Rescuing the Clinical Breast Examination: Advances in Classifying Technique and Assessing Physician Competency.
ABSTRACT: Develop new performance evaluation standards for the clinical breast examination (CBE).There are several, technical aspects of a proper CBE. Our recent work discovered a significant, linear relationship between palpation force and CBE accuracy. This article investigates the relationship between other technical aspects of the CBE and accuracy.This performance assessment study involved data collection from physicians (n = 553) attending 3 different clinical meetings between 2013 and 2014: American Society of Breast Surgeons, American Academy of Family Physicians, and American College of Obstetricians and Gynecologists. Four, previously validated, sensor-enabled breast models were used for clinical skills assessment. Models A and B had solitary, superficial, 2?cm and 1?cm soft masses, respectively. Models C and D had solitary, deep, 2?cm hard and moderately firm masses, respectively. Finger movements (search technique) from 1137 CBE video recordings were independently classified by 2 observers. Final classifications were compared with CBE accuracy.Accuracy rates were model A = 99.6%, model B = 89.7%, model C = 75%, and model D = 60%. Final classification categories for search technique included rubbing movement, vertical movement, piano fingers, and other. Interrater reliability was (k = 0.79). Rubbing movement was 4 times more likely to yield an accurate assessment (odds ratio 3.81, P < 0.001) compared with vertical movement and piano fingers. Piano fingers had the highest failure rate (36.5%). Regression analysis of search pattern, search technique, palpation force, examination time, and 6 demographic variables, revealed that search technique independently and significantly affected CBE accuracy (P < 0.001).Our results support measurement and classification of CBE techniques and provide the foundation for a new paradigm in teaching and assessing hands-on clinical skills. The newly described piano fingers palpation technique was noted to have unusually high failure rates. Medical educators should be aware of the potential differences in effectiveness for various CBE techniques.
Project description:Apart from texture, the human finger can sense palpation. The detection of an imbedded structure is a fine balance between the relative stiffness of the matrix, the object, and the device. If the device is too soft, its high responsiveness will limit the depth to which the imbedded structure can be detected. The sensation of palpation is an effective procedure for a physician to examine irregularities. In a clinical breast examination (CBE), by pressing over 1 cm(2) area, at a contact pressure in the 70-90 kPa range, the physician feels cancerous lumps that are 8- to 18-fold stiffer than surrounding tissue. Early detection of a lump in the 5-10 mm range leads to an excellent prognosis. We describe a thin-film tactile device that emulates human touch to quantify CBE by imaging the size and shape of 5-10 mm objects at 20 mm depth in a breast model using ?80 kPa pressure. The linear response of the device allows quantification where the greyscale corresponds to the relative local stiffness. The (background) signal from <2.5-fold stiffer objects at a size below 2 mm is minimal.
Project description:BACKGROUND:This study explores the long-term effectiveness of a newly developed clinical skills curriculum. METHODS:Students (N = 40) were exposed to a newly developed, simulation-based, clinical breast exam (CBE) curriculum. The same students returned one year later to perform the CBE and were compared to a convenience sample of medical students (N = 15) attending a national conferences. All students were given a clinical vignette and performed the CBE. CBE techniques were video recorded. Chi-squared tests were used to assess differences in CBE technique. RESULTS:Students exposed to a structured curriculum performed physical examination techniques more consistent with national guidelines than the random, national student sample. Structured curriculum students were more organized, likely to use two hands, a linear search pattern, and include the nipple-areolar complex during the CBE compared to national sample (p < 0.01). CONCLUSIONS:Students exposed to a structured skills curriculum more consistently performed the CBE according to national guidelines. The variability in technique compared with the national sample of students calls for major improvements in adoption and implementation of structured skills curricula.
Project description:Skilled piano performance requires considerable movement control to accomplish the high levels of timing and force precision common among professional musicians, who acquire piano technique over decades of practice. Finger movement efficiency in particular is an important factor when pianists perform at very fast tempi. We document the finger movement kinematics of highly skilled pianists as they performed a five-finger melody at very fast tempi. A three-dimensional motion-capture system tracked the movements of finger joints, the hand, and the forearm of twelve pianists who performed on a digital piano at successively faster tempi (7-16 tones/s) until they decided to stop. Joint angle trajectories computed for all adjacent finger phalanges, the hand, and the forearm (wrist angle) indicated that the metacarpophalangeal joint contributed most to the vertical fingertip motion while the proximal and distal interphalangeal joints moved slightly opposite to the movement goal (finger extension). An efficiency measure of the combined finger joint angles corresponded to the temporal accuracy and precision of the pianists' performances: Pianists with more efficient keystroke movements showed higher precision in timing and force measures. Keystroke efficiency and individual joint contributions remained stable across tempo conditions. Individual differences among pianists supported the view that keystroke efficiency is required for successful fast performance.
