Computed Tomography Utilization for the Diagnosis of Acute Appendicitis in Children Decreases With a Diagnostic Algorithm

Objective: The primary objective of this project was to decrease computed tomography (CT) utilization for the diagnosis of appendicitis in an academic children's hospital emergency department (ED) through a multidisciplinary quality improvement initiative.

Background: Appendicitis is the most common abdominal diagnosis leading to the hospitalization of children in the United States. However, the diagnosis of appendicitis in children can be difficult and many centers rely heavily upon CT scans. Recent recommendations emphasize decreasing CT use among pediatric patients because of an increased lifetime risk of radiation-induced malignancies.

Methods: A retrospective review was conducted of patients diagnosed with appendicitis in the ED at Children's Mercy Hospital from January 1, 2011 to February 28, 2014 to establish a baseline cohort. From August 1, 2014 to July 31, 2015, a newly designed diagnostic algorithm was used in the ED and patients were prospectively followed. Any patient discharged from the ED received a follow-up phone call. Patients treated for appendicitis before and after pathway implementation were compared. In addition, any patient evaluated for appendicitis after implementation of the algorithm was analyzed for adherence to the clinical pathway. Differences between the 2 groups were analyzed using ANOVA, Wilcoxon Rank Sum, χ2, and Fisher Exact tests.

Results: Of 840 patients seen after implementation of the diagnostic algorithm, 267 were diagnosed with appendicitis. After implementation of the algorithm, CT utilization decreased from 75.4% to 24.2% (P < 0.0001) in patients with appendicitis. CT utilization was 27.3% after implementation, regardless of the ultimate diagnosis or algorithm adherence. The diagnostic pathway had a sensitivity of 98.6% and specificity of 94.4%.

Conclusions: Implementation of a diagnostic algorithm for appendicitis in children significantly decreases CT utilization, whereas maintaining a high sensitivity and specificity.journals.lww.com

by Shah, Sohail R.; Sinclair, Kelly A.; Theut, Stephanie B.; Johnson, Kathy M.; Holcomb, George W. III; St. Peter, Shawn D. / Today, 5:30 AM

Systematic review and meta-analysis of the association between diabetes mellitus and incidence and mortality in breast and colorectal cancer

Background Increasing evidence suggests that diabetes mellitus (DM) is associated with increased cancer incidence and mortality. Several mechanisms involved in diabetes, such as promotion of cell proliferation and decreased apoptosis, may foster carcinogenesis. This study investigated the association between DM and cancer incidence and cancer-specific mortality in patients with breast and colorectal carcinoma. Methods A meta-analysis of controlled trials, prospective cohort studies and pooled cohort studies published after 2007 was conducted. Embase, PubMed and the Cochrane Library were searched. Summary hazard ratios (HRs) were calculated using a random-effects model. Sensitivity and subgroup analyses were performed to adjust for confounders, mode of DM assessment and follow-up time. Results Twenty studies were included to investigate the association between DM and breast and colorectal cancer incidence and cancer-specific mortality. The studies predominantly comprised patients with type II DM. The overall HR for breast cancer incidence was 1·23 (95 per cent confidence interval 1·12 to 1·34) and that for colorectal cancer was 1·26 (1·14 to 1·40) in patients with DM compared with those without diabetes. The overall HR was 1·38 (1·20 to 1·58) for breast cancer- and 1·30 (1·15 to 1·47) for colorectal cancer-specific mortality in patients with DM compared with those without diabetes. Conclusion This meta-analysis indicated that DM is a risk factor for breast and colorectal cancer, and for cancer-specific mortality.

British Journal of Surgery
Posted on: Wednesday, September 04, 2013 7:46 PM
Author: K. M. J. De Bruijn, L. R. Arends, B. E. Hansen, S. Leeflang, R. Ruiter, C. H. J. van Eijck
Subject: Systematic review and meta-analysis of the association between diabetes mellitus and incidence and mortality in breast and colorectal cancer

Opportunities and challenges of next-generation DNA sequencing for breast units

Background The aim of this review is to introduce the topic of next-generation DNA sequencing, a new technology that is being introduced into clinical practice, and to explain the potential impact for breast cancer surgeons and the wider breast cancer multidisciplinary team. Methods The PubMed database was used to identify relevant studies relating to breast cancer genetics. This evidence was then used to provide context and background information to demonstrate how next-generation sequencing (NGS) might change breast cancer practice. Results With NGS, breast cancer clinicians will know whether their patients carry high-risk mutations in genes, such as BRCA1 or BRCA2, before the start of treatment. This could alter treatment decisions; for instance, more women might opt for mastectomy instead of breast-conserving surgery, or for bilateral rather than unilateral surgery. Conclusion The introduction of NGS will have a significant impact on breast cancer services in the near future. Speed of testing will improve in regions of the world where NGS is adopted in place of conventional sequencing, and, as costs decrease, genetic testing will also become accessible and realistic in less well funded health economies. This will create opportunities to improve patient treatment and challenges for the breast cancer multidisciplinary team.

