In this forum paper we discuss how soil scientists can help to reach the recently adopted UN Sustainable Development Goals (SDGs) in the most effective manner. Soil science, as a land-related ...discipline, has important links to several of the SDGs, which are demonstrated through the functions of soils and the ecosystem services that are linked to those functions (see graphical abstract in the Supplement). We explore and discuss how soil scientists can rise to the challenge both internally, in terms of our procedures and practices, and externally, in terms of our relations with colleague scientists in other disciplines, diverse groups of stakeholders and the policy arena. To meet these goals we recommend the following steps to be taken by the soil science community as a whole: (i) embrace the UN SDGs, as they provide a platform that allows soil science to demonstrate its relevance for realizing a sustainable society by 2030; (ii) show the specific value of soil science: research should explicitly show how using modern soil information can improve the results of inter- and transdisciplinary studies on SDGs related to food security, water scarcity, climate change, biodiversity loss and health threats; (iii) take leadership in overarching system analysis of ecosystems, as soils and soil scientists have an integrated nature and this places soil scientists in a unique position; (iii) raise awareness of soil organic matter as a key attribute of soils to illustrate its importance for soil functions and ecosystem services; (iv) improve the transfer of knowledge through knowledge brokers with a soil background; (v) start at the basis: educational programmes are needed at all levels, starting in primary schools, and emphasizing practical, down-to-earth examples; (vi) facilitate communication with the policy arena by framing research in terms that resonate with politicians in terms of the policy cycle or by considering drivers, pressures and responses affecting impacts of land use change; and finally (vii) all this is only possible if researchers, with soil scientists in the front lines, look over the hedge towards other disciplines, to the world at large and to the policy arena, reaching over to listen first, as a basis for genuine collaboration.
Objective To identify an optimal imaging strategy for the accurate detection of urgent conditions in patients with acute abdominal pain.Design Fully paired multicentre diagnostic accuracy study with ...prospective data collection.Setting Emergency departments of two university hospitals and four large teaching hospitals in the Netherlands.Participants 1021 patients with non-traumatic abdominal pain of >2 hours’ and <5 days’ duration. Exclusion criteria were discharge from the emergency department with no imaging considered warranted by the treating physician, pregnancy, and haemorrhagic shock.Intervention All patients had plain radiographs (upright chest and supine abdominal), ultrasonography, and computed tomography (CT) after clinical and laboratory examination. A panel of experienced physicians assigned a final diagnosis after six months and classified the condition as urgent or non-urgent.Main outcome measures Sensitivity and specificity for urgent conditions, percentage of missed cases and false positives, and exposure to radiation for single imaging strategies, conditional imaging strategies (CT after initial ultrasonography), and strategies driven by body mass index and age or by location of pain.Results 661 (65%) patients had a final diagnosis classified as urgent. The initial clinical diagnosis resulted in many false positive urgent diagnoses, which were significantly reduced after ultrasonography or CT. CT detected more urgent diagnoses than did ultrasonography: sensitivity was 89% (95% confidence interval 87% to 92%) for CT and 70% (67% to 74%) for ultrasonography (P<0.001). A conditional strategy with CT only after negative or inconclusive ultrasonography yielded the highest sensitivity, missing only 6% of urgent cases. With this strategy, only 49% (46% to 52%) of patients would have CT. Alternative strategies guided by body mass index, age, or location of the pain would all result in a loss of sensitivity.Conclusion Although CT is the most sensitive imaging investigation for detecting urgent conditions in patients with abdominal pain, using ultrasonography first and CT only in those with negative or inconclusive ultrasonography results in the best sensitivity and lowers exposure to radiation.
Background
The clinical impact of sentinel lymph node (SN) biopsy in colorectal cancer is still controversial. The aim of our study was to determine the accuracy of this procedure from published data ...and to identify factors that contribute to the conflicting reports.
Methods
A systematic search of the Medline, Embase, and Cochrane databases up to July 2011 revealed 98 potentially eligible studies, of which 57 were analyzed including 3,934 patients (3,944 specimens).
