Background
Treatment strategies for diverticulitis with abscess formation have shifted from (emergency) surgical treatment to non‐surgical management (antibiotics with or without percutaneous ...drainage (PCD)). The aim was to assess outcomes of non‐surgical treatment and to identify risk factors for adverse outcomes.
Methods
Patients with a first episode of CT‐diagnosed diverticular abscess (modified Hinchey Ib or II) between January 2008 and January 2015 were included retrospectively, if initially treated non‐surgically. Baseline characteristics, short‐term (within 30 days) and long‐term treatment outcomes were recorded. Treatment failure was a composite outcome of complications (perforation, colonic obstruction and fistula formation), readmissions, persistent diverticulitis, emergency surgery, death, or need for PCD in the no‐PCD group. Regression analyses were used to analyse risk factors for treatment failure, recurrences and surgery.
Results
Overall, 447 patients from ten hospitals were included (Hinchey Ib 215; Hinchey II 232), with a median follow‐up of 72 (i.q.r. 55–93) months. Most patients were treated without PCD (332 of 447, 74·3 per cent). Univariable analyses, stratified by Hinchey grade, showed no differences between no PCD and PCD in short‐term treatment failure (Hinchey I: 22·3 versus 33 per cent, P = 0·359; Hinchey II: 25·9 versus 36 per cent, P = 0·149) or emergency surgery (Hinchey I: 5·1 versus 6 per cent, P = 0·693; Hinchey II: 10·4 versus 15 per cent, P = 0·117), but significantly more complications were found in patients with Hinchey II disease undergoing PCD (12 versus 3·7 per cent; P = 0·032). Multivariable analyses showed that treatment strategy (PCD versus no PCD) was not independently associated with short‐term treatment failure (odds ratio (OR) 1·47, 95 per cent c.i. 0·81 to 2·68), emergency surgery (OR 1·29, 0·56 to 2·99) or long‐term surgery (hazard ratio 1·08, 95 per cent c.i. 0·69 to 1·69). Abscesses of at least 3 cm in diameter were associated with short‐term treatment failure (OR 2·05, 1·09 to 3·86), and abscesses of 5 cm or larger with the need for surgery during short‐term follow‐up (OR 2·96, 1·03 to 8·13).
Conclusion
The choice between PCD with antibiotics or antibiotics alone as initial non‐surgical treatment of Hinchey Ib and II diverticulitis does not seem to influence outcomes.
This multicentre retrospective cohort study included 447 patients with Hinchey Ib and II diverticular abscesses, who were treated with antibiotics, with or without percutaneous drainage. Abscesses of 3 and 5 cm in size were at higher risk of short‐term treatment failure and emergency surgery respectively. Initial non‐surgical treatment of Hinchey Ib and II diverticular abscesses was comparable between patients treated with antibiotics only and those who underwent percutaneous drainage in combination with antibiotics, with regard to short‐ and long‐term outcomes.
Most do not need drainage
Background:
Thalamic atrophy is proposed to be a major predictor of disability progression in multiple sclerosis (MS), while thalamic function remains understudied.
Objectives:
To study how thalamic ...functional connectivity (FC) is related to disability and thalamic or cortical network atrophy in two large MS cohorts.
Methods:
Structural and resting-state functional magnetic resonance imaging (fMRI) was obtained in 673 subjects from Amsterdam (MS: N = 332, healthy controls (HC): N = 96) and Graz (MS: N = 180, HC: N = 65) with comparable protocols, including disability measurements in MS (Expanded Disability Status Scale, EDSS). Atrophy was measured for the thalamus and seven well-recognized resting-state networks. Static and dynamic thalamic FC with these networks was correlated with disability. Significant correlates were included in a backward multivariate regression model.
Results:
Disability was most strongly related (adjusted R2 = 0.57, p < 0.001) to higher age, a progressive phenotype, thalamic atrophy and increased static thalamic FC with the sensorimotor network (SMN). Static thalamus–SMN FC was significantly higher in patients with high disability (EDSS ⩾ 4) and related to network atrophy but not thalamic atrophy or lesion volumes.
Conclusion:
The severity of disability in MS was related to increased static thalamic FC with the SMN. Thalamic FC changes were only related to cortical network atrophy, but not to thalamic atrophy.
