Evaluation of the International Consensus Guidelines for the Surgical Resection of Intraductal Papillary Mucinous Neoplasms

Background

International consensus guidelines for intraductal papillary mucinous neoplasms (IPMNs) were revised in 2012.

Aims

We aimed to evaluate the clinical utility of each predictor in the 2006 and 2012 guidelines and validate the diagnostic value and surgical indications.

Methods

Forty-two patients with surgically resected IPMNs were included. Each predictor was applied to evaluate its diagnostic value.

Results

The 2012 guidelines had greater accuracy for invasive carcinoma than the 2006 guidelines (64.3 vs. 31.0%). Moreover, the accuracy for high-grade dysplasia was also increased (48.6 vs. 77.1%). When the main pancreatic duct (MPD) size ≥8 mm was substituted for MPD size ≥10 mm in the 2012 guidelines, the accuracy for high-grade dysplasia was 80.0%.

Conclusions

The 2012 guidelines exhibited increased diagnostic accuracy for invasive IPMN. It is important to consider surgical resection prior to invasive carcinoma, and high-risk stigmata might be a useful diagnostic criterion. Furthermore, MPD size ≥8 mm may be predictive of high-grade dysplasia.

     

Heel quantitative ultrasound in HIV-infected patients: a cross-sectional study

Purpose

HIV infection has been associated with increased risk of osteoporosis and fragility fractures. Dual-energy X-ray absorptiometry (DXA) is the reference standard to assess bone mineral density (BMD); however, it is not easily accessible in several settings. Heel Quantitative ultrasound (QUS) is a radiation-free, easy-to-perform technique, which may help reducing the need for DXA.

Methods

In this cross-sectional study, we used heel QUS (Hologic Sahara^®) to assess bone status in a cohort of HIV-infected patients. A QUS stiffness index (QUI) threshold >83 was used to identify patients with a low likelihood of osteoporosis. Moreover, we compared QUS results with those of 36 sex- and age-matched HIV-negative controls.

Results

244 HIV-positive patients were enrolled. Median heel QUI value was 83 (73–96) vs. 93 (IQR 84–104) in the control group (p = 0.04). 110 patients (45 %) had a QUI value ≤83. Risk factors for low QUI values were age (OR 1.04 per year, 95 % CI 1.01–1.07, p = 0.004), current use of protease inhibitors (OR 1.85, CI 1.03–3.35, p = 0.039), current use of tenofovir (OR 2.28, CI 1.22–4.27, p = 0.009) and the number of risk factors for secondary osteoporosis (OR 1.46, CI 1.09–1.95, p = 0.01). Of note, QUI values were significantly correlated with FRAX score (r = ?0.22, p = 0.004). According to EACS guidelines, 45 % of patients had risk factors for osteoporosis which make them eligible for DXA. By using QUS, we may avoid DXA in around half of them.

Conclusions

As HIV-positive patients are living longer, the prevalence of osteoporosis is expected to increase over time. Appropriate screening, prevention and treatment are crucial to preserve bone health in this population. The use of screening techniques, such as heel QUS, may help reducing the need for DXA. Further studies are needed to define the diagnostic accuracy of this promising technique in the setting of HIV.

     

Strukturierte onkologische Nachsorge

Background

Patients with cancer and recommendations for aftercare are increasing worldwide.

Objectives

Presentation of the current follow-up guidelines of selected gastrointestinal tumors.

Materials and methods

The current German S3 guidelines for colorectal cancer, pancreatic cancer, hepatocellular carcinoma, and gastric cancer are analyzed.

Results

The S3 guidelines for colorectal cancer and hepatocellular carcinoma favor structured aftercare. For a period of 2–5 years, a combination of case history, physical examination, imaging, endoscopy, and determination of tumor markers is recommended. Advocacy for structured aftercare for pancreatic or gastric cancer must be decided individually. In general, the follow-up time and interval should be adjusted to the complaints of the patient, regardless of the tumor type.

Conclusions

Structured aftercare makes sense and is already part in the monitoring of selected gastrointestinal tumors.

     

Choledocho- und Cholezystolithiasis

Background

Gallstones are present in approximately 10–20?% of the German population. Up to one fourth of them will develop symptoms or complications during their lifetime.