Results
The pooled SN identification rate was 90.7 % (95 % CI 88.2–93.3), with a significant higher identification rate in studies including more than 100 patients or studies using the ex vivo SN technique. The pooled sensitivity of the SN procedure was 69.6 % (95 % CI 64.7–74.6). Including the immunohistochemical findings increased the pooled sensitivity of SN procedure to 80.2 % (95 % CI 4.7–10.7). Subgroups with significantly higher sensitivity could be identified: ≥4 SNs versus <4 SNs (85.2 vs. 66.3 %,
p
= 0.003), colon versus rectal cancer (77.6 vs. 65.7 %,
p
= 0.04), early T1 or T2 versus advanced T3 or T4 carcinomas (93.4 vs. 58.8 %,
p
= 0.01). Serial sectioning and immunohistochemistry resulted in a mean upstaging of 18.9 % (range 0–50 %). True upstaging defined as micrometastases (pN1mi+) rather than isolated tumor cells (pN0itc+) was 7.7 %.
Conclusions
The SN procedure in colorectal cancer has an overall sensitivity of 70 %, with increased sensitivity and refined staging in early-stage colon cancer. Because the ex vivo SN mapping is an easy technique it should be considered in addition to conventional resection in colon cancer.
Objectives
The objective was to identify a set of clinical features that can rule out appendicitis in patients with suspected acute appendicitis and nondiagnostic ultrasound (US) results, allowing ...safe discharge and next‐day reevaluation without initial computed tomography (CT) or magnetic resonance imaging (MRI).
Methods
Data on clinical and US evaluation, including a number of prespecified variables potentially associated with acute appendicitis, were prospectively collected in two diagnostic accuracy studies of imaging. These studies included patients with suspected appendicitis seen in the emergency department (ED). For development and validation of the clinical decision rule (CDR), only patients with inconclusive or negative US results were included. There were 199 (of 422) patients in the development cohorts and 120 (of 211) patients in the validation cohort. Logistic regression analysis was used for data from patients with inconclusive or negative US results, and profiles were created of all possible combinations of predictors retained in the multivariable model. A final diagnosis was assigned by an expert panel based on perioperative data, histopathology, and clinical follow‐up of at least 3 months.
Results
The CDR selected patients after negative or inconclusive US for discharge and next‐day reevaluation without initial CT or MRI if fewer than two of the following predictors were present: male sex, migration of pain to the right lower quadrant, vomiting, and white blood cell (WBC) count higher than 12.0 × 109/L. Applying the CDR in the development set selected 126 of 199 (63%) patients with negative or inconclusive US results for discharge without further imaging. This rule reduced the probability of appendicitis from 26% (51 of 199) in the total group of patients with negative or inconclusive US results to 12% (15 of 126) in the group that would be discharged based on the rule (p = 0.001). In the validation set (n = 120), the decision rule selected 72 (60%) patients for discharge and next‐day reevaluation and reduced the probability of appendicitis from 20% (24 of 120) in the total group to 6% (4 of 72) in the patients selected on the rule (p = 0.001). The negative predictive value of the decision rule in the validation set was 94% (95% confidence interval CI = 87% to 98%). In comparison, the negative predictive value of CT in the same group was 99% (95% CI = 93% to 100%, p = 0.14), and that of MRI was 99% (95% CI = 94% to 100%, p = 0.12). Alternative decision rules based on combinations of the present decision rule with C‐reactive protein (CRP) results did not improve selection.
Conclusions
This newly developed CDR significantly reduces the probability of appendicitis in a large subgroup of patients with negative or inconclusive US results. These patients can be safely discharged for outpatient reevaluation without further initial imaging if proper follow‐up is available. This could assist in lowering the number of ED imaging investigations in patients with suspected appendicitis.
Resumen
Objetivos
Identificar un conjunto de hallazgos clínicos que pueda descartar una apendicitis en pacientes con sospecha de apendicitis aguda y resultados ecográficos no diagnósticos, de manera que permitan dar de alta de forma segura y reevaluarlos al día siguiente sin una tomografía computarizada (TC) o resonancia magnética (RM) inicial.
Metodología
Se recogieron de forma prospectiva datos sobre la evaluación clínica y la ecografía, que incluía un número de variables prestablecidas potencialmente asociadas con apendicitis aguda, en dos estudios de precisión de diagnóstico por imagen. Estos estudios incluyeron a pacientes con sospecha de apendicitis visitados en el servicio de urgencias (SU). Se incluyeron sólo los pacientes con resultados ecográficos negativos o no concluyentes para el desarrollo y la validación de la regla de decisión clínica (RDC). Hubo 199 pacientes (de 422) en la cohorte de desarrollo, y 120 pacientes (de 211) en la cohorte de validación. Se utilizó un análisis de regresión logística para los datos de pacientes con resultados ecográficos negativos o no concluyentes, y se crearon los perfiles de todas las posibles combinaciones de factores predictivos introducidos en el modelo multivariable. Se asignó un diagnóstico final por un panel de expertos en base a los datos de la cirugía e histopatológicos y del seguimiento clínico durante al menos tres meses.
