Is earlier diagnosis really better? The misleading effects of lead time and length biases

Association between conscientiousness and peritoneal dialysis-related peritonitis

AIM

Peritonitis is a critical complication in patients undergoing peritoneal dialysis. Patient characteristics, especially conscientiousness, potentially influence self-care activity. This study aimed to examine the relationship between the peritonitis risk and the patient conscientiousness.

METHODS

This retrospective observational study was conducted at three Japanese medical centres in 2018. Adult patients undergoing peritoneal dialysis were evaluated for conscientiousness with the Japanese version of the Ten-Item Personality Inventory. We followed the patients from peritoneal dialysis induction retrospectively on chart review. The primary outcome was time to first episode of peritonitis after initiation of peritoneal dialysis in the entire observation period. Hazard ratios were estimated using a Cox model adjusted for potential confounders.

RESULTS

Among 111 patients enrolled, 32 experienced peritonitis. The patients were divided into the more conscientious group (n = 64) and less conscientious group (n = 47) based on a mean conscientiousness score of 3.991. Additionally, less conscientious patients tended to be at higher risk for peritonitis during the entire study period (hazard ratio adjusted for age and sex, 1.99; 95% confidence interval, 0.98-4.03; p = .057). The increased risk in the less conscientious group was statistically significant in the first year (adjusted hazard ratio, 6.98; 95% confidence interval, 1.42-34.40; p = .017).

CONCLUSION

Less conscientious patients significantly have shorter peritonitis-free survival in the early phase after peritoneal dialysis induction although not significantly during the entire study period. Personality trait assessment using the Ten-Item Personality Inventory could be helpful in educating and following up patients undergoing peritoneal dialysis.

Utility of serum neuropilin-1 and angiopoietin-2 as markers of hepatocellular carcinoma

This study aimed to assess the diagnostic value of two serum angiogenetic markers neuropilin-1 (NRP-1) and angiopoietin-2 (ANG-2) in patients with hepatocellular carcinoma (HCC) and their relation to tumor characteristics. 149 subjects were recruited and divided into 50 patients with recently diagnosed HCC, 49 patients with cirrhosis on top of hepatitis C virus infection, and 50 healthy subjects. Serum NRP-1 and ANG-2 were estimated by ELISA. Alpha-fetoprotein (AFP) levels were measured using fluorescence immunoassay. Serum NRP-1 and ANG-2 levels were significantly higher in patients with HCC (2221.8±1056.6 pg/mL and 3018.5±841.4 pg/mL) than healthy subjects (219.3±61.8 pg/mL and 2007.7±904.8 pg/mL) and patients with cirrhosis (1108.9±526.6 pg/mL and 2179.1±599.2 pg/mL), respectively. In multivariate logistic regression analysis, NRP-1 and AFP were the only independent factors of HCC development and correlated positively with each other (r=0.781, p<0.001). Receiver operating characteristic curve analysis showed that the area under the curve (AUC) of NRP-1 was higher than that of ANG-2 in discriminating HCC from patients with cirrhosis (0.801 vs 0.748, p=0.250) and healthy subjects (0.992 vs 0.809, p<0.001). The AUC of NRP-1 was detected to be increased (0.994) when combined estimation with AFP was performed. Elevated serum NRP-1 and ANG-2 levels were detected in patients with HCC with tumor numbers >3, tumor size ≥5 cm, tumor stages B/C according to the Barcelona Clinic Liver Cancer staging system, vascular invasion, and distant metastasis. In conclusion, NRP-1 is a potential serological marker for HCC diagnosis and is better than ANG-2. It is feasible to be estimated in combination with AFP to enhance its diagnostic power. High serum NRP-1 and ANG-2 levels are associated with advanced HCC tumor characteristics.

Incidental findings on emergency CT scans: Predictive factors and medico-economic impact

PURPOSE

The main objective was to evaluate types and predictive factors of incidental findings (IFs) on multidetector computed tomographies (MDCTs) performed for an emergency department (ED). The secondary aim was to analyze additional investigations, their benefits, side effects, costs and the final diagnoses.

METHOD

One thousand consecutive patients over 18 years old who underwent an MDCT in the ED of our institution from January 2011 to November 2011 were retrospectively included, accounting for 300 head MDCTs and 700 other MDCTs. The following criteria were collected in patient electronic medical records: IFs (divided into low and high clinical significance), body areas covered, availability of a prior imaging, radiologist's experience and subspecialty, additional investigations, their outcomes and costs.

