Today's video is sponsored by Squarespace. Dr. Patient Communication is something that I am very passionate about because as someone who's been a patient in our medical system of chronic pain and chronic illness for over a decade, I've been in way too many doctor's offices and way too many appointments where I felt like I wasn't heard at all. I felt like I couldn't get out what I wanted to say. I feel like my feelings or my symptoms were invalidated. I wasn't listened to. This was not the outcome that I was looking for and I'm like, how did I even get here and what can I do? Hello there, my beautiful, lovely internet friends. Welcome back to my channel. Thank you for joining me here today. Very important note as we start out. I have no idea who this is on my shirt. It was a $4 shirt at a thrift shop and I really hope it's someone nice. Our topic today is drum roll, please. How to have a productive, healthy and happy conversation with your doctor. Okay, I may have over promised. We're just gonna go for productive conversation. As someone who has been a patient in way too many doctor's offices, I'm very familiar with the frustration of feeling like you aren't being listened to as a patient and I also know from the doctor end of things, patient communication is something that can be really difficult to manage sometimes. What is happening? Over the years, I have collected a small basket of tools that have helped me improve my communication with doctors even when I'm very stressed or overwhelmed or in a difficult situation. And I've saved like the boilerplate ones for the end but I have some unorthodox methods that I would like to share with you as well and I would love to hear your thoughts at the end of this video. Tip number one, this is something that I've recently implemented in my medical vocabulary is how I actually start these doctor conversations. As the professional walks into the room, I used to always kind of wait for them to start things and follow along and answer yes, no questions and just kind of go with the flow. But I found that oftentimes that led to me being confused, overwhelmed, not actually ever getting my questions out, not finding that any of my goals or needs were met in that conversation by the time the doctor walked out and not even knowing what happened. So what I've started doing instead is kind of doing an intro to any conversation. Recently, I've had to see a lot of doctors for some complicated medical stuff. And instead of just letting them take control of the conversation and answer their questions, I've started off by saying, hey, it's really great to meet you. I appreciate you taking time with me today. What I'm looking for is someone who is willing to actually dive into what's going on and go beyond symptom treatment and management. I know that there's something larger at play here. I've had a difficult time finding that. Are you someone who is willing to look for this with me? Are you someone who is willing to go beyond just kind of treating symptoms and really dig into a deeper cause? Starting conversations that way, stating what my goals are and asking them if they are on board to be a part of that has really shifted the dynamic because it kind of takes things from this amalgamess of, okay, this doctor's coming in and now I'm just listening to them to taking ownership of that appointment for your health, stating what you're looking for and seeing if they're the person to be on board to do that. And maybe they aren't. However, if a doctor agrees to that, if they're like, yes, that is something that I would love to help you with, I found that that really sets the tone for the conversation moving forward. Tip number two, what I will often do is use I statements. We're taught a lot about these growing up, at least I was.  Is this something we could talk about becomes a much healthier conversation because then you don't get the finger pointing back and forth. I think the same thing is true in communication with medical professionals. Using I statements if I feel like I'm not being heard or if maybe I feel disrespected or I'm unhappy with something has been really beneficial. So instead of saying, you aren't listening, you aren't hearing me, calling upon those difficult but good communication skills to instead say something like, I think I'm having difficulty conveying what I mean. Can we take a step back for just a second? Using communication like this where you aren't pointing fingers or saying, you know, you aren't listening or you aren't doing something, instead switching to I statements so maybe they can come alongside you and help, it's more of an invitation than like a finger pointing back and forth, I found to be very beneficial. This next tip in particular applies if you have had a lot of bad medical experiences like I have, I realize that I carry those into new appointments with me. And for the record, that's understandable. When we have bad experiences as people, it's really hard to just forget about them, right? But I began to realize that as I met with new doctors to try to figure out what was going on, I was treating those new doctors coming in fresh as if they had the same thoughts, opinions and level of respect for me and my care as previous doctors. So I get really anxious, I get really overwhelmed, I would think they're not even gonna listen to me anyways and I'd realized that I was leaving out key details that I needed to convey because I thought it doesn't matter anyways, they're not gonna help. So that ended up kind of being a wasted appointment for me and for them. Because I was approaching that situation like there was no hope anyways and thus really not trying to communicate everything that needed to be said. By no means am I saying this is an easy thing to do but as I have been able to kind of calm some of my anxiety and treat each person like a unique individual person, brand new to my case, haven't heard my story yet, I don't know how they're gonna interact with me and trying to bring a level of optimism into that appointment even if every single experience before has taught me that that is ridiculous has actually led to really good things. When I've been able to do that, I find that my mind is a little bit more clear instead of feeling defeated before I've even started. I have some hope and some motivation to make sure I'm communicating everything I need to communicate so they have the details to be able to figure out what's going on or to treat me. And this one is really hard when your body and your brain have so many bad experiences but as I've been able to, treating individual doctors as what they are, individuals has been really beneficial too. It's almost dinner time so they're getting very restless, aren't they? Oh, don't knock over my coffee. Can you go lay down, please? I've also found that if I am able to be honest with a doctor and say, hey, I've had some not great experiences in the medical community and I get really overwhelmed in doctor's appointments. Can we slow this conversation down a little bit so I can absorb things or would you mind if I asked you to restate that thing? Opening up and showing vulnerability and being honest about where you are if you're overwhelmed, if you're anxious, coming in with not the best experiences, allow someone to get to know you a little bit better. And though it is vulnerable, I have also found it to be really, really helpful to building that relationship and that partnership with your healthcare providers. Tip number four, are we on four? I think we are. Oftentimes people ask doctors, what would you do if you were in my situation? And while this can be a beneficial thing and if it works for you fantastic, I have found that this is actually pretty counterproductive to getting care tailored to me because the reality is, is that everybody is individual, right? What I want from my life and my body might be drastically different than what other people want. If I'm asking a doctor, if it was you, would you go through with the surgery? What I really want to be asking is given what you know about me, what I've talked about of my quality of life or the pain I'm experiencing or what is going on, what would you recommend for me? Reframing the classic, what would you do in my situation doc to what would you recommend for me given what I told you about my life? I think allows doctors to rely on their expertise to think about the medical outcome and what they've seen and their experience and give you a recommendation that's really tailored for you instead of something that they would prefer. Next tip, if I understand you correctly, this is a statement that I have found to be very helpful in general communication in my life but especially in conversations with medical professionals where sometimes there's terminology being thrown around that you might not understand or maybe the treatment suggested just doesn't make sense recapping the conversation with if I understand you correctly, it sounds like what you're saying is this pain will continue until X. Misunderstanding leads to a lot of tension, a lot of miscommunication, we got a shepherd crossing. Just recapping the conversation with how you've understood what they've told you can allow for errors to be quickly corrected can allow for a better treatment plan, better understanding of what's going on and at a bare minimum, you know that you've understood what they've said as you walk out of there.  Squarespace is your one stop shop for websites, online stores, or even if you just need a domain. I am currently using them right now to redesign my public speaking website which has been a long time coming and they have been fantastically simple to use. As someone who doesn't have a lot of extra time being able to go in and use their features to gain analytics, quickly redesign things, enter new text if I decide my old bunch that this wasn't good enough has been absolutely amazing to use and something I'd highly recommend to anyone. They also have fantastic blogging and commenting features, a lot of plugins. If you're interested in, for instance, building an online store and more and you can get 10% off by using the code in my description, using that link, not only does it support what I am doing here, but it also enables you to get a discount on your first order of a website or domain. Head to squarespace.com slash Footless Show to check out that discount and see how Squarespace can serve you today. These next two things I would recommend for every possible medical situation as you are able, bring someone with you. Having another set of ears in the room, especially when you're talking about something that can be stressful, that can be anxiety producing, your health or something that's going on, having someone else there who can remind you what questions you wanted to ask, who can remind you about things you might have missed, who can ask clarifying question to the doctors and who also can listen to what they are saying with the less biased set of ears is absolutely fantastic. My sweet husband comes with me to as many appointments as he can. I brought my mother with me in the past. Occasionally, really good friends have come with me as well. If you are in a position where it's possible for you to do this and as COVID restrictions apply, I would always recommend bringing someone with you if you can. The second thing along those lines is to always write down the questions that you have before you get there. I spent years thinking, I have a good brain. I'll remember what I wanna say when I get there, but the reality is, as soon as the conversation gets going with the doctor, he's asking questions, the conversation gets perhaps off track from where I originally planned it was gonna go and by the end, I've only asked one out of the three things that I was really there for and I'm frustrated and feel like I've wasted time. Actually writing things down and before your doctor leaves the room, like reviewing that list, did we go over this? Did we go over this? Okay, good. It can be really, really helpful both to you and to your doctor. It's shocking to me how many things I can forget in the midst of conversation, especially when there's kind of that authority figure power imbalance and when I get nervous in doctor's appointments anyways. So bring someone with you and write things down if you are able to. So having settled that to be completely transparent, communicating with doctors is something that I really struggle with. The reason that I've kind of come up with this list is because these are things that I have to remind myself of. Having had so many bad experiences over the years with medical professionals, it's very difficult for me to treat each new doctor, surgeon, nurse like they are an individual, unique person. And I have to actually remind myself of that because I start assuming that they're all just not gonna listen to me and not gonna care and so my anxiety ramps up and I get overwhelmed and I don't wanna talk and I don't wanna share things that I should share. These are just a few things that have really helped me in my journey to better communicate with doctors and I would love, love to hear any of your suggestions down below. If there has ever been anything that helped you communicate with doctors, especially if you're someone who has seen a lot of them like I have, please leave those suggestions down below. And I'm curious if you think any of these would work for you. If you enjoyed this video, I would love it if you'd give it that like button thumbs up as it does help it get out to more people but much more importantly than that. I'm really glad that you're joining me here today. I really appreciate it. Remember to use that link and code in the description to get 10% off your first order with them. To my beautiful, lovely patrons over on Patreon, thank you for supporting these videos and making them possible. If you're interested in joining my Patreon community, there's a link on screen or linked down below and to you, lovely watcher watching this video. You could be anywhere else in the world doing anything else and you chose to hang out with me for a few minutes and I truly appreciate that, thank you. I love you guys, I'm thinking about you and I'll see you in the next video. Bye guys.


