Long-acting porcine ACTH stimulated salivary cortisol reduces the overdiagnosis of adrenal insufficiency compared to serum cortisol in cirrhosis liver

BACKGROUND

There are no reliable methods in clinical practice to diagnose adrenal insufficiency (AI) in patients with cirrhosis owing to variable cortisol-binding protein levels. This leads to unreliable results in ACTH stimulated serum cortisol test. We aimed to estimate the long-acting porcine (LA)ACTH-stimulated serum and salivary cortisol levels of patients at different stages of cirrhosis using second generation electrochemiluminescence and to determine the prevalence of true adrenal insufficiency in these patients.

DESIGN, PATIENTS AND MEASUREMENTS

We included 135 noncritical patients with cirrhosis (45 each from CHILD A, B and C) and 45 healthy controls. Serum and salivary samples were collected at baseline in the morning and at 1 and 2 h after LA-ACTH injection.

RESULTS

In healthy subjects, the 2.5th centile of 2 h ACTH stimulated serum and salivary cortisol were 19.8 and 0.97 μg/dL, which were used as cut-offs for defining AI based on serum and saliva respectively. The median (interquartile-range) 2-h stimulated salivary cortisol in Child A, B, C categories and controls were 1.36(1.23-2.38), 1.46(1.18-2.22), 1.72(1.2-2.2) and 2.12(1.42-2.72) μg/dL respectively. Six subjects (4.4%) were diagnosed to have AI based on stimulated salivary cortisol cut-off, whereas 39 (28.9%) cirrhosis subjects had inadequately stimulated serum cortisol. Three patients (symptomatic) required steroid replacement therapy. Hypoalbuminemia was identified as a major risk factor for the misdiagnosis of adrenal insufficiency by serum cortisol-based testing.

CONCLUSIONS

Long-acting porcine ACTH stimulated salivary cortisol reduces the overdiagnosis of adrenal insufficiency compared to serum cortisol in cirrhosis liver. Stimulated salivary cortisol is a promising investigation for evaluation of adrenal function in cirrhosis and more studies are required for its further validation before clinical use.

Contents analysis of thyroid cancer-related information uploaded to YouTube by physicians in Korea: endorsing thyroid cancer screening, potentially leading to overdiagnosis

BACKGROUND

Thyroid cancer overdiagnosis is a major public health issue in South Korea, which has the highest incidence rate. The accessibility of information through the Internet, particularly on YouTube, could potentially impact excessive screening. This study aimed to analyze the content of thyroid cancer-related YouTube videos, particularly those from 2016 onwards, to evaluate the potential spread of misinformation.

METHODS

A total of 326 videos for analysis were collected using a video search protocol with the keyword "thyroid cancer" on YouTube. This study classified the selected YouTube videos as either provided by medical professionals or not and used topic clustering with LDA (latent dirichlet allocation), sentiment analysis with KoBERT (Korean bidirectional encoder representations from transformers), and reliability evaluation to analyze the content. The proportion of mentions of poor prognosis for thyroid cancer and the categorization of advertising content was also analyzed.

RESULTS

Videos by medical professionals were categorized into 7 topics, with "Thyroid cancer is not a 'Good cancer'" being the most common. The number of videos opposing excessive thyroid cancer screening decreased gradually yearly. Videos advocating screening received more favorable comments from viewers than videos opposing excessive thyroid cancer screening. Patient experience videos were categorized into 6 topics, with the "Treatment process and after-treatment" being the most common.

CONCLUSION

This study found that a significant proportion of videos uploaded by medical professionals on thyroid cancer endorse the practice, potentially leading to excessive treatments. The study highlights the need for medical professionals to provide high-quality and unbiased information on social media platforms to prevent the spread of medical misinformation and the need for criteria to judge the content and quality of online health information.