Project description:Vietnamese-American women underutilize breast cancer screening.An RCT was conducted comparing the effect of lay health workers (LHWs) and media education (ME) to ME alone on breast cancer screening among these women.Conducted in California from 2004 to 2007, the study included 1100 Vietnamese-American women aged > or = 40 years who were recruited through LHW social networks. Data were analyzed from 2007 to 2009.Both groups received targeted ME. The intervention group received two LHW educational sessions and two telephone calls.Change in self-reported receipt of mammography ever, mammography within 2 years, clinical breast examination (CBE) ever, or CBE within 2 years.The LHW+ME group increased receipt of mammography ever and mammography in the past 2 years (84.1% to 91.6% and 64.7% to 82.1%, p<0.001) while the ME group did not. Both ME (73.1% to 79.0%, p<0.001) and LHW+ME (68.1% to 85.5%, p<0.001) groups increased receipt of CBE ever, but the LHW+ME group had a significantly greater increase. The results were similar for CBE within 2 years. In multivariate analyses, LHW+ME was significantly more effective than ME for all four outcomes, with ORs of 3.62 (95% CI=1.35, 9.76) for mammography ever; 3.14 (95% CI=1.98, 5.01) for mammography within 2 years; 2.94 (95% CI=1.63, 5.30) for CBE ever; and 3.04 (95% CI=2.11, 4.37) for CBE within 2 years.Lay health workers increased breast cancer screening among Vietnamese-American women.Future research should focus on how LHWs work and whether LHW outreach can be disseminated to other ethnic groups [corrected].
Project description:Mammogram-detected breast cancers have a better prognosis than those identified through clinical breast exam (CBE) or through self-detection, primarily because tumors detected by mammography are more likely to be smaller and do not involve regional nodes. In a sample of 1,322 Black women, aged 40-75 years, diagnosed with breast cancer between 2002 and 2016, we evaluated factors associated with CBE and self-detection versus screening mammogram as the initial mode of breast cancer detection, using multivariable logistic regression models. Compared with screening mammogram, history of routine screening mammogram (OR 0.20, 95% CI: 0.07, 0.54) and performance of breast self-examination (BSE) (OR 0.31, 95% CI: 0.13, 0.74) before diagnosis were associated with lower odds of CBE as the initial mode of detection, while performance of CBEs before diagnosis (OR 11.04, 95% CI: 2.24, 54.55) was positively associated. Lower body mass index (<25.0 kg/m2 vs. ?35.0 kg/m2: OR 2.46, 95% CI: 1.52, 3.98), performance of BSEs before diagnosis (less than once per month: OR 4.08, 95% CI: 2.45, 6.78; at least monthly: OR 4.99, 95% CI: 3.13, 7.97), and larger tumor size (1.0-2.0 cm vs. <1.0 cm: OR 2.92, 95% CI: 1.84, 4.64; >2.0 cm vs. <1.0 cm: OR 6.41, 95% CI: 3.30, 12.46) were associated with increased odds of self-detection relative to screening mammogram. The odds of CBE and self-detection as initial modes of breast cancer detection among Black women are independently associated with breast care and breast cancer screening services before diagnosis and with larger tumors at diagnosis.
Project description:BACKGROUND:Since a previous meta-analysis reported that ultrasound guidance was associated with a higher first-attempt success rate in catheterization of the radial artery, a number of randomized controlled trials (RCTs) have reported inconsistent results. The aim of the present study is to conduct an updated meta-analysis to clarify the role of ultrasound guidance for radial artery catheterization. METHODS:A systematic literature search of PubMed, Embase, and Cochrane Central Register of Controlled Trials was conducted using specific search terms. Eligible studies were RCTs that compared ultrasound guidance with traditional palpation for radial artery catheterization. The Mantel-Haenszel method using the random effects model was adopted in this meta-analysis. RESULTS:Seven RCTs with 482 patients were included. Compared with traditional palpation, ultrasound guidance significantly increased the first-attempt success rate of radial artery catheterization (RR 1.51, 95% CI 1.07-2.14, P?=?0.02). Subgroup analyses suggested that the superiority of ultrasound guidance for radial artery catheterization was significant when the technique was operated by experienced users, performed in small children and infants, and on elective procedures in the operating room. In addition, ultrasound guidance significantly reduced mean-attempts to success (WMD -1.13, 95% CI -1.58 to -0.69, P<0.00001), mean-time to success (WMD -74.77s, 95% CI -137.89s to -11.64s, P?=?0.02), and the occurrence of hematoma (RR 0.17, 95% CI 0.07-0.41, P?=?0.0001). CONCLUSIONS:The present meta-analysis suggests a clear benefit from ultrasound guidance for radial artery catheterization compared with the traditional palpation. Preliminary training and familiarization with the ultrasound-guided technique is needed before applying it for radial artery catheterization, especially for inexperienced operators.