Resultados
La RDC seleccionó pacientes tras una ecografía negativa o no concluyente para dar de alta y reevaluar al día siguiente sin una TC o una RM inicial si presentaban al menos dos de los siguientes factores predictivos: sexo masculino, migración del dolor al cuadrante inferior derecho, vómitos y recuento de leucocitos por encima de 12,0 × 109/L. Aplicando la RDC en la cohorte de desarrollo, se seleccionó a 126 de 199 (63%) pacientes con resultados ecográficos negativos o no concluyentes para dar de alta sin más pruebas de imagen. Esta regla redujo la probabilidad de apendicitis de un 26% (51/199) en el grupo total de pacientes con resultados ecográficos negativos o no concluyentes, a un 12% (15/126) en el grupo que se habría dado de alta basándose en la regla (p = 0,001). En la cohorte de validación (n = 120), la regla de decisión seleccionó a 72 (60%) pacientes para dar de alta y reevaluar al día siguiente, y redujo la probabilidad de apendicitis de un 20% (24/120) en el grupo total a un 6% (4/72) de los pacientes seleccionados basándose en la regla (p=0,001). El valor predictivo negativo de la regla de decisión en la cohorte de validación fue de un 94% (intervalo de confianza IC 95% = 87% a 98%). En comparación, el valor predictivo negativo de la TC en el mismo grupo fue de un 99% (IC 95% = 93% a 100%, p = 0,14), y el de la RM fue de un 99% (IC 95% = 94% a 100%, p = 0,12). Las reglas de decisión alternativas basadas en las combinaciones de la presente RDC inicial junto con resultados de proteína C‐reactiva no mejoraron la selección.
Conclusiones
Esta RDC recientemente desarrollada reduce significativamente la probabilidad de apendicitis en un gran subgrupo de pacientes con resultado ecográfico negativo o no concluyente. Estos pacientes pueden ser dados de alta de forma segura para reevaluar de forma ambulatoria sin más pruebas de imagen iniciales si se dispone de un correcto seguimiento. Esto podría ayudar a reducir el número de pruebas de imagen en el SU en pacientes con sospecha de apendicitis.
Background
Rapid genetic counseling and testing (RGCT) in newly diagnosed high‐risk breast cancer (BC) patients may influence surgical treatment decisions. To successfully integrate RGCT in practice, ...knowledge of professionals’, and patients’ attitudes toward RGCT is essential.
Methods
Between 2008 and 2010, we performed a randomized clinical trial evaluating the impact of RGCT. Attitudes toward and experience with RGCT were assessed in 265 patients (at diagnosis, 6‐ and 12‐month follow‐up) and 29 medical professionals (before and after the recruitment period).
Results
At 6‐month follow‐up, more patients who had been offered RGCT felt they had been actively involved in treatment decision‐making than patients who had been offered usual care (67% vs 48%, P = 0.06). Patients who received DNA‐test results before primary surgery reported more often that RGCT influenced treatment decisions than those who received results afterwards (P < 0.01). Eighty‐seven percent felt that genetic counseling and testing (GCT) should preferably take place between diagnosis and surgery. Most professionals (72%) agreed that RGCT should be routinely offered to eligible patients. Most patients (74%) and professionals (85%) considered surgeons the most appropriate source for referral.
Conclusions
RGCT is viewed as helpful for newly diagnosed high‐risk BC patients in choosing their primary surgery and should be offered routinely by surgeons.
Female breast cancer patients carrying a BRCA1/2 mutation have an increased risk of second primary breast cancer. Rapid genetic counseling and testing (RGCT) before surgery may influence choice of ...primary surgical treatment. In this article, we report on the psychosocial impact of RGCT.
Newly diagnosed breast cancer patients at risk for carrying a BRCA1/2 mutation were randomized to an intervention group (offer of RGCT) or a usual care control group (ratio 2:1). Psychosocial impact and quality of life were assessed with the Impact of Events Scale, Hospital Anxiety and Depression Scale, Cancer Worry Scale, and the EORTC QLQ-C30 and QLQ-BR23. Assessments took place at study entry and at 6- and 12-month follow-up visits.