Objective

Based on recent guidelines, this paper reviews the evidence-based management of patients with gallstone disease.

Materials and methods

Most relevant recommendations of the updated S3 guidelines on the diagnosis and treatment of gallstone disease are provided. Developments are depicted in relation to the 2007 version of these guidelines. Complementary recommendations of the S2k guidelines on quality requirements for gastrointestinal endoscopy and of the European Federation of Societies of Ultrasound in Medicine and Biology (EFSUMB) guidelines on interventional ultrasound in gallstone disease are referred to.

Results

Based on recent scientific evidence, the guideline recommendations for diagnosis and treatment of patients with gallstone disease are presented. Requirements are rising for early surgical treatment of patients with acute cholecystitis (24 h), the timely management of patients with acute cholangitis and biliary pancreatitis (depending on severity) and on the sequential treatment of patients with simultaneous gallbladder and common bile duct stones (laparascopic cholecystectomy within 72 h after endoscopic bile duct clearance).

Conclusions

Up-to-date guideline-based management of patients with gallstone disease is an interdisciplinary task and requires comprehensive management concepts. A guideline-based algorithm is introduced.

     

Prediction Model for Two-Year Risk of Opioid Overdose Among Patients Prescribed Chronic Opioid Therapy

Background

Naloxone is a life-saving opioid antagonist. Chronic pain guidelines recommend that physicians co-prescribe naloxone to patients at high risk for opioid overdose. However, clinical tools to efficiently identify patients who could benefit from naloxone are lacking.

Objective

To develop and validate an overdose predictive model which could be used in primary care settings to assess the need for naloxone.

Design

Retrospective cohort.

Setting

Derivation site was an integrated health system in Colorado; validation site was a safety-net health system in Colorado.

Participants

We developed a predictive model in a cohort of 42,828 patients taking chronic opioid therapy and externally validated the model in 10,708 patients.

Main Measures

Potential predictors and outcomes (nonfatal pharmaceutical and heroin overdoses) were extracted from electronic health records. Fatal overdose outcomes were identified from state vital records. To match the approximate shelf-life of naloxone, we used Cox proportional hazards regression to model the 2-year risk of overdose. Calibration and discrimination were assessed.

Key Results

A five-variable predictive model showed good calibration and discrimination (bootstrap-corrected c-statistic?=?0.73, 95% confidence interval [CI] 0.69–0.78) in the derivation site, with sensitivity of 66.1% and specificity of 66.6%. In the validation site, the model showed good discrimination (c-statistic?=?0.75, 95% CI 0.70–0.80) and less than ideal calibration, with sensitivity and specificity of 82.2% and 49.5%, respectively.

Conclusions

Among patients on chronic opioid therapy, the predictive model identified 66–82% of all subsequent opioid overdoses. This model is an efficient screening tool to identify patients who could benefit from naloxone to prevent overdose deaths. Population differences across the two sites limited calibration in the validation site.

     

Therapy and prophylaxis of opportunistic infections in HIV-infected patients: a guideline by the German and Austrian AIDS societies (DAIG/ÖAG) (AWMF 055/066)

Introduction

There was a growing need for practical guidelines for the most common OIs in Germany and Austria under consideration of the local epidemiological conditions.

Materials and methods

The German and Austrian AIDS societies developed these guidelines between March 2010 and November 2011. A structured Medline research was performed for 12 diseases, namely Immune reconstitution inflammatory syndrome, Pneumocystis jiroveci pneumonia, cerebral toxoplasmosis, cytomegalovirus manifestations, candidiasis, herpes simplex virus infections, varizella zoster virus infections, progressive multifocal leucencephalopathy, cryptosporidiosis, cryptococcosis, nontuberculosis mycobacteria infections and tuberculosis. Due to the lack of evidence by randomized controlled trials, part of the guidelines reflects expert opinions. The German version was accepted by the German and Austrian AIDS Societies and was previously published by the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF; German Association of the Scientific Medical Societies).

Conclusion

The review presented here is a translation of a short version of the German–Austrian Guidelines of opportunistic infections in HIV patients. These guidelines are well-accepted in a clinical setting in both Germany and Austria. They lead to a similar treatment of a heterogeneous group of patients in these countries.