Project description:Over 80,000 people undergo pulmonary resection for a lung nodule in the United States each year. Small nodules are frequently missed or difficult to find despite preoperative imaging. We hypothesized that near-infrared (NIR) imaging technology could be used to identify and locate lung nodules during surgery.We enrolled 18 patients who were diagnosed with a pulmonary nodule that required resection. All patients had a fine-cut 1-mm computed tomography scan preoperatively. The patients were given systemic 5 mg/kg indocyanine green and then underwent an open thoracotomy 24 hours later. The NIR imaging was used to identify the primary nodule and search for additional nodules that were not found by visual inspection or manual palpation of the ipsilateral lung.Manual palpation and visual inspection identified all 18 primary pulmonary nodules and no additional lesions. Intraoperative NIR imaging detected 16 out of the 18 primary nodules. The NIR imaging also identified 5 additional subcentimeter nodules; 3 metastatic adenocarcinomas and 2 metastatic sarcomas. This technology could identify nodules as small as 0.2 cm and as deep as 1.3 cm from the pleural surface. This approach discovered 3 nodules that were in different lobes than the primary tumor. Nodule fluorescence was independent of size, metabolic activity, histology, tumor grade and vascularity.This is the first-in-human demonstration of identifying pulmonary nodules during thoracic surgery with NIR imaging without a priori knowledge of their location or existence. The NIR imaging can detect pulmonary nodules during lung resections that are poorly visualized on computed tomography and difficult to discriminate on finger palpation.
Project description:The variability in the numerous tasks in which we use our hands is very large. However, independent movement control of individual fingers is limited. To assess the extent of finger independency during full-range finger flexion including all finger joints, we studied enslaving (movement in non-instructed fingers) and range of independent finger movement through the whole finger flexion trajectory in single and multi-finger movement tasks. Thirteen young healthy subjects performed single- and multi-finger movement tasks under two conditions: active flexion through the full range of movement with all fingers free to move and active flexion while the non-instructed finger(s) were restrained. Finger kinematics were measured using inertial sensors (PowerGlove), to assess enslaving and range of independent finger movement. Although all fingers showed enslaving movement to some extent, highest enslaving was found in adjacent fingers. Enslaving effects in ring and little finger were increased with movement of additional, non-adjacent fingers. The middle finger was the only finger affected by restriction in movement of non-instructed fingers. Each finger showed a range of independent movement before the non-instructed fingers started to move, which was largest for the index finger. The start of enslaving was asymmetrical for adjacent fingers. Little finger enslaving movement was affected by multi-finger movement. We conclude that no finger can move independently through the full range of finger flexion, although some degree of full independence is present for smaller movements. This range of independent movement is asymmetric and variable between fingers and between subjects. The presented results provide insight into the role of finger independency for different types of tasks and populations.
Project description:Humans vary substantially in their ability to learn new motor skills. Here, we examined inter-individual differences in learning to play the piano, with the goal of identifying relations to structural properties of white matter fiber tracts relevant to audio-motor learning. Non-musicians (n = 18) learned to perform three short melodies on a piano keyboard in a pure audio-motor training condition (vision of their own fingers was occluded). Initial learning times ranged from 17 to 120 min (mean ± SD: 62 ± 29 min). Diffusion-weighted magnetic resonance imaging was used to derive the fractional anisotropy (FA), an index of white matter microstructural arrangement. A correlation analysis revealed that higher FA values were associated with faster learning of piano melodies. These effects were observed in the bilateral corticospinal tracts, bundles of axons relevant for the execution of voluntary movements, and the right superior longitudinal fasciculus, a tract important for audio-motor transformations. These results suggest that the speed with which novel complex audio-motor skills can be acquired may be determined by variability in structural properties of white matter fiber tracts connecting brain areas functionally relevant for audio-motor learning.
Project description:Extensive training can bring about highly-skilled action, but may also impair motor dexterity by producing involuntary movements and muscular cramping, as seen in focal dystonia (FD) and tremor. To elucidate the underlying neuroplastic mechanisms of FD, the present study addressed the organization of finger movements during piano performance in pianists suffering from the condition. Principal component (PC) analysis identified three patterns of fundamental joint coordination constituting finger movements in both patients and controls. The first two coordination patterns described less individuated movements between the "dystonic" finger and key-striking fingers for patients compared to controls. The third coordination pattern, representing the individuation of movements between the middle and ring fingers, was evident during a sequence of strikes with these fingers in controls, which was absent in the patients. Consequently, rhythmic variability of keystrokes was more pronounced during this sequence of strikes for the patients. A stepwise multiple-regression analysis further identified greater variability of keystrokes for individuals displaying less individuated movements between the affected and striking fingers. The findings suggest that FD alters dexterous joint coordination so as to lower independent control of finger movements, and thereby degrades fine motor control.