Evaluation of the implementation of a speech and language therapist-led referring model for VFSS using the Consolidated Framework for Implementation Research (CFIR)

BACKGROUND

Speech and language therapists (SLTs) use videofluoroscopic swallow study (VFSS) results to manage dysphagia. Yet, in some services only doctors can directly request a VFSS, potentially creating workflow inefficiencies and delaying patient access to VFSS. An alternative model, where SLTs directly refer patients for VFSS, is used in many services in the UK and Australia. However, processes for implementing and sustaining this model have not been reported.

AIMS

To evaluate the implementation of an SLT-led inpatient VFSS referring model using the Consolidated Framework for Implementation Research (CFIR) to ascertain implementation barriers, facilitators and critical sustainability factors.

METHODS & PROCEDURES

This implementation evaluation examined stakeholder perceptions of implementing the SLT-led VFSS referring model via interviews of (1) SLTs who treat and refer inpatients for VFSS; (2) doctors who manage and refer inpatients for VFSS; (3) radiologists; and (4) trained VFSS referring SLTs. The CFIR was used to prospectively guide implementation planning, evaluation and outcome reporting, regarding barriers, facilitators and sustainability factors.

OUTCOMES & RESULTS

Implementation facilitators were (1) the advantage of SLT-led VFSS referring over the standard model (doctors referring), in promoting high-quality VFSS referrals; (2) compatibility of the model with the SLT skill set; (3) supportive communication networks between staff groups; and (4) engaging stakeholders throughout implementation. Adequate availability of trained VFSS referring SLTs was both a barrier and a facilitator of implementation. It was also a critical sustainability factor, along with ongoing staff education and outcome monitoring.

CONCLUSIONS & IMPLICATIONS

The CFIR supported systematic evaluation of implementation facilitators and barriers, and adjustment of factors critical for implementing and sustaining the new model. Findings may assist other organizations to establish the SLT-led VFSS referring model.

WHAT THIS PAPER ADDS

What is already known on the subject Models where SLTs directly refer patients for VFSS have been described in the literature, with evidence of appropriate referrals and adherence to radiation safety standards. However, the process for establishing and sustaining this referring model has not been published. What this paper adds to existing knowledge This study describes the process and outcomes of implementing an SLT-led VFSS referring model, using the CFIR. A key advantage of the new model that facilitated implementation was the improved quality of VFSS referrals compared with the standard referring model. Important facilitating factors in the environment were the compatibility of the model with SLTs' skillset and supportive communication network between doctors and SLTs. Initially, an implementation barrier was the inadequate availability of trained SLT referrers. Using proactive implementation strategies, more referrers were trained (which was a facilitating factor for implementing and sustaining the model). What are the potential or actual clinical implications of this work? This study highlights that successful implementation requires more than just an effective model. Features of the environment require consideration to minimize barriers and optimize facilitating factors, supported by proactive implementation strategies. Planning and evaluating implementation processes and outcomes using a standardized implementation framework such as CFIR aided understanding of barriers and facilitators for introducing the SLT-led VFSS referring model. This process may assist other services to implement the model.

Implementation of a speech and language therapy-led referring model for videofluoroscopic swallow studies: An evaluation of service outcomes

BACKGROUND

Videofluoroscopic swallow studies (VFSS) are integral to diagnosing and supporting dysphagia management. However, in many countries, only doctors are authorized to complete medical imaging request forms, in accordance with radiation safety regulations. This can impact workflow and timely access to VFSS. Enhanced scope of practice (ESP) models of care exist, where speech and language therapists (SLTs) are authorized to complete VFSS request forms. However, formal evaluations of these ESP models are currently lacking.

AIMS

The primary aim of this study was to examine service outcomes regarding the safety and efficiency of SLTs completing VFSS request forms compared with the medical referring model (standard care). The secondary aim was to ascertain the impacts on SLTs' daily workflow and the utility of training for SLTs to complete VFSS requests.

METHODS & PROCEDURES

The study involved a mixed-method design. First, referrals completed using standard care versus those completed under the new SLT-led VFSS referring model were compared for efficiency (days to request completion, number of contacts between staff to complete requests and delay to VFSS appointments) and safety (compliance with radiation safety standards for requests, adverse events and change to dysphagia management to justify radiation exposure). Semi-structured interviews were then conducted with SLT referrers (n = 7) exploring the impacts of the model on daily workflow and the utility of training.