My name is Specialist Lenge, I'm a part of B-Co 1502, I'm an extra regiment. Today we're doing the Team Leader Academy M40 on Quall. We're learning how to develop ourselves as a leader to, you know, to zero our soldiers, to quality our soldiers, and help mentor our soldiers and coach them while they are on the range. So the purpose of us for here right now is to, you know, to help develop ourselves as leaders, to help develop ourselves as mentors, as coaches. So that way when we get back to our units and, you know, we see our soldiers again and when we go back to the range with them, you know, we can better coach them, we can better mentor them, so to be effective on the range and ultimately effective for engaging in the range.


Och välkomna, Vardy. I'm I'm Bonets. I'm Deputy Director General here at Sida headquarters. I want to welcome all of you to today's conference on aid and our changing environment. I'm very pleased to see all guests. Many of you have traveled long to contribute to today's program. And this meeting brings together leading experts. As we saw development professionals from ministries and donor agencies, parliamentarians, policy makers. From our partner countries. Civil Society, researchers and students. We are here to listen and discuss what makes aid work or maybe not work and how aid may contribute to sustainable development. You are all very welcome. Sida is happy to cohost this conference with our partner, ju en ju wider. The word institute for development, economic research and institute institution of the United Nations University and also Danila. And I think Sida has supported ju en ju wider for a number of years. Recently intensifying our collaboration within the frame of the recon program. And today we will discuss said what research has to say about how aid works. What has been successful in aid so far in coping with environmental problems and climate change and what could be the role of aid when tackling environmental. Challenges in the future. And how can we as development actors use research results in order to optimize impact and reduce power in the long run. We realize that these challenges are huge and fundamental. And we know that in order to reduce power to and sustain decent living conditions. We need to act in global partnerships and in a consorted way. These global partnerships. Must build on integrated knowledge and inclusive action. As a government agency. As experts in development cooperation. We at Sida needs to build on the best existing knowledge and in order to optimize our operations. We need to be in close dialogue with the research community. Both in Sweden and internationally and furthermore as the main implementing agency of Swedish Development Corporation. We have a special responsibility to bridge the science policy gap and facilitate communications of research results regarding to other stakeholders. It's our hope that the meeting today will be an occasion for all of you to share and discuss research results. And reflect on future directions for aid within the field of environment and climate changes. The research that will be presented today has been developed in the recon program coordinated by you and you wider. With support from the Swedish and Danish government through Sida and Danila and recon fokusis on what has worked in development cooperation. What could be scaled up and what is transferable across. Countries. The recon program addresses five themes that cover key issues in international development assistance. The themes reflect priority areas of the Danish and Swedish governments. It's growth and employment governance and fragility. Gender equality social sectors environment and climate change. And within each team a number of status are being produced and the research findings are summarized in position papers from Recon for each team. And I highly recommend you to visit the Recon homepage. I been there where all these studies and position papers are available. We have invested in Recon to find out what works in development cooperation. So please use the results. Today's meeting is the fifth in a series of seven open invitation meetings in which Recon research is presented and discussed with stakeholders. In the first part today of this meeting starting now ending at two o'clock existing research will be presented and use new research on the role of aid and relation to environment and challenge and climate change. In the second part starting at two o'clock. You and you why there will present the synthesis of research concerning aid and its relation to environmental change. And we look also forward to the panel discussion on politics policies and priorities in aid in relation to environmental change. With these words I would like to once again welcome all of you and all guests and participants and I would like to give the floor to our cohost professor Fintharp director at you and you wider. Thank you very much. I would like to add my words of welcome to those of Bo. It's a great pleasure to be here today. We've been looking forward to this event. It is an important event in the Recon program. Så I thought I should say a couple of words about Recon. I would try not to repeat what has been said. But the starting point for institution such as you and you wider and for the Recon program at large. And I should say that you and you wider means what. Well it's the United Nations University and then the World Institute for Development Economic Research. This abbreviation you and you is sometimes not quite well known. But now you know. But our starting point is that it is really very diverse and very complex. So this idea that any single individual can sort of have it all in the head is just not the right point of departure. When you look to the international debate about these issues you often see individuals who stand up and say that they know everything about it. You have the Dambisa Moyers. You have the east of these etc etc. Our starting point is a different one. Our starting point is that well in order to really come to grips with for an aid and in this case environment and climate change. Well you have to try to bring together a large global network of informed people from different perspectives. And that's what we've been trying to do. So we have been bringing together the UNU wider global network. We have partnered with institutions such as the Danish Institute for International Studies and we have really tried to be as open minded as we possibly can in bringing people together. And as an overall result of all of this there will be about 225 studies that will be available at the end of this year. And as Paul rightly said we will make a number of so-called position papers which will try to draw out to synthesize what it is that we can say. Paul has already mentioned the four key questions. He has already mentioned the five thematic areas. And let me just add why are we engaged in this. Why are we doing this program. Well our point of departure is the development job is very far from done. We still have about 1.3 billion people out there who are living as absolutely poor. We know that poor farmers have for many many years and still today are facing every day in their lives environmental challenges. You are seeing how they as I sometimes say walk with their feet in water regularly and they see their houses being flushed away and so on. So these issues these problems these challenges are still out there. And then on top comes climate change. We know that the global temperature is on the rise and there is a whole range of other issues that comes as a consequence. So we need to develop. We need to mitigate and we need to adapt. And as far as we can see it it becomes relevant to ask the question. Well how can aid help. How has aid help and what can we learn. How can we help provide a better evidence base for policymaking in this area just for the record. I prepared a couple of slides where I've sort of tried to outline the questions that we are going to raise today but I just hear concentrating on the first one. What works what does not work and what could work in foreign aid in the pursuit of a sustainable human development agenda characterized by global environmental change and the need for planetary stewardship. I would suggest that we try to keep this question this focus in mind throughout the day because that's the overall question that we are trying to address. Welcome and it is my pleasure now to hand over to Sharon Joma who will basically take us through the day and Sharon in her kind but firm way will lead us the whole way through part one through part two and to the conclusion at four o'clock. Welcome Sharon. Thank you. Let's do it.