RESULTS

Among the 1000 included patients, 232 had at least one IF and 122 had at least one IF of high clinical significance (IFCS). There were 340 IFs and 150 IFCSs. A significant association with the presence of at least one IF was noted for older patients, less-experienced radiologists, no subspecialty of the radiologist, the abdominopelvic area, and the absence of prior imaging. Eighteen IFs generated additional investigations in our institution, including five invasive samplings and three surgical operations, with two diagnoses of malignancy (a gastrointestinal stromal tumor and a Bosniak IV cystic renal lesion). One benign iatrogenic complication occurred. Total cost of these investigations was €41,247 (with an average of €2292 per IF investigated).

CONCLUSION

IFs on emergency MDCTs were frequent, rarely severe, rarely iatrogenic and relatively expensive.

Application of the Carolina Framework for Cervical Cancer Prevention

OBJECTIVE

The Carolina Framework for Cervical Cancer Prevention describes 4 main causes of cervical cancer incidence: human papillomavirus (HPV) infection, lack of screening, screening errors, and not receiving follow-up care. We present 2 applications of the Carolina Framework in which we identify high-need counties in North Carolina and generate recommendations for improving prevention efforts.

METHODS

We created a cervical cancer prevention need index (CCPNI) that ranked counties on cervical cancer mortality, HPV vaccine initiation and completion, Pap smear screening, and provision of Pap tests to rarely- or never-screened women. In addition, we conducted in-depth interviews with 19 key informants from programs and agencies involved in cervical cancer prevention in North Carolina.

RESULTS

North Carolina's 100 counties varied widely on individual CCPNI components, including annual cervical cancer mortality (median 2.7/100,000 women; range 0.0-8.0), adolescent girls' HPV vaccine initiation (median 42%; range 15%-62%), and Pap testing in the previous 3 years among Medicaid-insured adult women (median 59%; range 40%-83%). Counties with the greatest prevention needs formed 2 distinct clusters in the northeast and south-central regions of the state. Interviews generated 9 recommendations to improve cervical cancer prevention in North Carolina, identifying applications to specific programs and policies in the state.

CONCLUSIONS

This study found striking geographic disparities in cervical cancer prevention need in North Carolina. Future prevention efforts in the state should prioritize high-need regions as well as recommended strategies and applications in existing programs. Other states can use the Carolina Framework to increase the impact of their cervical cancer prevention efforts.

Do We Need Randomized Controlled Clinical Trials to Evaluate the Clinical Impact of Breast MR Imaging?

MR imaging of the breast has been shown to identify breast cancers that have gone undetected by mammography. There are a number of potential designs that can be used to further evaluate breast MR imaging, particularly with respect its impact on clinical care. Determination of whether using breast MR imaging to screen healthy individuals for breast cancer actually reduces breast cancer-specific mortality--and whether this can be accomplished at an acceptable cost--probably requires randomized, controlled clinical.

Interstitial 125I radiosurgery of supratentorial de novo WHO Grade 2 astrocytoma and oligoastrocytoma in adults: long-term results and prognostic factors

BACKGROUND

Detailed long-term outcome data are not available for adult patients with World Health Organization (WHO) Grade 2 astrocytoma or oligoastrocytoma.

METHODS

A previously published short-term data set of 239 adult patients with circumscribed de novo supratentorial astrocytoma (187 patients) and oligoastrocytoma (52 patients) treated with interstitial iodine-125 ((125)I) radiosurgery as primary treatment (1979-1992) was revisited. Survival, progression-free survival, functionally independent survival, postrecurrence survival, and time to malignant transformation were estimated with the Kaplan-Meier method. Prognostic factors were obtained from the Cox multivariate proportional hazards model.

RESULTS

Five-, 10-, and 15-year survival was 56%, 37%, and 26%, respectively (median follow-up, 10.3 yrs). Progression-free survival was 45%, 21%, and 14%, respectively. The corresponding malignant transformation rates were 33%, 54%, and 67%. No leveling off of the Kaplan-Meier curves could be observed for any of the chosen endpoints. Age > 50 years, a tumor volume > 20 mL, and/or a Karnofsky score < or = 80 were associated with decreased survival or progression-free survival. Age > 35 years and/or a tumor volume > 20 mL increased risk of malignant transformation. Prognostic factors determined subsets of patients with 10-year survival ranging from as low as 6% to as high as 55% and progression-free survival ranging 1-31%.