Medical students' awareness of overdiagnosis and implications for preventing overdiagnosis

Overdiagnosis is a growing health issue, yet our understanding of medical students' exposure to this concept within medical education is limited. Our aim was to explore students' experience of diagnostic learning to identify how overdiagnosis may be understood by students. During in-person and online semi-structured interviews throughout 2021, we explored the education experience of twelve Western Sydney University medical students in years 3-5. Through inductive thematic analysis we identified four themes. These themes encompassed student commitment to learning about diagnosis, lack of certainty surrounding diagnosis and emotional factors of medical care, overdiagnosis as seen through the lens of high and low-value care during clinical placements and student-identified missed learning opportunities related to overdiagnosis. This study found that medical students develop inherent knowledge of overdiagnosis through an interplay of personal factors, medical school curriculum and the setting in which their training takes place. Our findings allow insight for future improvement of medical curriculum to produce exceptional medical graduates.

A novel image deep learning-based sub-centimeter pulmonary nodule management algorithm to expedite resection of the malignant and avoid over-diagnosis of the benign

OBJECTIVES

With the popularization of chest computed tomography (CT) screening, there are more sub-centimeter (≤ 1 cm) pulmonary nodules (SCPNs) requiring further diagnostic workup. This area represents an important opportunity to optimize the SCPN management algorithm avoiding "one-size fits all" approach. One critical problem is how to learn the discriminative multi-view characteristics and the unique context of each SCPN.

METHODS

Here, we propose a multi-view coupled self-attention module (MVCS) to capture the global spatial context of the CT image through modeling the association order of space and dimension. Compared with existing self-attention methods, MVCS uses less memory consumption and computational complexity, unearths dimension correlations that previous methods have not found, and is easy to integrate with other frameworks.

RESULTS

In total, a public dataset LUNA16 from LIDC-IDRI, 1319 SCPNs from 1069 patients presenting to a major referral center, and 160 SCPNs from 137 patients from three other major centers were analyzed to pre-train, train, and validate the model. Experimental results showed that performance outperforms the state-of-the-art models in terms of accuracy and stability and is comparable to that of human experts in classifying precancerous lesions and invasive adenocarcinoma. We also provide a fusion MVCS network (MVCSN) by combining the CT image with the clinical characteristics and radiographic features of patients.

CONCLUSION

This tool may ultimately aid in expediting resection of the malignant SCPNs and avoid over-diagnosis of the benign ones, resulting in improved management outcomes.

CLINICAL RELEVANCE STATEMENT

In the diagnosis of sub-centimeter lung adenocarcinoma, fusion MVCSN can help doctors improve work efficiency and guide their treatment decisions to a certain extent.

KEY POINTS

• Advances in computed tomography (CT) not only increase the number of nodules detected, but also the nodules that are identified are smaller, such as sub-centimeter pulmonary nodules (SCPNs). • We propose a multi-view coupled self-attention module (MVCS), which could model spatial and dimensional correlations sequentially for learning global spatial contexts, which is better than other attention mechanisms. • MVCS uses fewer huge memory consumption and computational complexity than the existing self-attention methods when dealing with 3D medical image data. Additionally, it reaches promising accuracy for SCPNs' malignancy evaluation and has lower training cost than other models.

The over diagnosis of diffuse mesothelioma: An analysis of 311 cases with recommendations for the avoidance of pitfalls

BACKGROUND

The diagnosis of mesothelioma may be challenging. We investigated a large database of cases in order to determine the frequency with which a diagnosis of mesothelioma was made incorrectly and the most frequent causes of error.

DESIGN

A database including more than 4000 consultation cases of histologically confirmed mesothelioma was examined to identify cases in which mesothelioma was diagnosed by at least one pathologist when the available information pointed towards a different diagnosis.

RESULTS

There were 311 cases misdiagnosed as mesothelioma. The most common category was metastatic carcinoma to the pleura or peritoneum (129 cases: 73 lung carcinomas, 15 renal cell carcinomas). The next most common category was primary lung cancer (111 cases: 55 sarcomatoid carcinoma, 56 pseudomesotheliomatous carcinoma). The third most common category was primary malignancies arising from or near the serosal membranes (33 cases). The fourth most common category was fibrous pleurisy (38 cases). The most common errors were failure to consider important radiographic information regarding the gross distribution of tumor, lack of awareness or consideration of another malignancy, overreliance on certain immunohistochemical results, and failure to perform certain diagnostic histochemical, immunohistochemical, or ultrastructural studies.