Hello, and welcome to noon conferences hosted by MRI online response to the changes happening around the world right now and the shutting down of in person events. You decided to provide free daily noon conferences to all radiologists worldwide. Today, we're joined by Dr. Carolyn De Benedectis, who is an associate professor of radiology at the University of Massachusetts medical school. In addition, she has the roles of vice chair for education and radiology residency program director. A quick reminder, there'll be time at the end of the hour for a Q&A session. Please use the Q&A feature to ask your questions and we'll get to as many as we can before our time is up. That being said, thank you so much for joining us today. Dr. De Benedectis, I'll let you take it from here. All right, so some of you might have been able to join me for my first breath intervention lecture where we covered some parts of breath intervention. Today, we're going to cover ultrasound guided procedures. Thomas and the Cincinnati biopsies need a localization and savvy scout localization to sum up procedures and breast imaging. So what are the most common ultrasound guided procedures? Well, we can do a lot under ultrasound and it's honestly my preferred way if I can to do biopsies. I think it's more comfortable for the patient. Let's take more skill in the radiologist part, but it's quicker. The patients are happier and it takes less time. So the things we do under ultrasound guidance are final aspirations of both masses within the breast as well as axiolins notes. We can aspirate this. We can do core needle biopsies and we can do needle localization or savvy scout localization. Transducer selection. So when you're doing ultrasound guided procedures, you want to make sure you have a high frequency transducer at least 7.5 megahertz or higher. You want to focus on the near field to a depth of three to five centimeters and you want to make sure it's a linear array transducer. This is an example of a linear array transducer. So it's not that body transducer you guys use for your other rotations that's curved. This is flat. Before you do the biopsies, you want to make sure that the patient has been asked for an NSAID clavate for five days. If they're on Covenin, they must be up long enough at my institution. The rule is for an INR to be 1.2 or less. Again, you need to check with your specific institution on what they do. You want to stop heparin or lobenox at least 24 hours before. The one thing I drill and drill and drill into my residence is before you even start the procedure to identify the pectoralis muscle on the screen. Sometimes it might be so deep that it's not even in the image. So what I always tell them to do is have the test increase the depth so that they are guaranteed that that pectoralis muscle is far, far away. Because, honestly, the only time you can really do significant harm to a patient during a breast procedure is during an ultrasound biopsy if you violate the pectoralis muscle and puncture the pleura of the lung. You can cause a pneumothorax. So it's really important that the first thing you always do prior to starting a procedure is to identify the pectoralis muscle. You need to remember that objects and distances appear greater than they actually are. The image is magnified. And we went over the pneumothorax warning. So this is what I usually do. The first time I have a resident do a procedure is I will bring up an image from a ultrasound of biopsy we're doing. From that ultrasound, the pre-procedure ultrasound, I will have them identify all of the structures. So it's really important that you know the structure. So this is the skin here. And then here's our mass. This is all tissue here. But then this is the pectoralis muscle here. It's hypoachroic with some echogenic striations within it, okay? Right there.  Now this looks like it's really far apart, but the truth is this is a matter of centimeters. So you have to be really careful. So here this is when the procedure has already began. And you can see the needle coming in here. And notice that the needle is flat. You'd always rather to come in shallower than come into steep and end up within the pectoralis muscle or worse within the lung. So you want to make sure you explain the procedure prior to starting. I always take the patients through every single step from cleaning them off to numbing them to the biopsy itself, to placing the clip as well as any post-procedure mammograms that will occur. I always explain the risk. We include pain bleeding infection routinely. For pain, I just tell them that it's at any point they have pain. They have every right to tell us to stop and we want to know and we'll give them more numbing medicine. And that makes them feel a lot less anxious. And then bleeding is really a hematoma. I tell them it's really not like you're going to bleed to death. That it's more like you can get a large hematoma and these can last up to two months and can cause cosmetic discoloration. Infection, the rate of infection is less than 2%. Pneumothorax and chest tube I don't routinely consent for unless there is a reason to. For example, if I have a super, super, super thin patient or I've had patients that literally there's the skin, the mask and the chest wall, you know, I will consent them for that. But you really should never cause a pneumothorax, you need a chest tube. And then if the patients have implants, I always, always, always consent for implant rupture. And I actually, when we used to have paper, now we're all electronic, I used to actually have an initial right next to the word implant rupture in the wrist so that it was clear it's been explained to them. Again, give the patient the opportunity to ask questions and make sure you address all of them. This is a super important part of doing breast procedures. Patient positioning, you want to make sure they're supines. So, you know, we've all learned that it's always better to take your time to position the patient so that you feel you have the best and safest approach than to just be like, oh, it's okay, I'll make do because that's how problems happen. So you want to make sure the patient's supine you want to roll the patient on a wedge away from the side of the biopsy so that the, you know, the breast is falling and the pack is planting down.  The way they would purchase a breast physical exam, and you may need to turn the structure to the opposite side so that you're not reaching across the patient you always want to have the breath that you're doing the procedure on closest to you. So proper positioning of the patient would be like this, the ultrasound should be on the opposite side from the breast you're doing the procedure on. Whether you hold the probe or the tech holds the probe, it should still be on the opposite side. And then you should be closest to the breast you're doing the procedure on. So you really want to make sure you've looked at the images before you start the procedure. This is the most important thing in all image guided procedures you want to localize, locate the image on the lesion. Sorry, locate the lesion on the image. You also want to make sure you've read the diagnostic reports early to make sure you're biopsying the correct lesion a lot of patients have multiple different lesions and you want to make sure you're biopsying the correct one. When you actually get in there and you put the probe on before you put the needle in you want to put Doppler color Doppler on the lesion and the area around the lesion to make sure there's no large vessels in the path of the biopsy device. So just do your best to avoid those to avoid hematoma. Again, always double check the lesions relation to the pectoralis muscle and ensure you are far away from it. So just quick things on local anesthesia. We, at my institution, we use 1% buffer lidocaine we use when we see a bicarb to every 10 species of lidocaine. Not always possible. There's been shortages of bicarb over the last few years, but it is nice if you can buffer it, it's things less for the patient. I always tell my residents you always want to have a skin wheel, a good size skin wheel that leads to a lot of patient comfort because if you move the needle, they don't keep getting a stick in the skin if the skin is numb. Then you want to numb the path up to the lesion. I also tell them to numb around the lesion either above or below. We say to use the hydro dissection technique if the lesion is too close to the pectoralis muscle or the skin, and I'll show you what that is, but it involves dumping a nice pile of lidocaine either inferior or superior to the lesion depending on where you need more space to kind of create space, a virtual space between the lesion and the other area that you do not want to go through with the needle. If there's significant vascularity in the lesion, you can use lidocaine with epinephrine. Epinephrine causes vasoconstriction in the lesion and will decrease bleeding. What are the pros? Well, when you're there, there's less bleeding and you feel better, right? The radiologist feels better because we're not seeing a lot of bleeding. What's the cons? When the epinephrine lays off, you can get delayed bleeding and the patient is now out of the office and having bleeding. So I tend not to use lidocaine with epitone on ultrasound-guided procedures because of this, but if something's really vascular, I will do it to decrease the chance of an immediate post-biopsy hematoma. If you are going to use it, I always do a quick screen for any major cardiac issues. Again, if you're not using a lot, it's a minimal amount of epinephrine and it shouldn't be an issue, but again, always screen for anything, especially allergies, et cetera. Usually when patients aren't being monitored, the traditional teaching is you only want to use up to 30 cc's of lidocaine total for a procedure in the same day. You know, there's varying opinions on this. Is this the safest thing to do to be like really sure you're not going to have an adverse event, right? Because lidocaine tend to have cardiac toxicity, of course. But sometimes it's just not possible now because our imaging is so much better. Sometimes we're biasing two and three lesions. It's not more an abreast and sometimes 30 cc's doesn't cut it. But you should try to stay as close to this as you can when possible while still maintaining patient comfort. So this is a hydro dissection technique I was telling you guys about. Mainly we use it to create space between the pectoralis muscle and a lesion. However, you can also use it if the lesion is too close to the skin to make sure you don't go through the other side of the skin. So what you want to do is you want to aim your needle right at the perfect corner where you get a nice angle between the lesion and the pectoralis muscle. And then you just want to dump a ton of lidocaine there. And what it should do is it should create a tissue plane. It should hydrate that between tissue planes and create a temporary pillow almost between the lesion and the pectoralis.  So when we do ultrasound by this aspiration, you can use any size needle you want. It just depends on the thickness of the fluid. So if you see simple fluid start with your 21 or your 20. However, if you see a lot thicker fluid you'll probably want to upgrade to your 16 or 18 and sometimes it's really, really thick.  When you aspirate the fluid from assist aspiration you want to know the color and amount. Again, always staying parallel to the chest wall. At our institution we just guard fluid unless it's frankly hemorrhagic or dark maroon or dark brown. Generally hemorrhagic fluid can assist can be due to a papillary carcinoma in the wall. Normally you'll see a mural nodule it's very rare to aspirate assist that doesn't have a mural nodule or a really thickened wall. But if you ever do aspirate frankly hemorrhagic fluid the safest thing is to send it to psychology. So why don't we send the other colors of fluid to psychology. We don't because a lot of times assist is sitting around with this fluid in it a long time and you can get false atypia as a result because these cells have kind of been sitting in this fluid for a while and kind of start to look funky.  