     

Antithrombotic Therapy for ACS in Elderly Patients

Background

Patients over 75 account for more than one third of those presenting with myocardial infarction and more than 50% of intrahospital mortality. There are no specific guidelines for the management of acute coronary syndromes (ACS) in the elderly.

Setting

Although antithrombotic therapy seems to be effective and safe in such patients, it requires specific precautions and treatment adjustments because of the higher bleeding risk due to comorbidities such as renal function impairment and malnutrition.

Results

Scientific evidence concerning elderly patients is scarce as they are either excluded or underrepresented in most randomized trials. Overall, the antithrombotic therapy needs to be adapted to avoid complications, mainly bleeding complications, without compromising the effectiveness of the treatment in this high-risk population.

Conclusion

In the present paper, we review the current treatment strategies in ACS while focusing on data concerning the elderly, according to available data in pivotal trials and in both AHA/ACC and ESC guidelines.

     

Utilization of breast cancer screening with magnetic resonance imaging in community practice

Background

Breast cancer screening with magnetic resonance imaging (MRI) may be a useful adjunct to screening mammography in high-risk women, but MRI uptake may be increasing rapidly among low- and average-risk women for whom benefits are unestablished. Comparatively little is known about use of screening MRI in community practice.

Objective

To assess relative utilization of MRI among women who do and do not meet professional society guidelines for supplemental screening, and describe utilization according to breast cancer risk indications.

Design

Prospective cohort study conducted between 2007 and 2014.

Participants

In five regional imaging registries participating in the Breast Cancer Surveillance Consortium (BCSC), 348,955 women received a screening mammogram, of whom 1499 underwent screening MRI.

Main measures

Lifetime breast cancer risk (< 20% or ≥ 20%) estimated by family history of two or more first-degree relatives, and Gail model risk estimates. Breast Imaging Reporting and Data System breast density and benign breast diseases also were assessed. Relative risks (RR) for undergoing screening MRI were estimated using Poisson regression.

Key results

Among women with < 20% lifetime risk, which does not meet professional guidelines for supplementary MRI screening, and no first-degree breast cancer family history, screening MRI utilization was elevated among those with extremely dense breasts [RR 2.2; 95% confidence interval (CI) 1.7–2.8] relative to those with scattered fibroglandular densities and among women with atypia (RR 7.4; 95% CI 3.9–14.3.) or lobular carcinoma in situ (RR 33.1; 95% CI 18.0–60.9) relative to women with non-proliferative disease. Approximately 82.9% (95% CI 80.8%–84.7%) of screening MRIs occurred among women who did not meet professional guidelines and 35.5% (95% CI 33.1–37.9%) among women considered at low-to-average breast cancer risk.

Conclusion

Utilization of screening MRI in community settings is not consistent with current professional guidelines and the goal of delivery of high-value care.

     

Osteoporose und Typ-2-Diabetes

Background

Fractures are common in the elderly, have a detrimental effect on the quality of life and are associated with increased mortality. Patients with type 2 diabetes have a further moderately elevated risk of fractures although they show a comparable or even increased bone mineral density. This is clinically relevant due to the widespread occurrence of type 2 diabetes.

Objectives

Possible causes and mechanisms of the elevated risk of fractures in diabetics are discussed and advice for clinical management is given taking the higher fracture risk in this population into account.

Material and methods

This article is based on the currently available review articles on type 2 diabetes and bone health. Furthermore, the most relevant original articles on this topic are cited.

Results and discussion

Increased falls related to diabetic complications, longer disease duration and lack of glucose control are associated with a higher fracture risk in patients with type 2 diabetes. Even though the bone density is normal, a higher cortical porosity and alterations in collagen structure reduce bone quality. Some oral antidiabetic agents have detrimental effects on bone metabolism. General recommendations for optimal calcium and vitamin D intake in patients without diabetes are also appropriate in this population. Evidence regarding a possible altered effectiveness of pharmacological treatment of osteoporosis in diabetics is limited. According to post hoc analyses this does not appear to be the case; however, treatment of osteoporosis in patients with type 2 diabetes follows the current guidelines for non-diabetic postmenopausal women and men with osteoporosis.

