The Impact of Incidental Findings Detected During Brain Imaging on Research Participants of the Rotterdam Study: An Interview Study

Evaluating musculoskeletal imaging communication interventions using behavioural science: a scoping review using the COM-B model

OBJECTIVES

Clinicians and patients have been found to attribute musculoskeletal (MSK) pain to normal age-related changes seen on imaging, which can negatively impact patient outcomes and increase healthcare costs. While some studies have tested interventions to improve how MSK imaging findings are communicated, their impact has been limited. Applying a behavioural science framework has the potential to identify the rationale and target of these interventions to inform future intervention design-an analysis that has not yet been conducted. This study aims to identify the Behaviour Change Techniques (BCTs), the behavioural targets and the theoretical basis of interventions seeking to affect the communication of MSK imaging.

DESIGN

Scoping review using the Capability, Opportunity, Motivation - Behaviour (COM-B) model.

DATA SOURCES

Searches of MEDLINE, EMBASE, CINAHL, AMED and PsycINFO from inception to 9 February 2024.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included studies that have developed or evaluated interventions which target the communication of MSK imaging findings. Interventions targeting both patients and clinicians were included. Experimental and quasi-experimental study designs were included, and studies that focused on serious or specific known causes of MSK pain were excluded.

DATA EXTRACTION AND SYNTHESIS

Two independent authors extracted study participant data and intervention details. A theory of behaviour called the COM-B model was used to map the BCTs and behavioural components targeted by studies.

RESULTS

We identified 11 studies from 2486 studies in our electronic search. 11 different BCTs were identified across 11 studies. The most common techniques were framing/reframing (nine studies), adding objects to the environment (eight studies), incompatible beliefs (seven studies) and avoidance/reducing exposure to cues for the behaviour (four studies). Only two studies (feasibility studies) used behavioural theory to guide their intervention design. While one study showed a large effect, most interventions had little to no impact on pain, disability, or fear over time.

CONCLUSION

This review highlighted a lack of studies targeting clinician knowledge and the provision of high-quality patient resources about the nature of MSK pain, even though the broader literature identifies both as enablers of effective health communication. Additionally, the absence of a theory-informed design likely resulted in attempts to reassure patients about normal age-related imaging findings without providing an alternate, more coherent explanation for symptoms. Future interventions should focus on enhancing clinician psychological capability (knowledge) as well as clinician and patient reflective motivation (beliefs) to enable more helpful explanations of MSK symptoms. The key challenge for future interventions will be achieving these aims in a way that is effective, consistent and practical.

TRIAL REGISTRATION DETAILS

Open Science Framework (https://doi.org/10.17605/OSF.IO/ECYS8).

Prevalence and Clinical Impact of Incidental Findings on Preoperative Computed Tomography for Hip Arthroscopy

Background

Patients routinely undergo computed tomography (CT) before arthroscopy for femoroacetabular impingement as part of preoperative planning. These scans include the lower lumbar spine, entire pelvis, proximal femur, knees, and ankles, raising questions about the prevalence and clinical impact of incidental findings (IFs) from these images.

Purpose

To evaluate factors associated with IFs, as well as their prevalence, management, and impact on patient outcomes.

Study Design

Cohort study; Level of evidence, 3.

Methods

This was a retrospective review of preoperative pelvic CT scans from a single surgeon's hip outcomes registry. Additional details regarding specific participants were obtained through electronic medical records. Logistic regression analysis was used to compare the effects of predictors of interest on the likelihood of having an IF on CT imaging. Repeated-measures mixed modeling was utilized to examine the effect of IFs on patient-reported outcomes obtained at 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively.

Results

A total of 714 preoperative CT reports in 596 patients were reviewed; IFs were present in 306 of the scans (42.9%). Most IFs were of skeletal pathology (78.1%), followed by soft tissue (7.8%), reproductive (6.9%), abdominal (4.2%), and urologic (2.9%). Of the 306 IFs, 10 (3.3%) required further medical workup. Multivariate analysis indicated that patient factors associated with an IF included age (P < .0001). Presence of an IF on preoperative imaging was associated with lower values both pre- and postoperatively on the Hip Outcome Score activities of daily living (P = .04) and sports-specific subscale (P = .03), the 12-item International Hip Outcome Tool (P = .02), and the Patient-Reported Outcomes Measurement Information System-Mobility measure (P = .03). Although statistically significant, these findings did not exceed the minimal clinical important difference (MCID) for these scores.