You always want to aspirate assist completely if you can and on post biopsy images you want to confirm that it's resolved. If for any reason assist does not aspirate completely you want to convert to core biopsy. Because then there's a worry that this is not just a simple benign system or simple complicated system. Sometimes you may need post aspiration films if there was a mammographic correlate to ensure that mammographic correlate resolved. If you ever actually aspirate assist that you thought was a mammographic correlate and the mammographic correlate persists then you need to move to stereotactic biopsy of the mammographic correlate if it's worrisome.  Recurrent breast is 40% of breasts that are going to recur by two years recurrence of assist due to the presence of cancer on the wall is extremely rare. There's no scientific reason to re aspirate honestly you should only be aspirating simple for two reasons one you need to resolve a mammographic finding and you're unsure if the system fully correlates with it or to the patient a significant pain or just comfort from the pain. Honestly, otherwise you should just leave simple this alone. Some surgeons may if it recur ask you to core the wall. That's up to the surgeon. It's not playing I recommend. However, if you do have a complex this which has real modularity or thickened wall. There's no question that you should core it. It's not a complex this complicated this and simple this can be aspirated and if they fully resolve your fine but complex this should always be court ultrasound guided FNA. Again, we talked about this they can be used on a axillary lymph node or solid lesion that's too close to nipple implants or other things like the chest wall to safely do it. I actually did one of these I had a patient that was close next to me who had implants that were quite large in and there was very little space between the lesion and implants so I FNA that instead of court it. The way I perform is I use 21 gauge needle with a syringe and perform active suction the entire time using the syringe as I'm FNA. I usually do three passes and I put it inside a light and send it to psychology. This is an example of an FNA in a lymph node. So this is the big lymph node with lymph node you want to make sure you're taking the samples from the cortex which is hypocoic, not the echogenic. Highland, and that's very important that you take yourself from the cortex because that's where the cancer will be. So ultrasound guided corneal biopsy. There are multiple devices. Again, this is the real one you have to be careful with. Okay, this is the one procedure. Yeah, the FNA you could cause injuries to but this is the one where if you're going to cause an injury is going to be during the core biopsy with the spring loaded device. So there are plenty of spring loaded biopsy devices we use 14 gauge most commonly. There's the Bard monopsy. There's the achieve there's the vacuum assisted devices that are 14 gauge called the finesse. There's also a 12 gauge vacuum device from salaro or the finesse. Most of these have a throw. For example, the Bard monopsy is the one I'm going to talk about today because it's the one I use. It has a 2.2 centimeter grow. It has a one point XM sorry that's a type of it should be a 1.9 centimeter drop. And the total length of the needle vary. We use a 10 centimeter total length needle. It also comes in 13 and 15 but we only stock the 10 centimeter. So it's really important to read your package and understand understand the total length of the needle and which one you're using. Some devices can be deployed so that there is no throw two examples are the achieve in the salaro but there's also other devices that do it as well. And those can be used if you don't if you're if you're nervous about having a throw that you may be too close to other structures such as an implant or the pectoralis muscle or large vessel or something like that. I tend to not like this as much because I tend to find that I end up pushing FNA at that point, because a lot of times the masses are too difficult to fear with this already deployed needle, but it's a good thing to try first you can try to get a court and not FNA it. Most of these come with 13 gauge introducers or if there are 12 gauge they come with an 11 gauge introducer. And you use that so that you're only going through the skin one. So this is what I use and I'm just showing you the one I use this does not mean it's the best or the only one. There is definitely multiple devices that you can use. But this is a backfire spring loaded bar monopsy. What you do is you cock it twice clockwise using this green circle and then the green the light green circle at the back is the trigger to fire it. What happens here are. It's cocked like this and when you do the initial when you when you press the back button what happens is the trust brings out 2.2 centimeters from the distance when it was totally fully cocked and then this this sheet then cuts over it so that you end up with a core. And it all happens instantaneously. So I'll just invite about these I don't use skin incisions for 14 gauge devices. There are some exceptions if I'm close to an implant or close to the pack and I'm afraid the force I need to get through the skin could accidentally get me too far I will use a skin neck. You want to position the tip of the needle just proximal to the lesion if you talk to your pathologist and I really urge anyone that does breast intervention you should get to know your pathologist. You should really be close with your breast pathologist and you should talk to them about what they need, because your goal is not just to get the sample for the patient, your goal is to get the best sample for the patient so that the most accurate pathologic read can be performed. So I talked to pathologists pretty much through my fellowship and and being an attending to always ask them what they want and what most pathologists have told me is they don't want only the lesion tissue. They want you to have some of the normal tissue, the transition or capsule, and then the lesion, and that way they can make the best pathologic diagnosis. So you don't want to be within the lesion necessarily you want to be just proximal to it. Again, always make sure you're parallel to the chest wall. And if you can't be parallel to the chest wall you always want to make sure you're at least 2.2 centimeters from the pectoralis muscle how do you do that. Well you're going to put the needle into the device, and then you're going to have the technologist measure from the tip to the pectoralis muscle. I always tell my residents I just round up to 2.5 just to make myself feel better. So I know I have a little wiggle room. You need to make sure the needle is within the lesion after each biopsy what we do at my institution is we take one image in the plane of the biopsy and then we take an orthogonal image at least once and document it. The ACR guidelines do not say that you have to take this orthogonal image it's recommended but not required so for ACR certification if your institution does that. I don't need this image but I think it's great because if you get this cordon path, then you can show the pathologist and the breast surgeon hey I was right in the middle of it. Here's your orthogonal lesion. It's clear, the orthogonal image is clear I was in there. It's discordant. You know, I don't think rebiopsy is worth it. I think this needs an excision. At my institution we do a minimum of three to four cores with a 14 gauge or two to three cores with a 12 gauge. This is just an image of ultrasound guided biopsy from actually my one of the fellow. And you can see the pectoralis muscles down here the skin is up here it was a little deep I could not get completely parallel, but you can see my ectogenic needle going through my hypocoic mass and I'm well far away from the pectoralis muscle and pre level. So the specimen you can place the specimen directly in saline or on a saline so tell the pad, and then place it in formalin it's really important that you do not get the needle into formalin and then put it back into the patient. Every institution does this differently and what you guys are going to learn is some of you as residents rotate through different sites in different hospitals, some of you don't. So the ones of you that do, you know, it's really important that you ask each site, when they put a clear solution out in a cup, what is it, you want to make sure it's not formalin. Okay. Clearly it's helpful pad is always safe, but if they give you a couple of fluid and you want to make sure it's not formalin and don't assume just because one place gives you saline that all places give you saline right. We acquired a new hospital where I worked and I went to this new site for the first time to do a biopsy, and there was a specimen cup with clear fluid in it. I took the specimen out of the, you know, I took the needle out of the patient I opened the specimen I was just about to put it back in the patient and I thought, huh, let me just double check.  I said is that formalin and they said yes. So thank God I hadn't put the needle back into the patient. And from then on, you know, I asked them for a saline assessment cup full of saline that they could then pour the formalin into, or it's helpful pad. So it's really important to ask, especially when you're transitioning from residency to a new fellowship or from fellowship to a new attending job. There's a form of specimen rating graph on lesions if there were calcifications in the lesion. Again, if there were no calcifications on mammography within a lesion, this step isn't necessary, but if there were, it can be a nice way to confirm you've gotten calcifications and the lesion. Also, it's important to document the time out of the body from the for the specimen and the time into formula. And again, this is all to help your pathology colleagues get the best diagnosis possible. And then we send it to pathology or if it's a lymph node, we send it to psychology. It's important to know that if you want just psychology, you send it in at least at my institution, we send it in satellite, which I'm assuming is the same for everyone. However, if it's for flow cytometry, my institution likes it in saline or in our PMI or Hank. So it's always important to check with your psychologist. About what solution you should put your, your cores or your FNAs in. So definitely always really, this is why you need that open line of communication with your psychology department, your pathology department to make sure you're getting the best results for your patient. Micro markers. So before placing a micro marker, you want to confirm on the mammogram on the most recent pre procedure mammogram that there are no other micro markers in the same breast. So I always do this before I go into the patient. This is part of my pre procedure image review. So if there is a micro marker in the patient's breast, you want to make sure you select a different type of micro marker for each biopsy that way they can be easily distinguished if localization needs to be done. It's really important to remember that this is going to stay in the patient. And if this is denied, it's going to stay in the patient for a very long time. And it can be a night of infection if it gets contaminated. So I am super OCD. I'm sure it drives my residents crazy how I always do not uncover the tip of the of the introducer for the clip. Do not uncover it until you're ready to put it in the body and then uncover it. Make sure it doesn't touch anything until it gets into the introducer. So really be super careful. I have heard of a case once, not my direct patient, but an institution I was at where a patient had recurrent infection because, you know, the clip was not put in in a sterile way. So it's super important that you are really careful about this. Again, you also want to try to place the micro marker in the center of the lesion. And it's important to remember that it's a plunger device. So you actually want the tip of your, your micro marker introducer to be just proximal to center of the lesion because when you plunge it out, it's going to go a little further. And you always want to make sure you're not too far in the leisure also could plunge out outside of the lesion. The other thing I drill into my residence is it unlike the biopsy device where you can hub it and not worry about going farther than the introducer. This is not that case. The introducer for the micro marker is longer than the biopsy device introducer in most cases. So don't just hub it in there thinking that you're safe and it's going to stop. This could actually end up going to the pectoralis or an implant or something, some place you don't want it. So always remember that and watch, always watch the tip of your introducer as it's coming out of the biopsy introducer sheet to make sure you're not going too far. And then we always do a post clip mammogram to confirm placement of the clip and make sure it correlates with the mammographic finding if there was one. If there was a mammographic finding and your clip doesn't correlate with it, then you might need to do either a stereotactic biopsy of the finding on mammogram if it's concerning enough, or if it's not super concerning, you can do a six month follow up. So these are just an example of the clips. These are just the ones we use in our institution. Again, there are different ones everywhere you use.  