CONCLUSIONS

There are a number of diagnostic pitfalls that can lead to the over diagnosis of mesothelioma. Careful attention to clinical and radiographic information as well as performance of appropriate ancillary tests can help to prevent such misdiagnoses. Detailed examples will be presented to assist in the avoidance of these pitfalls with emphasis on the most commonly observed errors.

Overdiagnosis in malignant melanoma: a scoping review

OBJECTIVES

We aimed to systematically identify and scrutinise published empirical evidence about overdiagnosis in malignant melanoma and examine how frequent overdiagnosis of melanoma is and whether this is related to different types of interventions or diagnostic technologies.

DESIGN AND SETTING

Empirical studies that discussed overdiagnosis in malignant melanoma were eligible, including qualitative and quantitative studies in any type of population, age group and geographical location. We excluded studies that did not include empirical data, studies that only mentioned 'overdiagnosis' without addressing it further and studies that used the term overdiagnosis for cases of misdiagnosis or false positives.We developed the search strategy in cooperation with an information specialist. We searched five databases on 21 April 2022: MEDLINE, Embase, CINAHL, PsycINFO and Cochrane Library.This scoping review adheres to The JBI methodology and Prefered Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping reviews (PRISMA-ScR). Two reviewers independently screened titles, abstracts and full texts for inclusion and extracted data from the included studies. The data extracted include study characteristics, population details, research question, the context and the study's main results.

RESULTS

Our search resulted in 1134 potentially relevant studies. 35 studies were included: 29 register studies, 3 cohort studies, 1 case-control study, 1 survey study and 1 randomised controlled trial. Most register studies examined trends in melanoma incidence and/or mortality and found a significant increase in incidence between 0.39% and 6.6% annually and a little or no increase in mortality. Three cohort studies and one case-control study showed that skin screening was associated with increased detection of melanoma; especially in situ or thin invasive melanoma. Three studies estimated the degree of overdiagnosis which ranged from 29% to 60%.

CONCLUSIONS

Epidemiological data suggest a high degree of overdiagnosis in malignant melanoma. Studies that examined the association between skin screening and malignant melanoma all found increased detection of melanomas, mostly thin and in situ melanomas, which raises concern about overdiagnosis.

Cancer Screening, Incidental Detection, and Overdiagnosis

BACKGROUND

In the past, patients were only diagnosed with cancer because they had symptoms. Now, because of screening and incidental detection, some patients are diagnosed with cancer when they are asymptomatic. While this shift is typically viewed as desirable, it has produced an unfortunate side-effect: it is now possible to be diagnosed with a cancer not destined to cause symptoms or death-a phenomenon labeled as overdiagnosis.

CONTENT

We begin with a brief introduction to the heterogeneity of cancer progression: at one extreme, some cancers are already systemic by the time they are detectable; at the other, some grow extremely slowly or even regress. The ensuing sections describe the evidence that the pursuit of earlier detection has led to overdiagnosis. Although rarely confirmed in an individual, overdiagnosis is readily identifiable in a long-term follow-up of a randomized trial of screening. Furthermore, 2 population signatures for overdiagnosis exist: (a) rising incidence coupled with stable mortality and (b) rising early-stage incidence coupled with stable late-stage incidence. Finally, we review the misleading feedback produced by overdiagnosis-such as rising 5-year survival rates and more cancer survivors. This feedback is erroneously interpreted as reinforcing the value of early detection, encourages more screening/incidental detection and, ironically, promotes more overdiagnosis.

SUMMARY

Overdiagnosis is an unintended consequence of the desire to detect cancer early. Given the evolving understanding that tumor biology and host response are more relevant to prognosis than early vs late diagnosis, it is time to challenge the assertion that early diagnosis is always the best approach to curing cancer.

Evidence for overdiagnosis in noncancer conditions was assessed: a metaepidemiological study using the 'Fair Umpire' framework

OBJECTIVES

To evaluate the strength of the evidence for, and the extent of, overdiagnosis in noncancer conditions.

