before culture, there was no longer an independent association between IRAB infection or colonization and higher cost after culture and length of stay after positive culture result.Conclusions.Many A. baumannii isolates exhibit imipenem resistance, which is strongly associated with prior use of carbapenems. Given the high mortality rate associated with A. baumannii infection or colonization, interventions to curb further emergence of cases of IRAB infection and strategies to optimize therapy are needed.

Candida species are the fourth leading cause of health care–associated bloodstream infections (BSIs) and are associated with significant morbidity and mortality.1–3 In the United States, there has been a notable shift in the epidemiology of Candida BSIs. Bloodstream infections caused by Candida albicans have dramatically decreased, and there has been a concomitant increase in certain non–C albicans species, in particular, Candida glabrata.4–7 Historically, fluconazole has been the treatment of choice for Candida-related BSIs. However, unlike BSIs caused by C albicans, which are almost always fluconazole-susceptible, C glabrata BSIs are often associated with fluconazole resistance. The emergence of fluconazole-resistant C glabrata BSIs has had important implications because therapy requires higher doses of fluconazole or the use of other antifungal agents such as echinocandins or polyenes.8 Fluconazole use has been hypothesized as an important risk factor in the emergence of C glabrata infections. Resistance could be induced either by promoting the development of 1 or more resistance mechanisms including upregulating efflux pumps of the adenosine triphosphate–binding cassette transporter family or by altering patient endogenous flora, enabling colonization and subsequent infection with fluconazole-resistant C glabrata.9,10 Although biological plausibility exists, previous studies have reported conflicting results.11–15 One limitation of those studies is the absence of susceptibility testing to differentiate fluconazole-resistant from fluconazole-susceptible C glabrata even though resistance is the main concern with C glabrata. We therefore conducted this case-case-control study, which, to our knowledge, is the first to evaluate independent risk factors for BSIs caused by fluconazole-resistant C glabrata.

Background: Occult hepatitis B virus (HBV) is defined by the presence of HBV DNA in individuals with HBV core antibodies (anti-HBc) but without HBV surface antigen (HBsAg). The prevalence of occult HBV in HIV-infected patients remains controversial, and the risk factors and clinical significance are unknown. Objectives: To determine the prevalence, risk factors, and clinical significance of occult HBV among HIV-infected patients. Hypothesized risk factors include chronic hepatitis C virus (HCV), CD4 count 1000 copies/mL, and lack of use of anti-HBV antiretrovirals. Methods: We examined randomly selected HBsAg - /anti-HBC HIV-infected patients in the Penn Center for AIDS Research Adult/Adolescent Database and Specimen Repository. HBV DNA was qualitatively detected using a transcription-mediated amplification assay. Risk factors and transaminases were ascertained at the time sera were collected. Results: A total of 699 HBsAg - /anti-HBc + HIV-infected patients were identified. Of 179 randomly selected subjects, 17 (10%; 95% confidence interval [CI]: 5% to 14%) had occult HBV Differences in the prevalence of HBV surface antibody (anti-HBs) between those with (7 [41%]) and without (94 [58%]) occult HBV were not statistically significant (P = 0.3). An HIV RNA level >1000 copies/mL (adjusted odds ratio [OR] = 4.88, 95% CI: 1.01 to 30.26) and the absence of chronic HCV (adjusted OR = 0.26, 95% CI: 0.05 to 0.95) were associated with occult HBV Occult HBV did not increase the risk of transaminitis (adjusted OR = 0.42, 95% CI: 0.12 to 1.45). Conclusions: Occult HBV occurred in a sizable proportion of HIV-infected patients and was associated with detectable HIV and the absence of chronic HCV It did not increase the risk of transaminitis. The presence of anti-HBs does not rule out occult HBV Future studies should examine the long-term clinical implications of occult HBV in HIV-infected patients.