We call them all sorts of things for the patients. But this is the introducer. And as you can see, there's always a lock. Every introducer is different. Some you turn it and line up to red dots. Some you just remove a sheet. Some you like this one, you have to push this red lock device and then push it and then so it's unlocked so it can go down. It just depends. And then these are them. The most common are ribbons, wings, coils or springs. And different companies have different coils, wings and ribbons. So it's good to say this is a barred coil. This is a, you know, I don't know why I'm blanking on another name. But you want to make sure you give the company sometimes because sometimes there's multiple different coils and they actually have a different appearance depending on the company. So Tomo guided biopsies. So we're moving on. We're now done with ultrasound guided biopsies and we're going to cover ultrasound guided localizations and savvy under those subsequent topics. So Tomo said this is guided biopsies. What's the indication for this? If it's finding is only found on Tomo and you can't biopsy it any other way. There's no ultrasound correlate. It can't be seen on 2D mammography to do a stereo. And this usually for the most part is architectural distortion that we biopsy this way. Not only there can be asymmetries and other things, but I would say of all the Tomo biopsies we do at my institution, over 95% of them are architectural distortions. This can be done upright. The device we have is done upright. And it's stereotypic guided and mammographically guided and we use a 10 gauge vacuum assisted needle. So here's an example of distortion. So this could only be seen on Tomo. We could not see it on the 2D. That's actually a calc, not a clip there. We did an ultrasound, nothing. So now we had to target it. First, you do a scout image to make sure we're in the right area. Then we do prefire images here. As you can see, this is the distortion here and these would be Tomo, but you know, it's hard to show Tomo on on on PowerPoint, but you can kind of see the distortion here as well. And you make sure on the 3D image that you're there. And the way this works is the patient is sitting in a chair the way they would for like a typical needle look. And again, there's a paddle with a open, open paddle that has square that's open just like a needle localization. And there's a biopsy device attached to the Mamo machine, at least in the system we have there's all different types of systems. So once you ensure that the tip is near the lesion, then you fire, you do the biopsy, and then you'll do a post biopsy image here to ensure that you're that everything's in the right spot. And then you deploy a clip. And you're good to go needle localization. So once you biopsied everything. So now we've done stereotactic biopsies Tomo biopsies and ultrasound guided biopsies. Now what do you do if the lesion you biopsy needs to come out, right? And the lesions aren't palpable. And so traditionally, way back when we only did need a localization and the goal here was to place a wire within the lesion of interest that has a thickener in it. And it takes a non palpable lesion and makes it palpable because it's the thickener and the thickener part is localized within the lesion. Then all the surgeon has to do is cut down, feel down for the thickener and it's palpable. And so we know the thickener is in the middle of the lesion. So essentially it makes a non palpable lesion palpable to the surgeon. And this is the only way we did these for many, many years. Actually, my entire training was only need a localization that no other real methods existed, maybe until my fellowship, but maybe not even then. These can be performed under mammographic ultrasonic or MRI guidance. Most of the time we use the modified copans wire or Hawkins wire. And as I said, the wires have the stiffener. So the needle that you use to introduce the wire is a 20, 20, a hollow board 20 gauge needles. And there's also a wire with a hook and a stiffener that's associated with the kit. And it comes in multiple links. So it goes by the wire link. And then each wire has the corresponding appropriate links needle within the kit. So I'm sorry goes by the needle length and it has the appropriate wire within the kit. So depending on the distance from the skin to the lesion, you pick the appropriate thing and they come in 357.5 and 10 centimeter needle length. So here we go. I think I started on this at the end of our last lecture. This is that 20 gauge hollow board needle that you see here. And this is your wire. So here's your wire and you can see this part here is thicker. You guys see that. And then there's a hook. So this is the part that you want to bury in the lesion and it's important to note that from the tip of the hook to the center of the stiffener is 1.5 centimeters and that's very important. Because what we do know is if you bury the needle. I'm sorry if you bury the wire at the hub to the first hatch mark. Okay. And then you unsheathe it. You need to have the needle 1.5 centimeters distal to the center of the lesion. Okay, so past the center of the lesion in order for when you want to sheet it. The thickness to be in the center of the lesion. So what you do is you put this needle 1.5 centimeters past the center of your lesion, then you bury the wire within the needle to the first hatch mark. And then you do a double hatch mark further up and once in a while you make a poor decision and you pick too short a needle and you can't quite get there. Then your option is to bury it to the second hatch mark. However, the problem is the needle has a cutting device at the end the wire doesn't and in a fatty breath the wire should go pretty easily without the needle and advanced where you need it. However, if you're in a dense breath sometimes the wire will not go it's not sharp. So that's why you really want to make sure you do great pre procedure planning, and you have the appropriate length needle.  Well then hold the needle and the wire in place so it doesn't fall out. And once you unsheathe the hook is hard to get the wire out and you don't want to have to get it out because it's very uncomfortable for the patient. So indications for needle we do localization for biopsy proven lesions for lumpectomy or excision so if it's a cancer for lumpectomy if it's atypia or a high risk lesion for excision. However, we can also localize lesions that are not amenable for percutaneous biopsy for an excisional biopsy. So approach like all procedures as I cannot stress enough plan plan plan know your procedure know your lesion know what you're doing before you get in there. It's like carpenters say right measure twice cut once right we want to plan twice and only biopsy once. So you want to approach the lesion in the plane where the distance from the skin is the shortest to the lesion. And that's really important. However, if you can't see the lesion, the shortest distance isn't going to help you. So once you decide on the shortest distance, you want to take a look at the lesion in the view that you'll be looking at it. So if you're going to come from superior inferior on Mamo, you want to look at the CC view and you want to say alright the shortest distance is superior. Let me look at the CC view and you look and you say can I see the lesion now if it's a clip is always easy to see a clip, but sometimes if it's calcifications or an asymmetry can be different. And you say oh darn I can't see it well you can't look sign you can't see so in that case, you'd move to the longer distance from the skin, if you can see it better. And then again, with your approaching for medial or lateral you want to look at the true lateral view to ensure you can see the lesion. For ultrasound and MR lobes we only go for medial or lateral. Okay, that's really important to know. So Mamo localization. For Mamo you want to, you can do two things. You can use Mamo localizations for loping a micro marker with inhalation seen on ultrasound. That's not seen on ultrasound. Sorry, you can use it for calcifications or masses that are not amenable to percutaneous biopsy that require pathologic diagnosis. Usually the patient is sitting in it in a Mamo chair. However, if you're going to go from below the patient is standing so below sometimes can be trumps by your patient. If you've got a fainter, let me tell you if you have a fainter or a super nervous nilly, sometimes going from below does not work well. The other time it won't is that the patient has a large abdomen. Then sometimes the abdomen is so large it creates a block the light and you can't get the shadow for the crosshairs. So things to think about with below. I mean you always want to go from the shortest distance but if your patients going to pass out multiple times, and you're not going to be able to do it going from below isn't really worth it. The patient is in compression for the procedure. This can be performed as a single wire. You can also do multiple single wires, or you can do two wires to bracket larger lesions or spans of calcifications. All right, so kind of the look here's what we do we put the breast in compression using an alphanumeric grid, we take a scout film and localize the leash on the image, and then we take the coordinates from the alphanumeric grid, and we localize where the lesion is. So you'll see you'll get like a, a two or something like that. And then we'll use crosshairs to do that on the breast so we can see it, and then we'll num the area. Once you're nice and numb, we place the needle so that the hub of the needle is at the crosshair. So it projects right over the crosshairs. Once that happens, we then reposition the patient in the orthogonal view. So if you start in the CC, you'll move to the 90. And then this is where on the orthogonal view you want to adjust the needle to be 125 centimeters past the lesion. Your goal is probably you always would rather have your needle past the lesion when you go to the orthogonal view, then to have it short of the lesion, because you really want to make sure you're moving in the plane in the correct plane. So you always want to go past the lesion. So I almost always if there's room with compression, get the needle as close to the hub as I can on the initial placement with the crosshairs, and then pull back. So you'd rather pull back on the needle in the orthogonal view than advance. Again, then you're once you're in the right spot and you've taken the images to prove your 1.5 centimeters past the lesion, you're going to put the wire in and deploy to the first hatch mark, then you're going to remove the needle over the wire using a pinch tip pull And then for the OR, we always take at our institution CC and lateral views with with just the wire in place and we also put a BB on the entrance of the wire, and we send it to the OR and that's what our surgeon likes again it's all about communication I can't stress enough. Communicate with your surgeons, find out what they like. Our surgeons also like us to measure the length of the wire outside the body, give them the total length and do the math to show them the wire, the length of the wire inside the body. Remember, your goal here is to make sure the patient gets the best care possible and the surgeon's able to do the best surgery surgery possible. So knowing what the surgeon needs to do the procedure accurately is going to make you a better radiologist and provide better patient care. So here's an example. We have this mask here with architectural distortion and and calcifications in it.  