Background
The current standard treatment for external rectal prolapse and symptomatic high-grade internal rectal prolapse is surgical correction with minimally invasive ventral mesh rectopexy using ...either laparoscopy or robotic assistance. This study examines the number of procedures needed to complete the learning curve for robot-assisted ventral mesh rectopexy (RVMR) and reach adequate performance.
Methods
A retrospective analysis of all primary RVMR from 2011 to 2019 performed in a tertiary pelvic floor clinic by two colorectal surgeons (A and B) was performed. Both surgeons had previous experience with laparoscopic rectopexy, but no robotic experience. Skin-to-skin operating times (OT) were assessed using LC-CUSUM analyses. Intraoperative and postoperative complications were analyzed using CUSUM analyses.
Results
A total of 182 (surgeon A) and 91 (surgeon B) RVMRs were performed in total. There were no relevant differences in patient characteristics between the two surgeons. Median OT was 75 min (range 46–155; surgeon A) and 90 min (range 63–139; surgeon B). The learning curve regarding OT was completed after 36 procedures for surgeon A and 55 procedures for surgeon B. Both before and after completion of the learning curve, intraoperative and postoperative complication rates remained below a predefined acceptable level of performance.
Conclusions
36 to 55 procedures are required to complete the learning curve for RVMR. The implementation of robotic surgery does not inflict any additional risks on patients at the beginning of a surgeon’s learning curve.
Background
Cognitive impairment, a common and debilitating symptom in people with multiple sclerosis (MS), is especially related to cortical damage. However, the impact of regional cortical damage ...remains poorly understood. Our aim was to evaluate structural (network) integrity in lesional and non-lesional cortex in people with MS, and its relationship with cognitive dysfunction.
Methods
In this cross-sectional study, 176 people with MS and 48 healthy controls underwent MRI, including double inversion recovery and diffusion-weighted scans, and neuropsychological assessment. Cortical integrity was assessed based on fractional anisotropy (FA) and mean diffusivity (MD) within 212 regions split into lesional or non-lesional cortex, and grouped into seven cortical networks. Integrity was compared between people with MS and controls, and across cognitive groups: cognitively-impaired (CI; ≥ two domains at
Z
≤ − 2 below controls), mildly CI (≥ two at − 2 <
Z
≤ − 1.5), or cognitively-preserved (CP).
Results
Cortical lesions were observed in 87.5% of people with MS, mainly in ventral attention network, followed by limbic and default mode networks. Compared to controls, in non-lesional cortex, MD was increased in people with MS, but mean FA did not differ. Within the same individual, MD and FA were increased in lesional compared to non-lesional cortex. CI-MS exhibited higher MD than CP-MS in non-lesional cortex of default mode, frontoparietal and sensorimotor networks, of which the default mode network could best explain cognitive performance.
Conclusion
Diffusion differences in lesional cortex were more severe than in non-lesional cortex. However, while most people with MS had cortical lesions, diffusion differences in CI-MS were more prominent in non-lesional cortex than lesional cortex, especially within default mode, frontoparietal and sensorimotor networks.
Abstract
Background
Pre-scheduled appointments can increase attendance in breast cancer screening programmes compared to ‘open invitations’ but relatively few randomized controlled trials exist. We ...investigated the effect of a pre-scheduled appointment on uptake in the Flemish population-based mammography screening programme.
Methods
Between September and December 2022, a total of 4798 women were randomly assigned to receive either a pre-scheduled appointment or open invitation. The difference in attendance was compared with Poisson regression analysis for the primary endpoint (attendance ≤92 days after date of invitation), yielding relative risks (RRs). This was done separately for three groups: women invited to a mobile unit and a history of nonattendance (group M-NA); women invited to a hospital-based unit and a history of nonattendance (group HB-NA); women invited to a hospital-based unit and a history of irregular attendance (group HB-IA). There were no women invited to a mobile unit and a history of irregular attendance.
Results
The RRs in favour of the pre-scheduled appointment were 2.3 95% confidence interval (CI) 1.80–2.88, 1.8 (95% CI 1.07–2.97) and 1.8 (95% CI 1.43–2.39), for groups M-NA, HB-NA and HB-IA, respectively. We found no statistically significant difference between the various RRs. The respective absolute gains in attendance between pre-scheduled appointment and open invitation were 8.3%, 4.4% and 15.8%.
Conclusions
Sending an invitation with a pre-scheduled appointment is an effective tool to increase screening attendance in both mobile and hospital-based screening units. The pre-scheduled appointment is associated with a considerable absolute gain in attendance which varies depending on the screening history.