OUTCOMES & RESULTS

VFSS inpatient requests were examined across a 3-month period (n = 61 requests) using the standard model, and for 6 months (n = 109 requests) following the introduction of SLT-led VFSS referring. Regarding efficiency, there was no significant difference between the two models, with most request forms taking less than or equal to 1 day to be completed. Adherence to radiation safety requirements was significantly greater in the SLT-led VFSS referring model compared with the standard model (p < 0.001) in relation to the overall requisite clinical information being documented on the request forms. No adverse events occurred and 100% of VFSSs led to changed dysphagia management. Interviews of VFSS referring SLTs revealed that completing requests was not complex or onerous, and that the training equipped them well to undertake the role.

CONCLUSIONS & IMPLICATIONS

The SLT-led VFSS referring model was feasible for SLTs and resulted in satisfactory efficiency and greater adherence to radiation safety requirements for VFSS request forms than the standard model. Improved information on VFSS request forms provides clearer justification for the radiation procedure and helps optimize the diagnostic yield of VFSS. The evidence supports further widespread adoption of this model.

WHAT THIS PAPER ADDS

What is already known on the subject Models of care permitting selected allied health professionals to refer patients for diagnostic radiology procedures have been established to achieve healthcare efficiencies. Evidence supports the safety and efficiency of physiotherapists referring to radiology. However, limited published outcome data exist regarding models of SLTs referring for radiology procedures, such as VFSS. What this paper adds to existing knowledge This study describes the implementation of a SLT-led VFSS inpatient referring model in a quaternary hospital and examines service outcomes. The findings reveal that VFSS request forms completed in the SLT-led referring model had greater adherence to radiation safety standards compared with the standard referring model. Efficiency was similar across both models and there were no adverse events. Completing VFSS requests did not disrupt daily workflow for SLTs and training was effective preparation for the role. What are the potential or actual clinical implications of this work? Results demonstrate that the SLT-led VFSS referral model can be safely and appropriately implemented in the inpatient setting. Improved quality of information documented on request forms by SLTs increases adherence with radiation safety standards, providing clearer justification for radiation assessments and potentially eliciting more targeted diagnostic information to inform dysphagia treatment planning. These findings may support other hospital services to establish this type of referring model.

Implementation of hospital wide dysphagia screening in a large acute tertiary teaching hospital

Purpose: There are no examples in the literature of successful long-term hospital-wide implementation of nurse-led dysphagia screening. This article aims to describe strategies used to implement hospital-wide dysphagia screening in a large acute tertiary teaching hospital in Australia. It reports on compliance, accuracy and nursing staff satisfaction using the validated Royal Brisbane and Women's Hospital Dysphagia Screening Tool (RBWH DST).Method: A retrospective observational study of audit data was conducted to examine hospital-wide compliance and accuracy of dysphagia screen completion. A nursing staff survey measured staff satisfaction. Implementation included: (1) utilisation of validated tool (RBWH DST); (2) key stakeholder engagement and strong governance; (3) policy development; (4) education; and (5) review and monitoring processes.Result: Audits conducted over a 9-year period (n = 3726) showed an average hospital-wide compliance rate of 74% and an accuracy rate of 82%. A nurse satisfaction survey (n = 109) showed high levels of satisfaction associated with using the RBWH DST.Conclusion: The RBWH DST was implemented in a large acute tertiary teaching hospital with acceptable compliance and accuracy rates and favourable nursing staff satisfaction. Further study is required to objectively evaluate patient health and cost benefits associated with using the RBWH DST.

Abstract P2-01-06: How much agreement can we expect on BI-RADS mammographic findings? Observer agreement among 10 expert mammographers

Purpose: To determine the agreement between expert readers on mammographic findings and calcification patterns.

Materials and Methods: Ten academic radiologists from 5 centers reviewed 250 de-identified mammographic cases without prior exams which were previously assessed as BI-RADS 4 or 5 with subsequent pathologic diagnosis by percutaneous or surgical biopsy. For benign cases diagnosed by percutaneous biopsy, 1 year of benign or negative imaging follow-up was required. Using standardized forms, each radiologist assessed the presence of any suspicious mammographic findings (microcalcifications, asymmetry (1-vew), focal asymmetry (2-view), architectural distortion), and the morphology (none, round/punctate, amorphous, coarse heterogeneous, fine pleomorphic, fine linear branching) and distribution (none, diffuse, regional, grouped, linear, segmental) of any identified microcalcifications. Agreement between radiologists for presence/absence of findings, morphology, and distribution of calcifications was determined by calculating the Kappa (k) coefficient with 95% confidence interval (95% CI). The kappa coefficient proposed strength of agreement is ≤0 = poor, .01-.20 = slight, .21-.40 = fair, .41-.60 = moderate, .61-.80 = substantial, and .81-1 = almost perfect, as established by Landis and Koch.1