British Journal of Surgery
Posted on: Thursday, March 27, 2014 6:25 PM
Author: S. M. Pilgrim, S. J. Pain, M. D. Tischkowitz
Subject: Opportunities and challenges of next-generation DNA sequencing for breast units

Outcome of sleeve gastrectomy as a primary bariatric procedure

Background Sleeve gastrectomy is being performed increasingly in Europe. Data on long-term outcome would be helpful in defining the role of sleeve gastrectomy. The aim of this study was to evaluate the outcome of sleeve gastrectomy as a primary bariatric procedure. Methods Medical charts of all patients who underwent a primary sleeve gastrectomy at the authors' institution between August 2006 and December 2012 were reviewed retrospectively using a prospective online data registry. For evolution of weight loss and co-morbidity, only patients with follow-up of at least 1 year were included. A subgroup analysis was done to compare patients with an intended stand-alone procedure and those with an intended two-stage procedure. Results A total of 1041 primary sleeve gastrectomies were performed in the study period. Median duration of surgery was 47 min, and median hospital stay was 2 days. Intra-abdominal bleeding occurred in 27 patients (2·6 per cent) and staple-line leakage in 24 (2·3 per cent). Some 866 patients had at least 1 year of follow-up. Mean excess weight loss was 68·4 per cent after 1 year (P < 0·001) and 67·4 per cent after 2 years. Smaller groups of patients achieved a mean excess weight loss of 69·3 per cent (163 patients), 70·5 per cent (62) and 58·3 per cent (19) after 3, 4 and 5 years respectively. No difference in postoperative complications was found between the subgroups. Seventy-one (8·2 per cent) of 866 patients had a revision of the sleeve gastrectomy; reflux or dysphagia was the indication in 34 (48 per cent) of these patients. Conclusion Sleeve gastrectomy is a safe and effective bariatric procedure. Maximum weight loss was achieved after 4 years. Long-term results regarding weight loss and co-morbidities were satisfactory.

British Journal of Surgery
Author: P. W. J. van Rutte, J. F. Smulders, J. P. de Zoete, S. W. Nienhuijs
Subject: Outcome of sleeve gastrectomy as a primary bariatric procedure

Thyroid hormone replacement for subclinical hypothyroidism

Subclinical hypothyroidism is defined as an elevated serum thyroid-stimulating hormone (TSH) level with normal free thyroid hormones values. The prevalence of subclinical hypothyroidism is 4% to 8% in the general population, and up to 15% to 18% in women who are over 60 years of age. There is considerable controversy regarding the morbidity, the clinical significance of subclinical hypothyroidism and if these patients should be treated.

Objectives

To assess the effects of thyroid hormone replacement for subclinical hypothyroidism.

Search methods

We searched The Cochrane Library, MEDLINE, EMBASE and LILACS. Ongoing trials databases, reference lists and abstracts of congresses were scrutinized as well.

Selection criteria

All studies had to be randomised controlled trials comparing thyroid hormone replacement with placebo or no treatment in adults with subclinical hypothyroidism. Minimum duration of follow-up was one month.

Data collection and analysis

Two authors independently assessed trial quality and extracted data. We contacted study authors for missing or additional information.

Main results

Twelve trials of six to 14 months duration involving 350 people were included. Eleven trials investigated levothyroxine replacement with placebo, one study compared levothyroxine replacement with no treatment. We did not identify any trial that assessed (cardiovascular) mortality or morbidity. Seven studies evaluated symptoms, mood and quality of life with no statistically significant improvement. One study showed a statistically significant improvement in cognitive function. Six studies assessed serum lipids, there was a trend for reduction in some parameters following levothyroxine replacement. Some echocardiographic parameters improved after levothyroxine replacement therapy, like myocardial relaxation, as indicated by a significant prolongation of the isovolumic relaxation time as well as diastolic dysfunction. Only four studies reported adverse events with no statistically significant differences between groups.

Authors' conclusions

In current RCTs, levothyroxine replacement therapy for subclinical hypothyroidism did not result in improved survival or decreased cardiovascular morbidity. Data on health-related quality of life and symptoms did not demonstrate significant differences between intervention groups. Some evidence indicates that levothyroxine replacement improves some parameters of lipid profiles and left ventricular function.