     

Perspectives on Current Training Guidelines for Cardiac Imaging and Recommendations for the Future

Purpose of Review

To summarize current training guidelines for cardiac imaging and provide recommendations for future guidelines.

Recent Findings

The current structure of training in cardiac imaging is largely dictated by modality-specific guidelines. While there has been debate on how to define the advanced cardiac imager for over a decade, a uniform consensus has not emerged. We report the perspectives of three key stakeholders in this debate: a senior faculty member—former fellowship program director, a cardiology fellow, and an academic junior faculty imaging expert. The observations of these stakeholders suggest that there is no consensus on the definition of advanced cardiac imaging, leading to ambiguity in training guidelines. This may have negative impact on recruitment of fellows into cardiac imaging careers.

Summary

Based on the current status of training in cardiac imaging, the authors suggest that the relevant professional groups reconvene to form a consensus in defining advanced cardiac imaging, in order to guide future revisions of training guidelines.

     

Primary Care Validation of a Single-Question Alcohol Screening Test

BACKGROUND

Unhealthy alcohol use is prevalent but under-diagnosed in primary care settings.

OBJECTIVE

To validate, in primary care, a single-item screening test for unhealthy alcohol use recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

DESIGN

Cross-sectional study.

PARTICIPANTS

Adult English-speaking patients recruited from primary care waiting rooms.

MEASUREMENTS

Participants were asked the single screening question, “How many times in the past year have you had X or more drinks in a day?”, where X is 5 for men and 4 for women, and a response of >1 is considered positive. Unhealthy alcohol use was defined as the presence of an alcohol use disorder, as determined by a standardized diagnostic interview, or risky consumption, as determined using a validated 30-day calendar method.

MAIN RESULTS

Of 394 eligible primary care patients, 286 (73%) completed the interview. The single-question screen was 81.8% sensitive (95% confidence interval (CI) 72.5% to 88.5%) and 79.3% specific (95% CI 73.1% to 84.4%) for the detection of unhealthy alcohol use. It was slightly more sensitive (87.9%, 95% CI 72.7% to 95.2%) but was less specific (66.8%, 95% CI 60.8% to 72.3%) for the detection of a current alcohol use disorder. Test characteristics were similar to that of a commonly used three-item screen, and were affected very little by subject demographic characteristics.

CONCLUSIONS

The single screening question recommended by the NIAAA accurately identified unhealthy alcohol use in this sample of primary care patients. These findings support the use of this brief screen in primary care.

     

Cancer Center Volume and Type Impact Stage-Specific Utilization of Neoadjuvant Therapy in Rectal Cancer

Background

Neoadjuvant chemoradiation reduces local recurrence in locally advanced rectal cancer, and adherence to national and societal recommendations remains unknown.

Objective

To determine variability in guideline adherence in rectal cancer treatment and investigate whether hospital volume correlated with variability seen.

Design

We performed a retrospective analysis using the National Cancer Database rectal cancer participant user files from 2005 to 2010. Stage-specific predictors of neoadjuvant chemotherapy and radiation use were determined, and variation in use across hospitals analyzed. Hospitals were ranked based on likelihood of preoperative therapy use by stage, and observed-to-expected ratios for neoadjuvant therapy use calculated. Hospital outliers were identified, and their center characteristics compared.

Results

A total of 23,488 patients were identified at 1183 hospitals. There was substantial variability in the use of neoadjuvant chemoradiation across hospitals. Patients managed outside clinical guidelines for both stage 1 and stage 3 disease tended to receive treatment at lower-volume, community cancer centers.

Conclusions

There is substantial variability in adherence to national guidelines in the use of neoadjuvant chemoradiation for rectal cancer across all stages. Both hospital volume and center type are associated with over-treatment of early-stage tumors and under-treatment of more invasive tumors. These findings identify a clear need for national quality improvement efforts in the treatment of rectal cancer.

     

Guidelines for diagnosis and management of the cobalamin-related remethylation disorders cblC,cblD, cblE,cblF, cblG,cblJ and MTHFR deficiency

Background

Remethylation defects are rare inherited disorders in which impaired remethylation of homocysteine to methionine leads to accumulation of homocysteine and perturbation of numerous methylation reactions.