CONCLUSIONS

Long-term tumor stabilization is rare. As outcome is mainly determined by treatment-independent factors, minimization of any treatment-related risk must be considered essential.

Technology Assessment for Radiologists

Health technology assessment is the systematic and quantitative evaluation of the safety, efficacy, and cost of health care interventions. This article outlines aspects of technology assessment of diagnostic imaging. First, it presents a conceptual framework of a hierarchy of levels of efficacy that should guide thinking about imaging test evaluation. In particular, the framework shows how the question answered by most evaluations of imaging tests, "How well does this test distinguish disease from the nondiseased state?" relates to the fundamental questions for all health technology assessment, "How much does this intervention improve the health of people?" and "What is the cost of that improvement?" Second, it describes decision analysis and cost-effectiveness analysis, which are quantitative modeling techniques usually used to answer the two core questions for imaging. Third, it outlines design and operational considerations that are vital if researchers who are conducting an experimental study are to make a quality contribution to technology assessment, either directly through their findings or as an input into decision analyses. Finally, it includes a separate discussion of screening--that is, the application of diagnostic tests to nonsymptomatic populations--because the requirements for good screening tests are different from those for diagnostic tests of symptomatic patients and because the appropriate evaluation methods also differ.

Progress in long-term survival in adult patients with supratentorial low-grade gliomas: a population-based study of 993 patients in whom tumors were diagnosed between 1970 and 1993

Object. The goal of this study was to document and compare long-term survival during the periods 1970 through 1981 and 1982 through 1993 in all adult patients in Norway with histologically verified supratentorial low-grade gliomas (LGGs).

Methods. Nine hundred ninety-three patients 15 to 69 years of age were found to have a primary supratentorial diffuse astrocytoma, oligodendroglioma, oligoastrocytoma, or pilocytic astrocytoma. Survival time was analyzed in all patients and, in a subset of 451 patients, the influence of new imaging methods on the time from symptom onset to imaging diagnosis was estimated.

Overall median survival was 6.4 years (95% confidence interval [CI] 5.7–7.1 years). Survival times for patients in whom a diagnosis was made between 1970 and 1981 (397 patients) and between 1982 and 1993 (596 patients) were 4.1 years (95% CI 3.3–4.9 years) and 9.2 years (95% CI 7.9–10.6 years), respectively (p < 0.0001). Survival also improved in the later period within each histological subgroup. In patients in whom a biopsy was performed the median length of survival was 6.4 years (95% CI 3.1–9.7 years); in patients treated with subtotal tumor resection it was 6.8 years (95% CI 5.8–7.7 years); and in those treated with gross-total tumor resection it was 7.6 years (95% CI 5.5–9.7 years), a nonsignificant difference (p = 0.59). A considerable age-dependent variation in overall survival was demonstrated. The availability of computerized tomography (CT) scanning and/or magnetic resonance (MR) imaging as a diagnostic tool reduced the median period of symptoms prior to diagnosis by 6 months.

Conclusions. Long-term overall survival significantly improved, but age-related differences in prognosis persisted. The increased sensitivity of the diagnostic method due to the availability of CT scanning and/or MR imaging may partly, but not entirely, account for the observed magnitude of improvement in overall survival. Thus local tumor treatment improved during the study period.

Renal imaging for diagnosis and staging of renal cell carcinoma

The development and expansion of CT and MRI technology have enhanced the detection and characterization of renal lesions. Although these advancements should lead to earlier diagnosis of renal cell carcinoma with subsequent improved cure rates, the increased imaging has also uncovered many cases that are problematic not only in diagnosis but in management as well. The performance of high-quality examinations combined with growing experience should improve the ability to diagnose and manage these cases successfully. Continued advances in CT and MR technology combined with the current trend toward minimally invasive surgery will continue to expand the role of preoperative imaging and, it is hoped, improve the cure rate of renal cancer.

Early experience with percutaneous radiofrequency ablation of small solid renal masses

OBJECTIVE

Incidental small renal-cell masses are often seen in elderly patients with significant comorbidity who are unfit to undergo major surgery. This study was conducted to determine the safety and efficacy of percutaneous imaging-guided radiofrequency ablation in the management of small solid renal masses, almost all of which are renal cell cancers.