Results: Of the 250 lesions, 156 (62%) were benign and 94 (38%) malignant. Agreement among the 10 expert readers was strongest for recognizing the presence/absence of calcifications (k = 0.82, 95% CI: 0.80-84), “almost perfect”). There was substantial agreement among the readers for the identification of a mass (k = 0.67, 95% CI: 0.66-69), whereas agreement was fair for the presence of a focal (2-view) asymmetry (k = 0.21, 95% CI: 0.1900.23) or architectural distortion (k = 0.28, 95%CI: 0.26-0.30). Agreement for asymmetries (1-view) was slight (k = 0.09, 95%CI: 0.08-0.11). Among the 6 categories of microcalcification distribution and morphology, reader agreement was moderate (distribution k = 0.60, 95%CI:0.59-0.61; morphology k = 0.51, 95%CI: 0.50-0.52).

Conclusion: When asked to characterize suspicious mammographic findings, this sampling of 10 expert academic breast imagers across 5 centers revealed varying strength of agreement for different findings, ranging from slight to almost perfect. Strongest agreement (“almost perfect”) was found for identifying the presence or absence of microcalcifications, although agreement drops to moderate when readers are asked to specify microcalcification morphology and distribution.

1 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics.1977;33:159-174.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-01-06.

A pilot trial of a speech pathology telehealth service for head and neck cancer patients

We explored the feasibility of providing access to specialist speech pathology services via telehealth for patients with head and neck cancer. A weekly telehealth clinic was conducted between the speech pathology departments of a tertiary hospital and a regional hospital in Queensland. Over a 5-month period, 50 telehealth sessions were conducted for 18 patients. There were 38 patient consultations, nine case discussions between clinicians and three clinical training sessions relating to the skills needed for specific client management (e.g. voice prosthesis selection). Eight sessions had multidisciplinary involvement. All cases were successfully managed via telehealth. All patients agreed that they were comfortable using telehealth and would be happy to use it again in future. Both clinicians agreed that they could competently assess patients using the telehealth system. There appeared to be financial benefits for the patient, because by receiving specialist intervention at a local facility their travel expenses were lower. There was also the opportunity for workforce training and development through online case discussion and clinical consultation.

Social protection to support vulnerable children and families: the potential of cash transfers to protect education, health and nutrition

Investing in social protection in sub-Saharan Africa has taken on a new urgency as HIV and AIDS interact with other drivers of poverty to simultaneously destabilise livelihoods systems and family and community safety nets. Cash transfer programmes already reach millions of people in South Africa, and in other countries in southern and East Africa plans are underway to reach tens and eventually hundreds of thousands more. Cash transfers worldwide have demonstrated large impacts on the education, health and nutrition of children. While the strongest evidence is from conditional cash transfer evaluations in Latin America and Asia, important results are emerging in the newer African programmes. Cash transfers can be implemented in conjunction with other services involving education, health, nutrition, social welfare and others, including those related to HIV and AIDS. HIV/AIDS-affected families are diverse with respect to household structure, ability to work and access to assets, arguing for a mix of approaches, including food assistance and income-generation programmes. However, cash transfers appear to offer the best strategy for scaling up to a national system of social protection, by reaching families who are the most capacity constrained, in large numbers, relatively quickly. These are important considerations for communities hard-hit by HIV and AIDS, given the extent and nature of deprivation, the long-term risk to human capital and the current political willingness to act.

Decision analysis for the cost effectiveness of sestamibi scintimammography in minimizing unnecessary biopsies

BACKGROUND

The purpose of this study was to assess if breast cancer screening using sestamibi scintimammography (SSMM) in conjunction with mammography (MM) is cost effective in avoiding biopsies in healthy patients.

METHODS

Quantitative decision tree sensitivity analysis was used to compare the conventional MM alone strategy (strategy A) with two decision strategies for screening with SSMM; SSMM after an indeterminate mammogram (strategy B) or SSMM after both a positive and an indeterminate mammogram (strategy C). Cost effectiveness was measured by calculating the expected cost per patient and the average life expectancy per patient for baseline values as well as over a range of values for all of the variables of each strategy.