Conclusion

The presence of IFs on CT imaging was associated with significant decreases across multiple outcome scores; however, the differences in scores did not exceed the MCID for any outcome. The high prevalence of IFs necessitates implementation of a reliable standardized follow-up protocol. This could improve overall patient care by reassuring patients of benign findings or providing treatment for potentially harmful ones.

Do adrenal incidentalomas have an impact on mental health? A comprehensive review

Adrenal incidentalomas (AIs) are increasingly detected during imaging performed for conditions unrelated to adrenal pathology. Numerous studies have shown that the presence of AI is associated with a higher frequency of hypertension, type 2 diabetes, dyslipidemia, obesity, and osteoporosis. This increased morbidity is mostly related to mild autonomous cortisol secretion, which is the most common hormonal abnormality in these patients. It is well known that glucocorticoid excess affects the hippocampus and prefrontal cortex, brain structures involved in mood regulation and cognitive processes, leading to a wide range of psychiatric symptoms, including depression. While these effects are well documented in patients with Cushing's syndrome, data on mental health changes in patients with AIs remain scarce. Additionally, the few existing studies have several limitations, leaving important clinical questions unanswered. Consequently, the extent to which AIs are associated with impaired mental health and whether patients would benefit from surgical treatment remains unclear. Addressing these challenges is crucial for developing adequate management strategies. This review explores potential psychological and psychiatric implications of AIs. By synthesizing existing literature, we aim to explain the relationship between AIs and mental health disorders, providing a background for future research and clinical practice guidelines.

Exploring health and disease concepts in healthcare practice: an empirical philosophy of medicine study

In line with recent proposals for experimental philosophy and philosophy of science in practice, we propose that the philosophy of medicine could benefit from incorporating empirical research, just as bioethics has. In this paper, we therefore take first steps towards the development of an empirical philosophy of medicine, that includes investigating practical and moral dimensions. This qualitative study gives insight into the views and experiences of a group of various medical professionals and patient representatives regarding the conceptualization of health and disease concepts in practice and the possible problems that surround them. This includes clinical, epistemological, and ethical issues. We have conducted qualitative interviews with a broad range of participants (n = 17), working in various health-related disciplines, fields and organizations. From the interviews, we highlight several different practical functions of definitions of health and disease. Furthermore, we discuss 5 types of problematic situations that emerged from the interviews and analyze the underlying conceptual issues. By providing theoretical frameworks and conceptual tools, and by suggesting conceptual changes or adaptations, philosophers might be able to help solve some of these problems. This empirical-philosophical study contributes to a more pragmatic way of understanding the relevance of conceptualizing health and disease by connecting the participants' views and experiences to the theoretical debate. Going back and forth between theory and practice will likely result in a more complex but hopefully also better and more fruitful understanding of health and disease concepts.

Cardiovascular Disease and Alzheimer's Disease: The Heart-Brain Axis

Cardiovascular disease (CVD) remains one of the leading causes of morbidity and mortality in aging adults across the United States. Prior studies indicate that the presence of atherosclerosis, the pathogenic basis of CVD, is linked with dementias. Alzheimer's disease (AD) and AD-related dementias are a major public health challenge in the United States. Recent studies indicate that ≈3.7 million Americans ≥65 years of age had clinical AD in 2017, with projected increases to 9.3 million by 2060. Treatment options for AD remain limited. Development of disease-modifying therapies are challenging due, in part, to the long preclinical window of AD. The preclinical incubation period of AD starts in midlife, providing a critical window for identification and optimization of AD risk factors. Studies link AD with CVD risk factors such as hypertension, inflammation, and dyslipidemia. Both AD and CVD are progressive diseases with decades-long development periods. CVD can clinically manifest several years earlier than AD, making CVD and its risk factors a potential predictor of future AD. The current review focuses on the state of literature on molecular and metabolic pathways modulating the heart-brain axis underlying the potential association of midlife CVD risk factors and their effect on AD and related dementias. Further, we explore potential CVD/dementia preventive strategies during the window of opportunity in midlife and the future of research in the field in the multiomics and novel biomarker use era.