CONCLUSION

Early experience suggests that radiofrequency ablation is a safe, well-tolerated, and minimally invasive therapy for patients with solid renal masses. In the era of nephron-sparing surgery, radiofrequency ablation may have a role in the management of small problematic renal masses.

Prognostic significance of the number of bone scan abnormalities at the time of initial bone metastatic recurrence in breast carcinoma

BACKGROUND

To gain insight into the factors that contribute to the more favorable prognosis associated with recurrence limited to bone in patients with breast carcinoma, the authors analyzed the number of sites of initial involvement identified on radionuclide bone scans in relation to long term outcome.

METHODS

Records of 641 patients with clinical Stage I-III breast carcinoma that originally was diagnosed in 1974-1985 were reviewed. During follow-up, 295 patients (46%) experienced distant recurrence, including 116 with bone as the sole initial site of metastatic disease. Radionuclide bone scans identified the initial site(s) of recurrence in 113 of these latter 116 patients, and these studies were categorized by the number of skeletal lesions subsequently confirmed as metastases (1, 2, or > or = 3). Survival from time of recurrence and time of original diagnosis was analyzed using Kaplan-Meier methods, and factors associated with recurrence and mortality were examined using logistic and Cox regression.

RESULTS

Median survival from time of recurrence was 35 months in the patients with bone-only metastases, compared with 11-26 months for all other sites of visceral recurrence exclusive of bone. Number of positive lymph nodes and estrogen receptor status were the only predictive variables for recurrence. Median survival from time of recurrence and time of original diagnosis for the 3 bone scan categories was: 1 lesion (n = 47), 53 and 86 months; 2 lesions (n = 22), 38 and 68 months; and > or = 3 lesions (n = 44), 22 and 58 months (P < 0.0001 and P < 0.005 for 1 and 2 lesions vs. > or = 3). In the "bone-only" group, the number of scan lesions was the strongest predictor of length of survival.

CONCLUSIONS

Patients with breast carcinoma who experience a recurrence in bone at only one or two sites initially have a survival advantage over those with more extensive (> or = 3 sites) skeletal metastases and those with metastatic disease involving other visceral organs.

The diagnosis of delirium in 80 emergency unit patients

We evaluated the initial and final diagnosis of 80 patients with delirium arriving at the emergence unit of a university hospital in a large Brazilian city over a period of 30 months up to December 1991. The diagnosis was based on the DSM-IIIR criteria. Patients with a known history of head trauma or epileptic seizure and patients younger than 13 years were excluded. Only patients with a disease of up to 7 days were included. The patients were subdivided into four etiologic groups: vascular; associated with the use of alcohol; infectious-parasitic; miscellaneous. The results showed a rate of correct diagnosis ranging from 65 to 80% with the use of kappa test (standard good to excellent). Sensitivity, specificity, positive predictive and negative predictive values had results showing different conditions for initial diagnosis in each group. This study can help the initial diagnosis of delirium and the choice for diagnostic testing.

Helical and electron beam CT scanning in the evaluation of renal vein involvement in patients with renal cell carcinoma

PURPOSE

The purpose of this study was to assess helical and electron beam CT scanning in the evaluation of renal vein involvement in patients with renal cell carcinoma (RCC).

METHOD

Seventy-three patients with 76 pathologically proven RCC who underwent surgical resection or autopsy were evaluated for the accuracy of helical and electron beam CT scanning in the detection of renal vein tumor thrombus in patients with RCC. Patients were entered into the study only if they were scanned on either electron beam or helical CT scanners with intravenous contrast medium enhancement. The tumors involved the right kidney in 38 cases and the left kidney in 38 cases, with tumor size ranging from 1.5 to 19 cm (mean 7 cm). The pathologic grade of the tumor was Grade I in 21, Grade II in 37, Grade III in 15, and Grade IV, in 3 patients.

RESULTS

The accuracy of preoperative CT evaluation of the renal vein for presence or absence of tumor thrombus was 96%. The negative predictive value was 97% and the positive predictive value was 92%. Sensitivity was 85% with a specificity of 98%. In two cases we were unable to detect small intrarenal venous thrombus, although this was present on a microscopic level and did not affect surgical resection. A single false-positive CT result occurred secondary to unopacified blood flow from a capsular vein into the affected renal vein, resulting in a small flow void on CT.

CONCLUSION

The data show that preoperative staging of the renal vein in the patients with RCC is effectively provided with helical and electron beam CT scanning.