Published Online: 21 JAN 2009

Assessed as up-to-date: 30 MAY 2006

DOI: 10.1002/14651858.CD003419.pub2

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Radioiodine therapy for differentiated thyroid carcinoma with thyroglobulin positive and radioactive iodine negative metastases

Background

Differentiated thyroid carcinoma with thyroglobulin positive and radioactive iodine negative metastases has been observed in follow-up studies. The management of this condition remains controversial. Most studies support blind radioactive iodine treatment while others negate this approach.

Objectives

To assess the effects of radioiodine therapy for differentiated thyroid carcinoma with thyroglobulin positive and radioactive iodine negative metastases.

Search methods

Studies were obtained from computerised searches of MEDLINE, EMBASE, The Cochrane Library, China National Infrastructure (CNKI) and paper collections of conferences held in Chinese.

Selection criteria

Randomised controlled clinical trials and prospective controlled clinical trials.

Data collection and analysis

Two authors independently extracted data and interviewed authors of all potentially relevant studies by electronic mail to verify randomisation procedures. One author entered data into a data extraction form and the second one verified the results of this procedure.

Main results

Because of the absence of any suitable randomised or prospective controlled trial in this area, results currently cannot be presented.

Authors' conclusions

The currently available evidence is insufficient to reliably assess the potential of radioiodine treatment for differentiated thyroid carcinoma with thyroglobulin positive and radioactive iodine negative metastases.

Published Online: 21 JAN 2009

Assessed as up-to-date: 30 MAY 2008

DOI: 10.1002/14651858.CD006988.pub2

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Surgery versus primary endocrine therapy for operable primary breast cancer in elderly women (70 years plus)

Background

Several studies have evaluated the clinical effectiveness of endocrine therapy alone in women aged 70 years or over and who are fit for surgery.

Objectives

To identify and review the evidence from randomised trials comparing primary endocrine therapy (endocrine therapy alone) to surgery, with or without adjuvant endocrine therapy, in the management of women aged 70 years or over with operable breast cancer.

Search methods

For this update, the Cochrane Breast Cancer Group Specialised Register was searched 13th November 2007 using the codes for "early breast cancer", "endocrine therapy", "psychosocial" or "surgery".

Selection criteria

Randomised trials comparing primary endocrine therapy with surgery, with or without adjuvant endocrine therapy, in the management of women aged 70 years or over with early breast cancer and who are fit for surgery.

Data collection and analysis

Studies were assessed for eligibility and quality, and data from published trials were extracted by two independent reviewers. Hazard ratios were derived for time-to-event outcomes, where possible, and a fixed-effect model was used for meta-analysis. Toxicity and quality-of-life data were extracted, where present. Where outcome data were not available, trialists were contacted and unpublished data requested.

Main results

Seven eligible trials were identified of which six had published time-to-event data and one was published only in abstract form with no usable data. The quality of the allocation concealment was adequate in three studies and unclear in the remainder. In each case the endocrine therapy used was tamoxifen.

Data, based on an estimated 869 deaths in 1571 women, were unable to show a statistically significant difference in favour of either surgery or primary endocrine therapy in respect of overall survival. However, there was a statistically significant difference in terms of progression-free survival, which favoured surgery with or without endocrine therapy.

The hazard ratios (HR) for overall survival were: 0.98 (95% confidence interval (CI) 0.74 to 1.30, P value 0.9) for surgery alone versus primary endocrine therapy; 0.86 (95% CI 0.73 to 1.00, P value 0.06) for surgery plus endocrine therapy versus primary endocrine therapy. The HRs for progression-free survival were: 0.55 (95% CI 0.39 to 0.77, P value 0.0006) for surgery alone versus primary endocrine therapy; 0.65 (95% CI 0.53 to 0.81, P value 0.0001) for surgery plus endocrine therapy versus primary endocrine therapy (each comparison based on only one trial). Tamoxifen-related adverse effects included hot flushes, skin rash, vaginal discharge, indigestion, breast pain, sleepiness, headache, vertigo, itching, hair loss, cystitis, acute thrombophlebitis, nausea, and indigestion. Surgery-related adverse effects included paresthesia on the ipsilateral arm and lateral thoracic wall in those who had axillary clearance. One study suggested that those undergoing surgery suffered more psychosocial morbidity at three months postsurgery, although this difference had disappeared by two years.

Authors' conclusions

Primary endocrine therapy should only be offered to women with oestrogen receptor (ER) positive tumours who are unfit for or who refuse surgery. In a cohort of women with significant co-morbid disease and ER-positive tumours it is possible that primary endocrine therapy may be a superior option to surgery. Trials are needed to evaluate the clinical effectiveness of aromatase inhibitors as primary therapy for an infirm older population with ER-positive tumours.