Between 2008 and 2010, 265 patients were recruited into the study. Completeness of follow-up data was more than 90%. Of the 178 women in the intervention group, 177 had genetic counseling, of whom 71 (40%) had rapid DNA testing and 59 (33%) received test results before surgery. Intention-to-treat and per-protocol analyses showed no statistically significant differences between groups over time in any of the psychosocial outcomes.
In this study, RGCT in newly diagnosed breast cancer patients did not have any measurable adverse psychosocial effects.
Objectives: The objective was to evaluate the diagnostic accuracy of clinical features and laboratory test results in detecting acute appendicitis.
Methods: Clinical features and laboratory test ...results were prospectively recorded in a consecutive series of 1,101 patients presenting with abdominal pain at the emergency department (ED) in six hospitals. Likelihood ratios (LRs) and the areas under the receiver operating characteristic curve (AUC) were calculated for the individual features. Variants of clinical presentation, based on different combinations of clinical features, were investigated and the accuracies of combinations of clinical features were evaluated.
Results: The discriminative power (AUC) of the individual features in patients with suspected appendicitis ranged from 0.50 to 0.65. For five of the 23 predictor sets, the accuracy for appendicitis was more than 85%. This accuracy was only found in male patients. The relative frequency of these predictor sets ranged from 2% to 13% of patients with suspected appendicitis. A combination of the clinical features migration of pain to the right lower quadrant (RLQ), and direct tenderness in the RLQ, was present in only 28% (120/422) of clinically suspected patients, of whom no more than 85 patients had appendicitis (71%). A “classical” presentation (combination of migration of pain to the RLQ, tenderness in the RLQ, and rigidity) occurred in only 6% (25/422) of patients with suspected appendicitis and yielded an accuracy of 100% in males but only 46% in females.
Conclusions: The discriminative power (AUC) of individual clinical features and laboratory test results for appendicitis was weak in patients with suspected appendicitis. Combinations of clinical features and laboratory tests with high diagnostic accuracy are relatively infrequent in patients with suspected appendicitis.
The present report describes a patient with septic thrombosis of the inferior vena cava (IVC) related to a subhepatic abscess adjacent to the IVC. Despite prolonged antimicrobial therapy and systemic ...anticoagulation, sepsis and septic embolism persisted while the size of the thrombus increased. Percutaneous mechanical thrombectomy was performed, resulting in removal of the infected thrombus and complete clinical recovery.
We treated 11 young children (3-6 years old) who had uncomplicated femoral shaft fractures primarily with an external fixator. 9 children were available for follow-up and were evaluated for the ...amount of overgrowth and rotational deformity. All underwent a clinical examination and an MRI after mean 21 (13-25) months. The mean overgrowth was 0.4 (-0.3 - -1.1) cm and the anteversion angle showed a mean increase of 12°, as compared to the contralateral femur. In 5 children with an anteversion angle difference of 10° or more, a second MRI was done 4 years after the trauma. The mean anteversion angle difference of the femora in these 5 children had diminished from 15° on the first MRI to 7.4° on the second. 3 of the 5 children had a full correction of their rotational deformity. Growth did not correct the rotational deformity in the oldest child in this group.
Objectives
Head-to-head comparison of ultrasound and CT accuracy in common diagnoses causing acute abdominal pain.
Materials and methods
Consecutive patients with abdominal pain for >2 h and <5 days ...referred for imaging underwent both US and CT by different radiologists/radiological residents. An expert panel assigned a final diagnosis. Ultrasound and CT sensitivity and predictive values were calculated for frequent final diagnoses. Effect of patient characteristics and observer experience on ultrasound sensitivity was studied.
Results
Frequent final diagnoses in the 1,021 patients (mean age 47; 55% female) were appendicitis (284; 28%), diverticulitis (118; 12%) and cholecystitis (52; 5%). The sensitivity of CT in detecting appendicitis and diverticulitis was significantly higher than that of ultrasound: 94% versus 76% (
p
< 0.01) and 81% versus 61% (
p
= 0.048), respectively. For cholecystitis, the sensitivity of both was 73% (
p
= 1.00). Positive predictive values did not differ significantly between ultrasound and CT for these conditions. Ultrasound sensitivity in detecting appendicitis and diverticulitis was not significantly negatively affected by patient characteristics or reader experience.
Conclusion
CT misses fewer cases than ultrasound, but both ultrasound and CT can reliably detect common diagnoses causing acute abdominal pain. Ultrasound sensitivity was largely not influenced by patient characteristics and reader experience.
PDF