Objectives
To assess the suitability of the Breast Imaging Reporting and Data System (BI-RADS) as a quality assessment tool in the Dutch breast cancer screening programme.
Methods
The data of 93,793 ...screened women in the Amsterdam screening region (November 2005–July 2006) were reviewed. BI-RADS categories, work-up, age, final diagnosis and final TNM classification were available from the screening registry. Interval cancers were obtained through linkage with the cancer registry. BI-RADS was introduced as a pilot in the Amsterdam region before the nationwide introduction of digital mammography (2009–2010).
Results
A total of 1,559 women were referred to hospital (referral rate 1.7 %). Breast cancer was diagnosed in 485 women (detection rate 0.52 %); 253 interval cancers were reported, yielding a programme sensitivity of 66 % and specificity of 99 %. BI-RADS 0 had a lower positive predictive value (PPV, 14.1 %) than BI-RADS 4 (39.1 %) and BI-RADS 5 (92.9 %;
P
< 0.0001). The number of invasive procedures and tumour size also differed significantly between BI-RADS categories (
P
< 0.0001).
Conclusion
The significant differences in PPV, invasive procedures and tumour size match with stratification into BI-RADS categories. It revealed inter-observer variability between screening radiologists and can thus be used as a quality assessment tool in screening and as a stratification tool in diagnostic work-up.
Key Points
•
The BI-RADS atlas is widely used in breast cancer screening programmes.
•
There were significant differences in results amongst different BI-RADS categories.
•
Those differences represented the radiologists’ degree of suspicion for malignancy, thus enabling stratification of referrals.
•
BI-RADS can be used as a quality assessment tool in screening.
•
Training should create more uniformity in applying the BI-RADS lexicon.
The COVID-19 pandemic forced the Dutch national breast screening program to a halt in week 12, 2020. In week 26, the breast program was resumed at 40% capacity, which increased to 60% in week 34. We ...examined the impact of the suspension and restart of the screening program on the incidence of screen-detected and non-screen-detected breast cancer. We selected women aged 50–74, diagnosed during weeks 2–35 of 2018 (n = 7250), 2019 (n = 7302), or 2020 (n = 5306), from the Netherlands Cancer Registry. Weeks 2–35 were divided in seven periods, based on events occurring at the start of the COVID-19 pandemic. Incidence of screen-detected and non-screen-detected tumors was calculated overall and by age group, cT-stage, and cTNM-stage for each period in 2020, and compared to the incidence in the same period of 2018/2019 (averaged). The incidence of screen-detected tumors decreased during weeks 12–13, reached almost zero during weeks 14–25, and increased during weeks 26–35. Incidence of non-screen-detected tumors decreased to a lesser extent during weeks 12–16. The decrease in incidence was seen in all age groups and mainly occurred for cTis, cT1, DCIS, and stage I tumors. Due to the suspension of the breast cancer screening program, and the restart at reduced capacity, the incidence of screen-detected breast tumors decreased by 67% during weeks 9–35 2020, which equates to about 2000 potentially delayed breast cancer diagnoses. Up to August 2020 there was no indication of a shift towards higher stage breast cancers after restart of the screening.
•Breast cancer incidence decreased by 37% during weeks 9–35 2020 in women aged 50–74, compared to weeks 9–35 2018/2019.•The incidence of lower stage tumors mainly decreased.•Due to the temporary suspension of the screening program, 67% fewer screen-detected breast tumors have been diagnosed.•The incidence of non-screen-detected tumors was less influenced by the pandemic and decreased only 7% in weeks 9–35 2020.•Up to August 2020 no shift towards a higher tumor stage at diagnosis was seen.
Overdiagnosis is the main harm of cancer screening programs but is difficult to quantify. This review aims to evaluate existing approaches to estimate the magnitude of overdiagnosis in cancer ...screening in order to gain insight into the strengths and limitations of these approaches and to provide researchers with guidance to obtain reliable estimates of overdiagnosis in cancer screening.
A systematic review was done of primary research studies in PubMed that were published before January 1, 2016, and quantified overdiagnosis in breast cancer screening. The studies meeting inclusion criteria were then categorized by their methods to adjust for lead time and to obtain an unscreened reference population. For each approach, we provide an overview of the data required, assumptions made, limitations, and strengths.