RESULTS

Based on Medicare reimbursement values, strategies B and C showed a cost savings of $9 and $20 per patient respectively as compared to strategy A. This translates into respective savings of $189 and $420 million per year assuming 21 million females undergo screening each year. Strategies B and C did however have a loss of mean life expectancy of 0.000178 and 0.000222 years respectively as compared to strategy A due to interval progression of breast cancer in a small number of women. Strategies B and C significantly lowered the number of biopsies performed on healthy patients in the screening population by 750,063 and 1,557,915 biopsies respectively as compared to strategy A.

CONCLUSIONS

These results quantitatively verify the potential utility of using SSMM in avoiding unnecessary biopsies.

Functional speech outcomes after laryngectomy and pharyngolaryngectomy

OBJECTIVE

To compare and contrast functional speech outcomes of patients having undergone total laryngectomy and pharyngolaryngectomy who use tracheoesophageal speech as their primary mode of communication.

DESIGN

Group comparison design.

SETTING

Adult acute tertiary care hospital.

PATIENTS

Thirty patients who underwent total laryngectomy and 13 who underwent pharyngolaryngectomy with free jejunal interposition reconstruction. All patients used tracheoesophageal speech.

INTERVENTION

Group comparisons across measures of speech intelligibility, voice quality, tracheoesophageal speech use, voice satisfaction and levels of perceived voice disability, handicap, and well-being/distress.

MAIN OUTCOME MEASURE

The existence of any significant differences between the 2 groups on measures of intelligibility, voice quality, tracheoesophageal speech use, and voice satisfaction and levels of voice disability, handicap, and well-being/distress.

RESULTS

Statistical comparisons confirmed reduced functional intelligibility (P<.05), reduced vocal quality (P<.01), and higher levels of disability (P<.05) in the pharyngolaryngectomy group. However, no significant difference was observed between the proportion of patients classified as "successful" tracheoesophageal speech users in either group. Low levels of handicap and high levels of patient well-being were recorded in both groups.

CONCLUSION

Despite the perceptual differences in voice quality and intelligibility observed between the 2 groups, tracheoesophageal speech that is functional, effective, and perceived by the patients as satisfactory can be achieved after total laryngectomy and pharyngolaryngectomy with free jejunal interposition reconstruction.

A study on the cost effectiveness of sestamibi scintimammography for screening women with dense breasts for breast cancer

The potential impact of Sestamibi scintimammography (SSMM) on the cost effective management of women with dense breasts is not known. This study addresses this issue quantitatively by examining the impact of SSMM based screening strategies on the approximately 3,000,000 women over 40 with very dense breasts (DY patterns) without palpable masses and who have had one or more prior mammograms, who undergo routine screening each year. Quantitative decision tree sensitivity analysis was used to compare the conventional mammography (MM) strategy (strategy A), which does not subject patients with negative mammograms to any further examination until their next screening, with two decision strategies for screening with SSMM; SSMM after a negative mammogram (strategy B) or SSMM as the only screening test for women already identified as having dense breasts by a previous mammogram (strategy C). Cost effectiveness was measured by calculating the incremental cost effectiveness ratio (ICER) of strategies B and C, which is the cost of achieving an additional year of life in the screening population by choosing a SSMM based decision strategy rather than the conventional strategy. Strategies B and C reduced the number of false negative diagnoses by 62% and 8%, respectively. The ICER was $632,000 and $3.18M per life year for strategy B and C, respectively. To be cost effective, the pre-test probability of cancer in the study population must be greater than 3% for strategy B or the cost of SSMM must be less than $50 for strategy C. These results show the ICER of an SSMM based breast cancer screening strategy in the management of patients with dense breasts is not currently within the range (approximately $50,000 per year life saved) of other commonly performed medical interventions that are considered cost effective.

Stereotactic core-needle biopsy of the breast: a report of the Joint Task Force of the American College of Radiology, American College of Surgeons, and College of American Pathologists

A national task force consisting of members from the American College of Radiology, the American College of Surgeons, and the College of American Pathologists examined the issues surrounding stereotactic core-needle biopsy for occult breast lesions. Their report includes indications and contraindications, informed consent, specimen handling, and management of indeterminate, atypical, or discordant lesions.