Okay, then we put the needle in to project the shadow of the needle directly over the crosshairs which we did and this is a hub of the needle right here. So now we're going to move to the orthogonal view. Here is the orthogonal view. And like I said, I have the needle and we're past the lesion. So then I'll measure 1.5 centimeters which this looks a little far so I probably pulled back a bit. Then I'm going to put the wire in. Then I'm going to use seldinger text meat to take the needle out and as you can see here, the stiffener is within the lesion and the hook is just distilled to the lesion to hold it in place. And then you can see here it's the post procedure images the CC in the 90. Again, you can see the the wire right at the clip and the mask and the hook just distilled and you can see the BB on the entrance to the skin as well as we usually do a nipple marker to I forgot to mention that. And same here and then when the surgeon send you the specimen, the surgeon is going to send you the specimen and what you want to find in the specimen is the lesion. Or clip depending on what was visible pre surgery and the wire. Now, this is where you serve a vital purpose. Okay. This specimen is not one that you call the OR and you say all good. Close the patient. Our surgeons at our institution wait to hear from us. If you look, the clip and the mass are on the edge of the specimen, which is going to mean either maybe they didn't get the whole lesion or the borders, the margins are going to be close, which would need the patient to have a reassession. So this is where you contribute hugely to patient care. You should get on the phone to your surgeon, you should say, you know, Dr so and so the clip and the math are really close to the X edge. Now, I don't know what happens at your, your institution at ours they ink the different margins so I'll look up. They'll send me a paper that says red is lateral green is inferior blue is superior. So let's say this margin is green, and it's superior I'll say you know Dr larkin, the clip is close to the superior green margin, you should re excise that before closing others will use a short and a long string to orient the lesion. And you can help them that way but this is where you really help your surgeon and provide really good patient care. So you want to always make sure the lesion is in the center of the specimen to ensure that the surgeon got good margins and got the whole lesion. And that's what they rely on you to do remember it's all a team effort. And we all have to play as part of the team with these procedures. Here's an example of a bracket just to show you so this was a span of calcifications that are hard to see projecting on this image with two clips. And so you want to do like parentheses and, and this is perfect or you want to be just outside of both of the clips right you don't want to be within in between the two clips, you want to create parentheses right if you have the word. And you put parentheses around it, you're not going to have the parentheses between the B and the R and the E and the T right, you're going to have it outside to be an outside the T, and you want to do that with a bracket look as well you want it outside of the area of interest whether it's the span of calc, or the clip. So as you can see on the orthogonal view here this is perfect just like parentheses right we're trying to put parentheses around the two clips. And we have it just outside just posterior to one clip and anterior to the other clip. And that is absolutely perfect for the needles and they're 1.5 centimeters just digital solution. We then put the wires in and as you can see here the stiffeners are projecting right where the clips are, and they're just outside of it. And when the surgeon does the specimen radiates, takes out the specimen and sends it to it. It's perfect. This is a perfect specimen. The lesions of interest are in the center of the specimen. We see both lesions of interest are clipped and we also see the wire. So this is perfect. So this is one where you can call your surgeon and you say everything looks great. You're good to close. Ultra sound low. So again we do the ultrasound look when it's clearly visible under ultrasound, i.e. a solid mass. However, it's really important what I do is I always look at the pre biopsy images. I look at how big it is and if it doesn't look very big. I then look at the post biopsy ultrasound images like when they document the clip in there. And I look and if I see solid mass because we've removed some and now there's a clip in there, I will convert to a mammal look. You don't want to look a clip under ultrasound. Some of these new beautifully seen ultrasound. These are some clips that are really meant for ultrasound like the hydra mark and things like that that create assist around them. If you have one of those, maybe it's possible, but I cannot tell you how many times I've been burned saying, oh yeah, I see the clip.  They need to pull the other wire. So the safest thing to do is if you don't see the mask clearly on the post biopsy images or wasn't very big on the pre biopsy images to just convert and look the clip under memo. So why do I like ultrasound look? First of all, the patient is so much more comfortable. There's no compression. There's two kinds are much, much quicker. And of course, there's no radiation exposure. So if you can do it, this is a good way to do it. You want to localize the lesion under ultrasound, then you insert the needle through the largest part of the lesion. Of course, after you've administered lidocaine. And then again, just like with a mammal look, you make sure it's 1.5 centimeters past the center of the lesion and the tech can measure that for you. Then you deploy the wire to the first hatch mark. Again, do seldom here and then get post procedure mammograms. Okay, I remember you're always doing this in the medial or lateral because you want the whole length of the needle to be seen in the in the image. And if you were to do it from superior in here, all you'd be seeing is a dot. And you wouldn't be able to see the whole length of the needle, which would be dangerous and not accurate. So always do it in the medial or lateral again, where the lesion is closest to. As for length of needles, honestly, what I always use, I always use a 7.5 for an ultrasound look, you always need a longer needle than you think for an ultrasound look. However, if the lesion is very superficial, you know, close to the skin, I will go down to a seven to a five. And if the lesion is ever super, super deep, I'll go to the 10. I hate using 10 surgeon pay 10. You know, if you don't have to use a 10 don't use a 10 it's just too long, and they lose, you know, their, their land landmarks and their orientation. So here's an example of an ultrasound look on imaging. So here's my needle approaching my math. So my math is right here. Here's my pack right right here is my pack. Here's my flora. Okay, so we're going to come in parallel. We don't want to come into feet. You can see I'm trying to come in as parallel as possible. I then go through my lesion my tech measures 1.5 centimeters from the tip to the center as you can see right here 1.5 to okay I was point two millimeters off.  And as you can see, look at the beautiful hook here, and the stiffener is right in the center of the lesion. This is a perfect look. Sorry, again, you do post procedure mammogram. And again, you'll get a specimen radiograph and you want to ensure the lesion isn't it we're a little close here but I think it was around leaving it was time to see it.  You might be a little close on whatever margin that says MRI look, this is done when the lesion is not accessible for percutaneous ever guided biopsy and can only be seen on MR. This is rarely done. I think I've only done two or three of these and the entire like 10 years I've been practicing. And it's really done and the truth is if you're going to do this, and it wasn't pre biopsies, the lesion, I always place a clip before I put the needle in. And that's so that when they have the specimen radiograph you can confirm it's in the lesion so always drop a clip, even for ultrasound or any other type of look you do if there is no clip present, you really want to drop a clip before you look it. And the other important thing to do is please make sure your localization kit, your needle and wire is MR compatible, right, you always want to make sure you're using an MR compatible needle and wire kit. Again, just like everything else, you'd image first so for MRI that means you're going to admit or contrast, you're then going to target the lesion again it's kind of like a stereotype technique with MR place that micro marker in the lesion if it hasn't already been placed. And then you're going to use your MR compatible localization needle insert at 1.5 centimeters past the enhancing lesion or in this point it'll probably just be a target marker because the enhancement the contrast will probably have washed out by them. Confirm the needle position then deploy the wire remove the needle. Again, additional MR images are done to confirm the needle and yet again. This is just an image as I said I don't have many images. This is actually not from when I personally did, but you know, it looks just like a biopsy the images are not really that great for an MR low. Again, you're coming from medial or lateral. Now we have something amazing, which is just totally. I think in my opinion is made my job so much less stressful on our days. So, when there are needle localization, the patient would come in that day for their needle localization and they already had no our time and we never fail that the first patient of the day would be a fainter and the surgeon would be calling where's my patient there. I'm just screwing up my time and the patient's passing out and I can't get the needle in or the patient's really difficult or the locust really difficult. Yeah, it never fails. This new savvy system is great because you can place the savvy scout. I apologize. Hold on, sorry. You can place the savvy scout anywhere from 30 days to the morning of if you so desired or the day before before the surgery, which means the patient comes in. No one's in a rush. No surgeon is waiting for you and I really like it. Um, so this is a savvy scout system. There is a guide, which is actually it emits ultrasound so that it reflects sound that reflects off the reflector. This is the reflector that you put in the breath. This is the reflector introducer, which kind of looks like a clip introducer. So really putting the savvy scout in is just like putting a clip in. Okay, so it's pretty simple and it's really great. And then you'll confirm we have one of these boxes, the console and the guide in our department and there's also one in the OR. And so we confirm the reflector works. And what happens is just it's kind of like, you know, with a Geiger counter as you get close to radiation at beef, when you get to the reflector this beat. So we will just ensure that it beats and we usually will mark the skin where the where the signal comes. The reflector looks like it's the size of a dime. This is the reflector here, but these are the antenna. So as long as the either span of the antenna is covering the lesion, they can get accurate localization. So what are the indications of contraindications and the same indications as Anita low for pre localization of non public lesion. So the absolute contraindication is a large hematoma at the site of the mass to be localized. You know, sometimes you do a biopsy and the patient gets this big hematoma. The problem is the heme and the blood interferes with signal transmission. So we can't do it until the hematomas results. The other thing is usually you don't want the lesion more than eight centimeters deep from one surface of the breath, because then sometimes it's too deep for the signal to come back. So we can make sure of that too. The other thing is you can undergo MRI in a three T or lower Tesla magnet after this is placed. However, you do get a big artifact from it, not horrible, but I think they should have their staging MR before the savvy scout is placed and that's why we don't place them, even if it looks like a cancer, we usually don't place these at the time of biopsy, because it is better to have your staging MR without the savvy and if you can help it. Modalities are placed and this is just taken directly from the savvy scout website. Again, it can place, it can be placed in the tissue, you know, for greater than 30 days. And it can be