Obesity and HIV infection are ongoing epidemics in the United States. Obesity predisposes to diabetes and cardiovascular disease, which are complications also associated with HIV and/or its treatment.To determine the prevalence and risk factors for overweight and obesity in HIV-infected individuals.Retrospective cross-sectional study in which 1689 patients enrolled in the University of Pennsylvania Center for AIDS Research Adult/Adolescent Database at 1 university hospital clinic, 2 affiliated practices, and 1 Veterans Administration clinic in Philadelphia had demographic, social, and medical data collected prospectively since 1999.Body mass index (BMI) data were available for 1669 HIV-infected subjects: 78% were men, and 60% were African American. The median CD4 count was 381 cells/microL, 47% of subjects had a viral load400 copies/mL, and 9% of subjects were treatment naive.The prevalence and risk factors for overweight (BMI: 25-29.9 kg/m) and obesity (BMIor=30 kg/m) in HIV-infected subjects.Obesity and overweight were more prevalent than wasting (14%, 31%, and 9%, respectively; P0.0005), but they were not more common than in the general population. Although women and men were equally overweight (30% vs. 31%), women were more obese than men (28% vs. 11%; P0.001). Among women, African American race (odds ratio [OR]=1.8, 95% confidence interval [CI]: 1.1-2.9) and a CD4 countor=200 cells/microL (OR=2.8, 95% CI: 1.6-4.9) were associated with overweight and obesity. Among men, only a CD4 countor=200 cells/microL (OR=1.6, 95% CI: 1.04-2.4) was associated with increased BMI. In men and women, smoking was associated with decreased obesity and overweight (OR=0.59, 95% CI: 0.47-0.74 and OR=0.65, 95% CI: 0.43-0.98, respectively). Age, income, employment, education, past or current intravenous drugs, being on HIV treatment, and viral load were not associated with obesity in the multivariate model. There was a positive correlation between BMI and total cholesterol, triglycerides, and glucose.Obesity is more common than wasting in this therapeutic era. Women, particularly those of African American race, are at high risk. Obesity might add to metabolic abnormalities associated with HIV or its treatment and contribute to morbidity, as patients with HIV live longer.

We conducted a descriptive study to assess the relationship between increasing age and the reporting of melanoma signs/symptoms in 634 hospital-based and 624 population-based incident cases of melanoma. Multivariate logistic regression was used to evaluate the relationship between older age (> or = 50 years) and the reporting of melanoma signs/symptoms. Older patients were less likely to report itching and change in elevation of their lesions (P < 0.05). Change in color was also less likely to be reported by older patients, although not statistically significant. Ulceration of the lesion was reported significantly more by older patients (P < 0.05). Older individuals may be less likely to report itching and change in elevation/color of their lesions, but more likely to report ulceration, a symptom associated with advanced disease and poor prognosis. Further research is necessary to provide a better understanding of the development of melanoma in older populations so that new strategies can be explored to improve early detection in this age group.

A retrospective review of 552 patients with clinical stage I primary cutaneous malignant melanomas was undertaken comparing margins of resection and local recurrence between 1966 and 1981. The overall local recurrence rate was 8 per 552 (1.45 percent). We observed no instances of local recurrence in lesions less than 1.40 mm thick with resection margins of at least 1 cm. A comparison of resection margins greater than 2 cm versus less than 2 cm for lesions less than 1.00 mm thick showed no difference at the 0.05 level of significance for local recurrence (0 per 228 versus 2 per 154; 1.3 percent) or survival. While narrower margins of resection for thinner, low-risk stage I malignant melanomas appear safe, the exact minimum margin of resection needed to satisfy both oncologic and cosmetic considerations, whether 1 or 2 cm, will need to be determined by a large prospective, randomized study.

We used the lesional steps in tumor progression and multivariable logistic regression to develop a prognostic model for primary, clinical stage I cutaneous melanoma. This model is 89% accurate in predicting survival. Using histologic criteria, we assigned melanomas to tumor progression steps by ascertaining their particular growth phase. These phases were the in situ and invasive radial growth phase and the vertical growth phase (the focal formation of a dermal tumor nodule or dermal tumor plaque within the radial growth phase or such dermal growth without an evident radial growth phase). After a minimum follow-up of 100.6 months and a median follow-up of 150.2 months, 122 invasive radial-growth-phase tumors were found to be without metastases. Eight-year survival among the 264 patients whose tumors had entered the vertical growth phase was 71.2%. Survival prediction in these patients was enhanced by the use of a multivariable logistic regression model. Twenty-three attributes were tested for entry into this model. Six had independently predictive prognostic information: (a) mitotic rate per square millimeter, (b) tumor-infiltrating lymphocytes, (c) tumor thickness, (d) anatomic site of primary melanoma, (e) sex of the patient, and (f) histologic regression. When mitotic rate per square millimeter, tumor-infiltrating lymphocytes, primary site, sex, and histologic regression are added to a logistic regression model containing tumor thickness alone, they are independent predictors of 8-year survival (P less than .0005).