Mammography film processor replenishment rate: bromide level monitoring

The effects of the mammography film processing replenishment rate on contrast and speed are studied sensitometrically. Two experiments studied decreasing replenishment rates in the Kodak RP developer and quantified changes in the developer by measuring bromide ion concentrations. First, values of NaBr concentration from 1.7 to 8.4 g/L, achieved by reducing the replenishment rate, were tested with sensitometry strips. Second, the developer replenishment rate of a high volume dedicated mammography processor was reduced by one-third, to 20 cm3/1560 cm2, so that the NaBr concentration rose from 2.0 to 12.36. Sensitometric results for four film types and patient films were tested for changes from standard values as NaBr concentration was restored to 3.31 g/L. Fifty-five clinical images obtained at 7.3-9.3 NaBr g/L were compared to their matching previous films, with NaBr levels of 2-3 g/L, for contrast and visibility of the skin line. For the range of the NaBr ion from 1.7 to 7 g/L, no significant sensitometric differences were found. Above 7 g/L, different film types had different sensitometric results. From 7.3 to 9.3 NaBr g/L, 47.5% of the clinical films reviewed by four radiologists had less contrast compared to previous films. Dedicated mammography processors with high film volume (i.e., those that do not have excessive oxidation or foreign dye problems) can operate at lower replenishment rates than are currently employed. All common mammography film types are stable at these lower replenishment rates up to 7.0 NaBr g/L.

Percutaneous core biopsy of the breast: effect of operator experience and number of samples on diagnostic accuracy

OBJECTIVE

The purpose of our study was to assess the degree of operator experience and the number of core biopsy samples required to achieve an accurate histologic diagnosis for each of five common mammographically defined lesions, using percutaneous core breast biopsy performed on a dedicated prone biopsy table.

SUBJECTS AND METHODS

A prospective multisite study was performed that involved nine institutions (academic and private) with experienced breast radiologists and the use of dedicated prone biopsy table units with digital assistance and standardized protocol. Asymptomatic women evaluated during a 2-year study period were assigned a mammographic diagnosis reported in a manner prescribed by the American College of Radiology Breast Imaging Reporting and Data System lexicon. Mammographic lesions evaluated included masses, masses with calcifications, clustered calcifications, focal asymmetries, and architectural distortions. Where histologic diagnosis was indicated, core biopsy was performed with five individual samples obtained and sequentially analyzed. Two hundred thirty patients had immediate excisional biopsy, the results of which provided the basis for a statistical analysis to compare the accuracy of each sequential core biopsy sample with surgical results. Statistical analysis was also done to ascertain the accuracy of core biopsy diagnosis as a function of operator experience.

RESULTS

Trends toward increasing accuracy were observed by increasing the number of core biopsies for each of five types of mammographically defined lesions, especially for clustered calcifications. Statistically significant increased accuracy was observed when the number of biopsies was increased beyond one (p = .003). Trends toward increased accuracy with more experience were observed for all lesions, especially for calcifications. Of the 230 lesions studied with immediate surgical validation, more than 80% of all lesions except clustered calcifications (75%) were diagnosed on the basis of two core biopsies; accuracy after five biopsies was 98% for masses, 91% for calcifications, 100% for masses with calcification, 100% for focal asymmetries, and 86% for architectural distortions.

CONCLUSIONS

Accuracy of diagnosis based on the results of percutaneous core breast biopsy improved with an increase in the number of core biopsy samples obtained for any given lesion seen on mammograms and with increased experience in performing the procedure. Five samples yielded an overall diagnostic accuracy of 97%. Familiarity with expected accuracy from this procedure for different mammographic lesions and following increased experience may assist physicians in planning patient management.

Mammography screen-film selection: individual facility testing technique

Variations in tube output, film processing, and radiologist's preferences affect the screen-film combination that is appropriate for any particular mammographic facility. A technique to test a variety of screen-film combinations for screening mammography is described. Films are selected for testing because of their densitometric characteristics. Dose and clinical reliability are established with phantoms before the screen-film combinations are used to image consecutive patients having bilateral examinations. The mammograms selected for evaluation are those with similar optical density ranges, and which also may be compared to available previous mammograms or which have unusual mammographic findings. All radiologists reading mammograms at a facility independently score the selected cases. Scores of "unacceptable," "acceptable," or "outstanding" are assigned to four basic imaging characteristics: sharpness, contrast, visibility of skin line, and noise. Interobserver variations by this method require normalization, unlike ROC analysis which is not applicable for this data because of the absence of proved pathologic diagnoses. The testing of 5 films and two screens using 42 patient examinations required 2 h of time from each radiologist. It took 7 h of the physicist's time to pretest the 5 films, select the 42 acceptable examinations for testing by the radiologists, and summarize the data.