done under ultrasound MRI or radiography. So you want to make sure I'm sure they have an MR compatible. I have not done one of these under MR, but I'm sure they have an MR compatible one. Again, you probably you do not bring the guidance box into the MR right to do that outside, but this is just some of the instructions of what you can do, but it is compatible with all image guidance. So this is what it looks like. So I was looking this clip right so is that a and like 11 and a half. So then I put make sure the hub projects directly just like a meal localization over it. We then go to a different the different view, we can see the clip, we can see the device now instead of 1.5 centimeters past the lesion you wanted six millimeters past the lesion okay. So you do it six millimeters and that allows the reflector to be centered over the lesion. Also, if you can you want this to be answered to your clip now the clip is so much smaller than the lesion that if you happen to get it behind it. There's probably, there's probably still a part of the reflector that even though the clip is in front of it is available to get the sound wave, but they technically tell you should try to place an anterior if you can. So there's no chance the clip blocks the signal. And as you can see, I deploy it once it's deployed. Here is the savvy scout reflector here is the clip right anterior to it. Here's the savvy scout reflector here's the clip in the specimen you see the savvy scout reflector and the clip is nice and in the center of the lesion. So this was done accurately ultrasound placement again, just like ultrasound wire localization or clip placement, except this time you need to be six millimeters distal to the center of the lesion. So you want to put your tip six millimeters just, you know, this goes to the center of the lesion and here it's hard to see this one a little further than we had like this is the savvy here. So there's an antenna still in the lesion and that's what matters. And then you can see here is the savvy with the antenna near the lesion. You can also do savvy savvy scout placement just so you know in abnormal axillary lymph nodes it's really important if the patient's going to have neoadjuvant chemo that you place the savvy before chemo. Because once the patient has chemo the lymph node most likely is going to look normal and it's going to be hard to find that node. So this is just an example we place it in the cortex of the lymph node. And you can see the scat savvy here in the hypochoric cortex right here. And then you can see it on the film. Okay, and this helps them for some surgeons. And I'm sure really guarantee that the lymph node that was positive comes out and that they get the correct one note and this helps them with that. And that's it for my talk and I think I tried to leave I actually did not do the Dr. Graham part because I felt it would run over and people really know a few Dr. Graham set much anymore now we do MRI so I felt that I most people would rather me answer a few minutes of questions. And I will answer them. So can we aspirate complicated system are the complications yes you can ask you can absolutely aspirate complicated system that's a good way to ensure that it's a complicated system not a solid mess. The complications are the same as a regular this infection and bleeding. So, same complications. And yeah you can absolutely aspirate that complicated system if you need to resolve a mammographic abnormality, or if you for if you need to just prove it's not solid. If the tip touches the formalin is it possible. No, no to clean it off. No, the safest thing is to get a new needle. The safest thing is if it touches the formalin. If your needle touches the formalin just get a new needle, get a new needle and make sure it doesn't happen again. That's the safest thing I wouldn't try to clean it with alcohol or anything else, I would just get a new needle. Can you discuss performing a Thomas and this is biopsy and the lateral decubitus position for a lesion the lower part of the breath from when a from below approach would be the short distance so so we don't where I am we don't do this in the lateral decubitus ever. We will use the non shortest distance in this case, because we don't have the. We don't have the capability at our site to put a patient in a lateral decubitus position to do this. So what we will do is if it if it should if the shortest distance is from below, we'll then take the second shortest distance. So I can't speak to that as we do not do that. I'm sure there are places that do do it and I'm sure there's somebody who performed it that could answer that for you my apologies that I can't. Let me see if we have some more questions. Here's another one. If you need to use to give local anesthesia, the lesion is deep or near the pectoralis muscle. Good question. So I tend to use it for a regular numbing I use a 25 gauge. If it's deep or near the pectoralis. So if it's near the pectoralis, but the length of a regular 25 is fine. I still use a 25. Okay, if it's deep. What I'll do is I'll numb with the 25 first as far down as I can get and then I'll take a final. I'll use the thinnest final I can find to numb deeper to the lesion. So that's normally what I do. Another one. Which is the correct schedule and localize a mass on ultrasound. I don't fully know what this question is asking. Unfortunately, can you clarify. I'm happy to answer if it's clarified. If you're asking when to do it.  If you're doing a savvy, we usually do it a couple of days or whatever it's convenient for the patient. Usually when they do their preoperative visit. We will usually have them then come for their savvy. I assume that's what you're talking about. And that would be the same for ultrasound or. Mama. So sorry about if I miss under. I hope I understood your question. Another question. Non enhancement. Non enhancing mass biopsy procedure. So. Not quite sure what this question is asking either, but I wonder if what's being asked is what do you do if you see non mass enhancement on an MR. So people have different schools of thought. Non mass enhancement is not likely to be seen on on ultrasound. So right normally when we see mass enhancement on a MRI. We usually do a second look ultrasound see if we can find it on ultrasound and then biopsy it under ultrasound if possible if not we'll do an MR biopsy with non mass enhancement. I rarely do a second look ultrasound unless it's a really large area of non mass enhancement, and even then most likely you're not going to find anything. So for non mass enhancement, I usually go straight to MR guided biopsy.  I hope that answers that question. And then hold on there's some chat things I want to make sure I covered them all. Oh, I think we're all set. So yeah. So any other questions. We are heading, we've got about two minutes if there are other questions and I'm happy to take them. All right. Oh wait, here we go. Cost of the savvy scout. So the savvy scout is more expensive than any localization I do not know the exact cost but I do know it's more expensive. We have our MAMO department and our surgeons all decided the cost was worth it for the efficiency. There's other things to there's a magnetic version there's a nuclear there's a radio nucleotide version. So there's all different versions of other non needle non wire localizations and you can compare costs I know the one that involves radioactivity is difficult because there's all as you can imagine all sorts of precautions with that one and God forbid you can't find it and the whole or be locked down. But there's, but definitely these new localization techniques such as savvy magnet scout than the radioactive one those are all more expensive than you need a localization I do not honestly know the exact cost of a savvy scout but it is definitely more expensive than you need a localization. Do you have do you use a clip. I'm sorry, hold on me because this will be our last question because now I think we just hit one o'clock. Do you use a clip with large lesion. Well seen on autism. Yes, I always use a clip. It's just always the safest it's better safe and sorry if if a patient is really losing it over the fact that I'm going to put a clip in them and it's a big lesion and they're like really freaked out then that would be the only exception but I would find it just absolutely safest to to use a clip always and be consistent. Last question, do you have a video on how you do a mammal low hook wire, I don't have a video. Personally, I've never made a video, you know, I've never made a video of me doing a look on a patient. Thank you everybody. I don't want to hold people over but thank you so much. I should bring this to a close. I want to thank you Dr Devin elect this for your time today and thank you all for participating our new conference. A quick reminder is coming to be available on demand at MRI online calm in addition to all the previous Please follow us on social media at the online calm for updates. And tomorrow, please join us for a new conference with Dr Suresh Mukherjee on head and neck. Thank you.


What was your first experience into the construction world? I can remember standing on top of the Boston University Student Services Center that we built that was a five-story building right behind Fenway Park, and it was opening day of the Red Sox, and we were standing on top of a roof slab that had not been poured yet so we're balancing on the rebar, me and like ten guys, and the Blue Angels flew overhead and we're all standing there and it's like a hot April day next to Fenway Park and we were all just so happy and so excited and I was like this is the coolest shit I've ever seen in my life like this is what I want to be doing forever like this is so cool. It's beautiful.


Resistance escalation waseration between the مثل speculate and the situation continued to die down. The CCTV picturesPLICED. the images crewt be very careful that there are people out of the car. who have kicked the petrol and drink the Matcha in this going oks flooding. The people who had shook the14v couldn't even power up. UsingpaGate in this show. Again, fish satellites and other smallpox were perilousopy emcofoall in such a situation. The incident hurled against the Benedictine National Reserve.


What we're seeing here today is the first arrival of an MH-139 to the 908th Airlift Wing. Almost two years to the day since our last C-130 left, we finally have aircraft showing up for our next mission to be the flight training unit for the MH-139. What aircraft arrival means for the base is, we are now fully aligned with the base in terms of doing air education training command missions. Just like Air University on the base trains Air Force officers and NCOs in their craft we're going to train MH-139 air crew to fly to defend missile sites in the West and do DV support in Washington DC. Correct, this is the first aircraft and the current program is 10 aircraft but there might be adjustments later on in the year as Congress and the President figure out what the budget's going to look like. It represents a generational improvement from the aircraft that Global Strike Command flies now. I don't know if it's in the shot but there is an older UH-1 Huey in the ramp as well that aircraft is what Global Strike flies now. The MH-139 is faster, more powerful, better armed and is more capable in almost every respect so it finally catches up Global Strike in order to bring it into the 21st century instead of flying a 20th century aircraft. What we've established in the area within 60 nautical miles of Montgomery is a training area that's going to have landing zones and where we will do aerial training and training out in the countryside in order to train the pilots and flight engineers to operate the aircraft. So as we get more aircraft delivered and as we start getting students in about a year there's going to be more and more aircraft in the air you'll see us and you'll hear us but we're not too loud I promise. I appreciate enormously the support that we've gotten from the Montgomery community. I'm able to go downtown frequently and talk with business leaders, with political leaders and the support that the 908 gets from the community is enormous. We feel it every day, we feel it on our training UTAs when my reserve wing is full strength and we can't wait to give back to the community on the air show this weekend so that people can see us and we can meet them.