The diagnosis and management of small (< or = 3 cm) renal neoplasms: a commentary

Many renal cell carcinomas are discovered incidentally. This phenomenon is largely attributable to advances in renal imaging, particularly regarding CT, to the widespread use of cross-sectional imaging in the diagnosis of abdominal disease, and to growing experience with the detection and diagnosis of renal masses. Accompanying the apparent increasing prevalence of renal masses are several controversies that specifically concern small (< or = 3 cm) neoplasms, those that are of a size associated with relatively slow growth and a low risk of metastasis. Are some of these small neoplasms renal adenomas? What is their growth pattern, and of what significance is their enlargement? Are all small renal carcinomas truly "cancers"? And what are the implications for management of such lesions in an asymptomatic individual? These controversies are discussed in depth in the hope of stimulating further investigation of this complex problem.

Clinical efficacy of imaging modalities in the diagnosis of low-back pain disorders

This review provides methodological background and some guidelines for the evaluation of imaging modalities for the lumbar spine and reviews the current literature on the basis of different levels of efficacy which consider standards beyond technical quality or diagnostic accuracy. From a MEDLINE search, 672 articles (1985-1995) were retrieved which focused on the development or application of imaging modalities for lumbar spinal disorders. The papers were categorized according to different efficacy levels at which the imaging modalities were assessed. This review has demonstrated that the vast majority of reports evaluate imaging studies for the lumbar spine only at the technical efficacy level. A minor proportion of the articles focus on the evaluation at the level of diagnostic accuracy. Articles which assess imaging studies on a higher level of efficacy (e.g., diagnostic and therapeutic impact, patient outcome and cost-benefit analysis) are sparse. This review has outlined frequent methodological flaws in patient selection and design of imaging studies for the lumbar spine. The spine specialist should therefore become very critical in the interpretation of those studies and pay attention to patient selection and spectrum, choice of the reference standard, sample size, various forms of biases, and the reasoning behind clinical recommendations in order to improve his patient care.

Management of solitary pulmonary nodules

The solitary pulmonary nodule (SPN), a single intrapulmonary spherical lesion that is fairly well circumscribed, is a common clinical problem. About half of SPNs seen in clinical practice are malignant, usually bronchogenic carcinomas. Some nodules are primary tumors of other kinds or metastatic. Virtually all benign SPNs are tuberculous or fungal granulomas. The standard management of the SPN of unknown cause is prompt surgical removal unless benignity is established by prior chest roentgenograms showing that the nodule has been stable (i.e., showing no growth) for 2 years or by the presence of a "benign" pattern of calcification. Less universally accepted criteria for benignity include (1) transthoracic needle aspiration biopsy (TNAB) showing a specific benign process, and (2) patient's age under 30 to 35 years. Bronchoscopy has a low diagnostic yield, particularly for benign nodules. SPNs usually grow at constant rates, expressed as the "doubling time" (DT). A nodule with a DT between 20 and 400 days is usually malignant. Benign nodules usually have a DT greater than 400 days. The prospective determination of DT by serial chest roentgenograms (the "wait and watch" strategy) is widely criticized but has clinical utility in special circumstances, particularly if the likelihood of malignancy is low and/or the anticipated surgical mortality is high. The presence and pattern of calcification are best shown by high-resolution thin-section computed tomography (CT). Diffuse, laminated, central or "popcorn" patterns of calcification indicate benignity. An eccentric calcium deposit or a stippled pattern does not rule out malignancy. CT densitometry will often show "occult" calcification in nodules that show no direct visual evidence of calcium deposition. The characteristics of the edge of the nodule correlate with the likelihood of malignancy. Nodules with irregular or spiculated margins are almost always malignant. The probability that the nodule is malignant (pCA) is related to the age of the patient, the diameter of the nodule, the amount of tobacco smoke inhalation, the overall prevalence of malignancy in SPNs, the nature of the edge of the lesion, and the presence or absence of occult calcification. It is possible by Bayesian techniques to combine these factors to calculate a more precise and comprehensive prediction of pCA in any given nodule. The 5-year survival after nodule resection depends on the size of the nodule at the time of surgery; it may be as high as 80% with nodules that are 1 cm in diameter. Lymph node involvement is uncommon with small tumors, and many authorities question the need for CT staging in such cases.(ABSTRACT TRUNCATED AT 400 WORDS)