Magnetic resonance imaging identifies early femoral head ischemic necrosis in patients receiving systemic glucocorticoid therapy

Ischemic necrosis of bone, a frequent complication of glucocorticoid therapy, can result in disability due to bone collapse and destruction. Some investigators have suggested that core decompression of involved marrow benefits patients with early disease. As radiographs are normal in early disease, identification of patients has been dependent on nonspecific radionuclide imaging or more specific but invasive hemodynamic studies. In order to define a sensitive, noninvasive diagnostic tool, we compared magnetic resonance imaging (MRI) to 99mtechnetium diphosphonate and 99mtechnetium sulfur colloid scintigraphy in 10 consecutive glucocorticoid treated patients with suspected femoral head ischemic necrosis of bone but normal roentgenograms. MRI identified the ischemic necrosis (defined by characteristic radiographic progression or histology) in 13/13 femoral heads. Both scans together identified only 5/13 of the cases. Only 1/20 osteoarthritic femoral heads had MRI patterns similar to those seen in ischemic necrosis of bone. We conclude that MRI is a sensitive and relatively specific method to detect early femoral head ischemic necrosis of bone.

Anatomic correlation of cadaver cryomicrotomy with magnetic resonance imaging

The performance of frozen sections of a thickness varying between 5 and 50 microns in fresh undecalcified cadaveric human specimens was perfected in Sweden by one of the authors in 1983. This technique makes it possible to obtain anatomic images of high definition which were correlated with MRI sections made at intervals of 20 microns.

The grid radiograph. A simple technique for consistent high-resolution visualization of the hip

The grid radiograph, a new technique for radiographic evaluation of total hip replacements, ensures reproducible positioning of the hip and the x-ray beam. When this method was used, the images of stable acetabular and femoral components on one radiograph could be superimposed perfectly on the images of these components on subsequent radiographs. Subtle shifts in the positions of the components, such as tilting of the femoral surface replacement, subsidence of the femoral component, or migration of the acetabular component, were detected. When used with high-contrast radiographic technique and film, the implant-bone interfaces were depicted better by this method than by others. Grid radiographs can be used for detailed prospective evaluation of total hip replacements and are of practical value in counseling patients about the probable durability of the replacement.

Methods of Sample Preparation for Detecting Alkaline Phosphatase in Casein: Collaborative Study

A collaborative study was conducted in which 2 different sample preparation techniques were used to determine alkaline phosphatase in casein by the rapid colorimetric test. Seven collaborators tested 10 unknown casein products containing different amounts of residual phosphatase. Results indicated that the phosphatase contents of casein prepared by the 2 methods were not significantly different. The collaborators correctly analyzed 100% of the test samples that were ground and 98 % of the test samples that were unground. The alternative rapid sample preparation method has been adopted official first action.

Solenoid surface coils in magnetic resonance imaging

A nonplanar solenoidal surface radiofrequency coil is used as a receiver with a conventional transmitter coil in a magnetic resonance imaging system. The improved signal-to-noise ratio, compared with that of conventional fixed saddle or solenoid receiver coils, permits higher resolution imaging and thinner image sections. In addition, the problem of signal dropoff that occurs in deep structures with planar and other noncircumferential surface coils is eliminated. Solenoid surface coils are particularly useful in imaging deep structures in anatomic regions that do not fit standard head and body coils, such as the neck, knees, and other smaller body parts.

Ultrasound mammography: effects of focal zone placement

In order to avoid serious pitfalls in the diagnosis of breast masses by sonography, it is important to understand the effects of technical factors such as focal zone placement and time gain compensation.

Anatomic correlations of magnetic resonance images with cadaver cryosections

The authors present here a correlation of the normal anatomy of the pelvis, as depicted by MRI in multiple planes, with corresponding cadaveric specimens.

Percutaneous biopsy following positive bone scans

When a bone scan reveals an abnormal radionuclide accumulation and the cause is uncertain, bone biopsy is sometimes necessary. One hundred thirty biopsies have been performed in our institution with a percutaneous needle guided by fluoroscopy. This procedure is safe and effective.

Measuring consumer satisfaction in a mental health center

In this age of consumerism, the degree of patient satisfaction should be considered when evaluating mental health services, according to the authors. They attempted to measure consumer satisfaction of mental health center patients by correlating it with various demographic and therapeutic parameters such as length of treatment, age, socioeconomic status, and previous expectations. One surprising finding was that patients treated by the approach least popular with the therapists, extended intake, rated the services higher than those treated by approaches considered more acceptable.