Everyone and welcome. This is Melissa Arma with the Stock Swooshing and Reviewing Netflix. I called puts in this today. And actually, even though this hasn't had the extension yet, I'm expecting, I do think that this has the potential to be one of the biggest trades that I called today on the options newsletter. Why?  First of all, the chart's very, very strong, okay? So you have a lot of people that have been long Netflix because it looked like, and this is before today's gap down in the market, but in the last two, three days, and even here, back here, which I got called calls, this was a great call. I did a video on this. You can go back and watch it on YouTube from last week, but it looked like the stock was going to make new highs. It actually looked like it was going to continue, get over the high. The high back on here, again, this is September 1st, was $557.39. And the previous high, $713 was $575.37. This looked like it was going to do it, but unfortunately, it ran out of steam. The market gap down, the market is dragging and pulling everything down with it. You have this happen. It does happen. It's happening today. And this potentially could fall all the way down. If it breaks $520 to $500, that would be devastating to the stock because what do I mean? I mean, it could completely wipe out the bar that it had, the breakout bar that it had on A26. The low of this bar was $492. And again, I called calls on this. It were great trades. Everybody got out, I think, because everybody was up so much. But anyways, today, I called puts in this, and for this to retrace this, if in fact this does this, would be devastating for this chart, for this stock, and for all the people that went long and held it, thinking that it was going to go over the high. But when you get up this morning and you see a gap down, and this is what's so unique about what I do, I get up in the morning and I look at the gap, whether something's gapping up or it's gapping down, and I also look at the gap in the market. And that is how I make the choices of the trades that I call. And that's how I make the choices of the direction, whether it's a long or short. So this has not really got going quite yet. But once it gets full, first it has to break $525. But after $525, then it's $520, and then it just could completely go straight down. And literally, that's literally what this could do if this breaks $520. So watch this, a lot of time left in the day. Great, great put I called here in the Netflix. Good luck, everyone. If you're interested in the Gap Shop options newsletter, email me at melissathestalkschwisch.com. And if you want to learn how I rate the gaps and find and pick and play them, then you have to take the Golden Gap course. That's the two full day course that I have once a month. And that's $69.99. If you're interested in that, email me. Have a great day, everyone.


So we're here with Bruno. Hi. Yes, hi. I'm Gary. Nice to meet you. And what are we seeing here? Okay, this tiny camera is a tie-lapse camera. That means you can set a time interval for this camera. So this camera will take every photo at the time interval. Like one second, one minute, or one hour. And then the camera can auto-combination those photos into a tie-lapse video. And most important is this camera also runs on the 4W battery. And our strength is the power saving. So this 4W can run for over one year if you choose a one-hour interval. So let me do a very quick demo for you. One-year battery life for one hour interval. Yes, one hour interval. And just doing a 4K image? Okay, so this one is only stored in the 4HD. Okay, 1080p. And as you see that we have a display. The display is small, but actually it's very clear. We use the IP as the display. It's actually the same with the Apple Watch. So you can do every setting here. And you can check the info here. You can check all the status right now in the camera. We have a system date and we have a schedule off. And if we press the nest, you can see all information on this screen. And also we can do the manual setting here. For the Tyler's camera, only two things you need to do. One is to select the interval. So you can select what kind of interval you want. Like five minutes. Okay, and then I can set the schedule. I can let the camera to record from 8am to 5pm. Nice. Yes, and then even I can select which week date I want the camera to work. I can select the whole week or I can just want to... I want to skip Sunday. Also I want to skip Saturday here. So the camera now will only capture the photo during the weekdays. Is it mechanized the way it turns? It's manually. It's manually, yeah, because of the power saving. So right now the camera is ready to shoot. And then I can just press... Oh no, sorry. I don't want to turn off. I want to ease it. So right now I can let the camera to start recording. So I can just press OK. And now the camera will be start recording. And you can, as you can see, you can fix up or put it in this waterproof box. And just hanging it up on the pole. Yes, we have a different kind of a bundle. Different kind of accessory bundle here. So for this one, yeah, this we have a clamp bundle here. Let me show you. Okay, like this one. We have a clamp bundle here. Also we have a warm-up bundle here. All the bundles include the waterproof housing. And also we have the bungee coats. So it's a very easy communion for you to mount it anywhere you want. So you can just mount it there and leave it for a year. Up to a year. For a month. Say it and forget it, yeah. But you have to remember to start recording, yeah. So this is our new product. And you're building upon past successes. So your company has made this a few times before? We already sell, the previous model already sell over one million devices. Which one? Right now it's already the end of the line. We don't show it anymore. Yeah, not anymore. But it depends on our success. We launch the new one. Here's an example of what a time lapse looks like. This is somebody just record the hole. It's built up on the hole. It's efficient setup. And we also have a construction and remodeling. Different kind of application. Even right now if you go to the YouTube and YouTube, you can select to like... I remember it's the ring. So that's the movie. The movie, yeah. They have the movie stuff because Jack is an author. She used our camera to record the whole process of the movie set to sell out, yeah. Nice. What else you show here at the booth? What is this? Okay, so this is our higher model. It is a construction bundle here. So actually include this waterproof housing. Include our high-end camera. Also include our clamp. And also we have the data transfer here. The kids. So you will see we have a very long USB cable. And the idea is we want to let the user can very convenient use the cable and plug into your Windows computer, Windows laptop. You can very easy to control the camera. I can show you a demo here right now. This is real time? This is real time. This is real time. Yeah, I can just... Upstairs? Where is this? Yeah, okay. So right now we already set up a camera. Camera is recording right now. And we can just plug in this USB cable. And then open our program. Connect to the camera. We can use this software to connect to the camera here. Okay, so now we got the camera status right now. Yeah, the camera is now already recording for this friend. And I can just stop recording. Or I can just download those complete files. You can open them? Yes, like I can... Okay, just re-opening the windows. It's border here. And so basically it's photos? Not photos. As I said, the camera will auto-combine those photos into a video. So right now you will check all the video files in the SD card. Six video files. Yes. Seven. And we can let the camera... Let me check if I can direct it to play the video. Yeah. I think... That's a video file. That's a video file, yeah. So you don't need to spend your time to use the software to do the editing. Yeah. Yeah, there is. Yeah, there is. Yeah. One video for each hour. Like one minute? Maybe. Yeah. Yeah, so it's a bit convenient. And actually the camera is still recording, so we don't bother the camera. Alright, so... So the idea is... The idea is we want to use this camera to become a tool for those videographers as you. If you work for your client, if your client is asking you to do a tie-lapse recording, you can use our solution to do a tie-lapse video very easily, yeah. And just leave it there and forget about it. Yes, especially... Just remember to come back when it's finished. As you see, right now we have a new accessory here, okay? We have the solar panel, and also we have a rechargeable battery inside the housing. So actually, this kind of camera will have forever battery power, yeah. So it can run all night? Run all night, all day, all month, even all year, yeah. Cool. Alright, and you sell over a million. Where are you based? Taiwan, yeah. We designed Taiwan, we made it in Taiwan, yeah. And you sell worldwide? Yes, we sell worldwide, yeah. Global distribution. What's the price for this one? Is there a price? For the market price, this one is a $249 US dollar. Alright, and the big professional one? And the professional one is a $720 US dollar. And we have a different kind of the bundle. We have the can bundle, we have the mount bundle, yeah. The pricing range will be $249 to $349. Yeah, depends on the different kind of accessory bundles. Here at Computex 2023, there's a bunch of 8K displays, there's 4K 120, and all these new TVs can come with HDMI 2.1, and there's a whole bunch of updates that I'm going to be filming at the Computex 2023 with the HDMI licensing administrator, which are organizing all the display makers, the cable manufacturers, and making sure that they are compatible with each other. There's a stable performance, there's no interference, and there's a smooth 8K future with 48 gigabit per second support. And there's the whole infrastructure for certifying, for testing, for making sure there's no interference with the Wi-Fi and Bluetooth and stuff that people have. So thanks a lot for watching. Check out my HDMI playlist in hdmi.charbacks.com.


I'm Ann Strainchamps, and this is to the best of our knowledge. It seems like science is always under attack. Creation versus evolution, the atomic bomb, the abortion pill, Galileo, anyone? But there is one other thing to be said about science. It's freaking cool. We're talking right now, anybody listening? We're probably in a beta brainwave state. I think that having empathy with chimpanzees is an immensely powerful tool. It's correlated with activity in the prefrontal cortex, which is the front part, the complex part of our brain. So that stuff's up and running at full speed. Humming along with beta waves. You have your little folding microscope. Yeah, something made out of paper. Yes, just like pencils are everywhere, so should be microscopes. This hour, kitchen physics. Hanging out with chimps and orangutans and more random but totally cool science.