A total of 442 studies were identified in the initial search. Forty studies met the inclusion criteria for the qualitative review. We grouped the approaches to adjust for lead time in two main categories: the lead time approach and the excess incidence approach. The lead time approach was further subdivided into the mean lead time approach, lead time distribution approach, and natural history modeling. The excess incidence approach was subdivided into the cumulative incidence approach and early vs late-stage cancer approach. The approaches used to obtain an unscreened reference population were grouped into the following categories: control group of a randomized controlled trial, nonattenders, control region, extrapolation of a prescreening trend, uninvited groups, adjustment for the effect of screening, and natural history modeling.
Each approach to adjust for lead time and obtain an unscreened reference population has its own strengths and limitations, which should be taken into consideration when estimating overdiagnosis.
Background
The results of the DIRECT trial, an RCT comparing conservative management with elective sigmoid resection in patients with recurrent diverticulitis or persistent complaints, showed that ...elective sigmoid resection leads to higher quality of life. The aim of this study is to determine the cost‐effectiveness of surgical treatment at 1‐ and 5‐year follow‐up from a societal perspective.
Methods
Clinical effectiveness and resource use were derived from the DIRECT trial. The actual resource use and quality of life (EQ‐5D‐3L™ score) were documented prospectively per individual patient and analysed according to the intention‐to‐treat principle for up to 5 years after randomization. The main outcome was the incremental cost‐effectiveness ratio (ICER), expressed as costs per quality‐adjusted life‐year (QALY).
Results
The study included 106 patients, of whom 50 were randomized to surgery and 56 to conservative treatment. At 1‐ and 5‐year follow‐up an incremental effect (QALY difference between groups) of 0·06 and 0·43 respectively was found, and an incremental cost (cost difference between groups) of €6957 and €2674 respectively, where surgery was more expensive than conservative treatment. This resulted in an ICER of €123 365 per additional QALY at 1‐year follow‐up, and €6275 at 5 years. At a threshold of €20 000 per QALY, operative treatment has 0 per cent probability of being cost‐effective at 1‐year follow‐up, but a 95 per cent probability at 5 years.
Conclusion
At 5‐year follow‐up, elective sigmoid resection in patients with recurring diverticulitis or persistent complaints was found to be cost‐effective. Registration number: NTR1478 (www.trialregistrer.nl).
Maintained benefits
Between 2003 and 2010 digital mammography (DM) gradually replaced screen-film mammography (SFM) in the Dutch breast cancer screening programme (BCSP). Previous studies showed increases in detection ...rate (DR) after the transition to DM. However, national interval cancer rates (ICR) have not yet been reported.
We assessed programme sensitivity and specificity during the transition period to DM, analysing nationwide data on screen-detected and interval cancers. Data of 7.3 million screens in women aged 49-74, between 2004 and 2011, were linked to the Netherlands Cancer Registry to obtain data on interval cancers. Age-adjusted DRs, ICRs and recall rates (RR) per 1000 screens and programme sensitivity and specificity were calculated by year, age and screening modality.
41,662 screen-detected and 16,160 interval cancers were analysed. The DR significantly increased from 5.13 (95% confidence interval (CI):5.00-5.30) in 2004 to 6.34 (95% CI:6.15-6.47) in 2011, for both in situ (2004:0.73;2011:1.24) and invasive cancers (2004:4.42;2011:5.07), whereas the ICR remained stable (2004: 2.16 (95% CI2.06-2.25);2011: 2.13 (95% CI:2.04-2.22)). The RR changed significantly from 14.0 to 21.4. Programme sensitivity significantly increased, mainly between ages 49-59, from 70.0% (95% CI:68.9-71.2) to 74.4% (95% CI:73.5-75.4) whereas specificity slightly declined (2004:99.1% (95% CI:99.09-99.13);2011:98.5% (95% CI:98.45-98.50)). The overall DR was significantly higher for DM than for SFM (6.24;5.36) as was programme sensitivity (73.6%;70.1%), the ICR was similar (2.19;2.20) and specificity was significantly lower for DM (98.5%;98.9%).
During the transition from SFM to DM, there was a significant rise in DR and a stable ICR, leading to increased programme sensitivity. Although the recall rate increased, programme specificity remained high compared to other countries. These findings indicate that the performance of DM in a nationwide screening programme is not inferior to, and may be even better, than that of SFM.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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