Objective

To summarise clinical and biochemical characteristics of these severe disorders and to provide guidelines on diagnosis and management.

Data sources

Review, evaluation and discussion of the medical literature (Medline, Cochrane databases) by a panel of experts on these rare diseases following the GRADE approach.

Key recommendations

We strongly recommend measuring plasma total homocysteine in any patient presenting with the combination of neurological and/or visual and/or haematological symptoms, subacute spinal cord degeneration, atypical haemolytic uraemic syndrome or unexplained vascular thrombosis. We strongly recommend to initiate treatment with parenteral hydroxocobalamin without delay in any suspected remethylation disorder; it significantly improves survival and incidence of severe complications. We strongly recommend betaine treatment in individuals with MTHFR deficiency; it improves the outcome and prevents disease when given early.

     

Radiological features for the approach in trans-sphenoidal pituitary surgery

Introduction

In order to perform trans-sphenoidal endoscopic pituitary surgery safely and efficiently it is important to identify anatomical and pituitary disease features on the pre-operative CT and MRI scans; thereby minimising the risk to surrounding structures and optimising outcomes. We aim to create a checklist to streamline pre-operative planning.

Methods

We retrospectively reviewed pre-operative CT and MRI scans of 100 adults undergoing trans-sphenoidal endoscopic pituitary surgery.

Results

Radiological findings and their incidence included deviated nasal septum (62%), concha bullosa (32%), bony dehiscence of the carotid arteries (18%), sphenoid septation overlying the internal carotid artery (24% at the sella) and low lying CSF (32%). The mean distance of the sphenoid ostium to the skull base was 10 mm (range 2.7–17.6 mm). We also describe the ‘teddy bear’ sign which when present on an axial CT indicates the carotid arteries will be identifiable intra-operatively.

Conclusions

There are significant variations in the anatomical and pituitary disease features between patients. We describe a number of features on pre-operative scans and have devised a checklist including a new ‘teddy bear’ sign to aid the surgeon in the anatomical assessment of patients undergoing trans-sphenoidal pituitary surgery.

     

Endoscopic ultrasonography and computed tomography scanning for preoperative staging of colonic cancer

Purpose

With an increasing demand for more accurate preoperative staging methods for colon cancer, we aimed to compare preoperative tumour (T)- and nodal (N)-stage in patients with left-sided colon cancer by endoscopic ultrasonography (EUS) and computed tomography (CT) with post-operative histology as gold standard.

Methods

A total of 44 patients were prospectively recruited at Herlev and Roskilde University Hospitals during November 2014–January 2016. Thirty-five patients were included in the final analysis and underwent EUS, CT and surgery within 2 weeks. Diagnostic values were evaluated for “low risk” (T1+T2+T3 with ≤5 mm extramural invasion) and “high risk” (T3 with >5 mm of extramural spread + T4) colonic cancer.

Results

Sensitivity and specificity in “low risk” colonic cancer evaluated with EUS was 0.90 [0.74;0.98] and 0.75 [0.19;0.99] and with CT 0.96 [0.80;0.99] and 0.25 [<0.01;0.81]. EUS and CT were poor in predicting N0 or N+ disease.

Conclusions

The sensitivity of EUS and CT were good and comparable regarding T-stage evaluation, while EUS had a significantly higher specificity in the evaluation of “low risk” tumours. The results obtained for “high risk” colonic cancer were difficult to evaluate due to small patient numbers. EUS could be considered as a supplement to CT scans in selecting patients for neoadjuvant therapies, or local transmural treatment, in the future.

Trial registration

NCT02324023

     

Therapie von Atemnot,Angst und Depression bei fortgeschrittenen Lungenerkrankungen

Background

Dyspnea, anxiety and depression are common symptoms in patients with advanced lung disease and markedly impair the quality of life of these patients.

Objective

Summary of non-pharmacological and pharmacological measures for dyspnea, anxiety and depression based on the available evidence.

Material and methods

Analysis of primary studies, reviews and guidelines for the named symptoms and their management.