The meaning of screening: detection of brain metastasis in the adjuvant setting for stage III melanoma

BACKGROUND

The incidence of melanoma is increasing and 37% of patients with metastatic melanoma eventually have brain metastasis (BM). Currently, there is no consensus on screening for BM in patients with resected stage III melanoma. However, given the high incidence of BM, routine screening magnetic resonance imaging (MRI) of the brain is considered in patients with completely resected stage III melanoma before the start of adjuvant treatment. The aim of this study was to assess the yield of screening for BM in these patients.

MATERIALS AND METHODS

A single-center cohort study was carried out in the Erasmus MC, Rotterdam, The Netherlands, a large tertiary referral center for patients with melanoma. Eligible patients with complete resection of stage III melanoma and a screening MRI of the brain, made within 12 weeks after resection and before adjuvant treatment (programmed cell death protein 1 inhibitors, dabrafenib-trametinib), available between 1 August 2018 and 1 January 2021, were included.

RESULTS

A total of 202 patients were included. Eighteen (8.9%) of 202 patients had extracranial metastasis at screening. Two (1.1%) of the remaining 184 patients had BM at screening, resulting in a switch from adjuvant treatment to ipilimumab-nivolumab. At a median follow-up of 21.2 months, BM was detected in another 4 (2.4%) of 166 patients who started with adjuvant treatment.

CONCLUSIONS

The yield of screening MRI of the brain is low after complete resection of stage III melanoma, before the start of adjuvant treatment. Therefore, routine screening MRI is not recommended in this setting.

The impact of reporting magnetic resonance imaging incidental findings in the Canadian alliance for healthy hearts and minds cohort

BACKGROUND

In the Canadian Alliance for Healthy Hearts and Minds (CAHHM) cohort, participants underwent magnetic resonance imaging (MRI) of the brain, heart, and abdomen, that generated incidental findings (IFs). The approach to managing these unexpected results remain a complex issue. Our objectives were to describe the CAHHM policy for the management of IFs, to understand the impact of disclosing IFs to healthy research participants, and to reflect on the ethical obligations of researchers in future MRI studies.

METHODS

Between 2013 and 2019, 8252 participants (mean age 58 ± 9 years, 54% women) were recruited with a follow-up questionnaire administered to 909 participants (40% response rate) at 1-year. The CAHHM policy followed a restricted approach, whereby routine feedback on IFs was not provided. Only IFs of severe structural abnormalities were reported.

RESULTS

Severe structural abnormalities occurred in 8.3% (95% confidence interval 7.7-8.9%) of participants, with the highest proportions found in the brain (4.2%) and abdomen (3.1%). The majority of participants (97%) informed of an IF reported no change in quality of life, with 3% of participants reporting that the knowledge of an IF negatively impacted their quality of life. Furthermore, 50% reported increased stress in learning about an IF, and in 95%, the discovery of an IF did not adversely impact his/her life insurance policy. Most participants (90%) would enrol in the study again and perceived the MRI scan to be beneficial, regardless of whether they were informed of IFs. While the implications of a restricted approach to IF management was perceived to be mostly positive, a degree of diagnostic misconception was present amongst participants, indicating the importance of a more thorough consent process to support participant autonomy.

CONCLUSION

The management of IFs from research MRI scans remain a challenging issue, as participants may experience stress and a reduced quality of life when IFs are disclosed. The restricted approach to IF management in CAHHM demonstrated a fair fulfillment of the overarching ethical principles of respect for autonomy, concern for wellbeing, and justice. The approach outlined in the CAHHM policy may serve as a framework for future research studies. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT02220582 .