Results

Recognition and assessment are initially essential for the management of dyspnea, anxiety and depression. Various non-pharmacological measures, such as general information, a management plan for coping with dyspnea, use of a handheld fan, physical activity and rollators are available for the management of dyspnea. Opioids are the drugs of choice for intractable dyspnea. Slight to moderate depression should be primarily treated by psychotherapy. Antidepressants are additionally indicated for moderate to severe depression. There is insufficient evidence for the pharmacological treatment of anxiety.

Conclusion

Dyspnea, anxiety and depression have a marked impact on the quality of life of patients with advanced lung disease. There are a number of treatment options which can be used to help relieve symptoms.

     

Improving Provider Adherence to Guideline Recommendations in Heart Failure

Purpose of Review

Heart failure clinical practice guidelines are fundamental and serve as framework for providers to deliver evidence-based care that correlates with enhanced patient outcomes. However, adherence, particularly to guideline-directed medical therapy, remains suboptimal for a multitude of reasons.

Recent Findings

Despite robust clinical trials, updated guidelines and an expert consensus statement from American Heart Association, American College of Cardiology, and Heart Failure Society of America registry data signal that heart failure patients do not receive appropriate pharmacotherapy and may receive an intracardiac device without prior initiation or optimization of medical therapy.

Summary

Strategies to improve provider adherence to heart failure guidelines include multidisciplinary models and appropriate referral and care standardization. These approaches can improve morbidity, mortality, and quality of life in HF patients.

     

Cancer Risk Communication with Low Health Literacy Patients: A Continuing Medical Education Program

BACKGROUND

Low health literacy (HL) is an important risk factor for cancer health disparities.

OBJECTIVE

Describe a continuing medical education (CME) program to teach primary care physicians (PCP) cancer risk communication and shared decision-making (SDM) with low HL patients and baseline skills assessment.

DESIGN

Cluster randomized controlled trial in five primary care clinics in New Orleans, LA.

PARTICIPANTS

Eighteen PCPs and 73 low HL patients overdue for cancer screening.

INTERVENTION

Primary care physicians completed unannounced standardized patient (SP) encounters at baseline. Intervention physicians received SP verbal feedback; academic detailing to review cancer screening guidelines, red flags for identifying low HL, and strategies for effective counseling; and web-based tutorial of SP comments and checklist items hyperlinked to reference articles/websites.

MAIN MEASURES

Baseline PCP self-rated proficiency, SP ratings of physician general cancer risk communication and SDM skills, patient perceived involvement in care.

RESULTS

Baseline assessments show physicians rated their proficiency in discussing cancer risks and eliciting patient preference for treatment/decision-making as “very good”. SPs rated physician exploration of perceived cancer susceptibility, screening barriers/motivators, checking understanding, explaining screening options and associated risks/benefits, and eliciting preferences for screening as “satisfactory”. Clinic patients rated their doctor’s facilitation of involvement in care and information exchange as “good”. However, they rated their participation in decision-making as “poor”.

DISCUSSION

The baseline skills assessment suggests a need for physician training in cancer risk communication and shared decision making for patients with low HL. We are determining the effectiveness of teaching methods, required resources and long-term feasibility for a CME program.

     

Die Rolle der Selbsthilfegruppen in der Onkologie

Background

Little is known about self-help associations and their possibilities. Obstacles often prevent early contacts between affected people.

Objectives

The psychosocial support given by self-help associations in different phases is evaluated.

Materials and methods

Based on the experience of the Deutsche ILCO and from cooperation with other organizations and institutions, various dimensions of self-help groups are investigated.

Results

On the professional side, there is a lack of knowledge and of attitude. Suitable structures are rare.

Conclusions

The removal of barriers and development of effective structures are overdue.

     

Treatment of acute hepatitis C: recommendations from an expert panel of the Italian Society of Infectious and Tropical Diseases

Aim

This paper is aimed at providing practical recommendations for the management of acute hepatitis C (AHC).

Methods

This is an expert position paper based on the literature revision. Final recommendations were graded by level of evidence and strength of the recommendations.

Results

Treatment of AHC with direct-acting antivirals (DAA) is safe and effective; it overcomes the limitations of INF-based treatments.

Conclusions

Early treatment with DAA should be offered when available.