STUDY DESIGN AND SETTING

We systematically searched for studies investigating overdiagnosis in noncancer conditions. Using the 'Fair Umpire' framework to assess the evidence that cases diagnosed by one diagnostic strategy but not by another may be overdiagnosed, two reviewers independently identified whether a Fair Umpire-a disease-specific clinical outcome, a test result or risk factor that can determine whether an additional case does or does not have disease-was present. Disease-specific clinical outcomes provide the strongest evidence for overdiagnosis, follow-up or concurrent tests provide weaker evidence, and risk factors provide only weak evidence. Studies without a Fair Umpire provide the weakest evidence of overdiagnosis.

RESULTS

Of 132 studies, 47 (36%) did not include a Fair Umpire to adjudicate additional diagnoses. When present, the most common Umpire was a single test or risk factor (32% of studies), with disease-specific clinical outcome Umpires used in only 21% of studies. Estimates of overdiagnosis included 43-45% of screen-detected acute abdominal aneurysms, 54% of cases of acute kidney injury, and 77% of cases of oligohydramnios in pregnancy.

CONCLUSION

Much of the current evidence for overdiagnosis in noncancer conditions is weak. Application of the framework can guide development of robust studies to detect and estimate overdiagnosis in noncancer conditions, ultimately informing evidence-based policies to reduce it.

Routine MRI Among Patients With a Suspected Scaphoid Fracture Risks Overdiagnosis

BACKGROUND

In the setting of a suspected scaphoid fracture, MRI may result in overdiagnosis and potential overtreatment. This is in part because of the low prevalence of true fractures among suspected fractures, but also because of potentially misleading variations in signal that may be more common than fracture-related signal changes. To better understand the risk of overdiagnosis, we first need insight into the relative prevalence of useful and potentially distracting signal changes among patients with a suspected scaphoid fracture.

QUESTION/PURPOSE

What is the proportion of signal changes representing definite and possible scaphoid fractures relative to other types of signal changes on MRI among patients with a suspected scaphoid fracture?

METHODS

In a retrospective study in an orthopaedic trauma clinic associated with a Level I trauma center, we evaluated MR images of patients 16 years and older with a clinically suspected scaphoid fracture. At our institution, patients with symptoms and signs of a possible scaphoid fracture and negative radiographs undergo MRI scanning. Between January 1, 2012, and September 1, 2019, a total of 310 patients 16 years or older had an MRI to evaluate a suspected scaphoid fracture. Exclusion criteria included a scaphoid fracture that was visible on radiographs before MRI as reported by the radiologist (four patients), no available radiographs before MRI (two), MRI more than 3 weeks after injury (28), unknown date of injury (nine), and repeat or bilateral MRI scans (11), leaving 256 MR images for analysis. Sixty percent (153) of patients were women, and the median age was 34 years (IQR 21 to 50 years). The images were taken a median of 8 days (IQR 2 to 12 days) after injury. MR images were screened for the presence of scaphoid signal changes. We identified the following patterns of signal change with a reliability of kappa 0.62: definite scaphoid fracture, possible scaphoid fracture, signal in the waist area other than possible or definite fractures, and other signal changes. A definite scaphoid fracture was defined as a linear, focal, and bicortical signal abnormality, with adjacent edema and a relatively transverse orientation relative to the scaphoid long axis. The transverse linear signal was visible on more than one cut in multiple planes. A possible scaphoid fracture had a transverse linear signal on more than one cut on sagittal or coronal planes, with or without adjacent edema.

RESULTS

Six percent (16 of 256) of MR images were categorized as revealing definite (2% [four of 256]) or possible (5% [12 of 256]) scaphoid fractures, whereas 29% (74 of 256) were categorized as revealing nonspecific signal changes at the waist (14% [35 of 256]) and other areas (15% [39 of 256]). Of the 51 patients with scaphoid waist signal changes, 69% (35) were categorized as having distracting and potentially misleading MRI findings.

CONCLUSION

The high prevalence of signal changes that are distracting and potentially misleading, the low prevalence of signal changes that clearly represent a scaphoid fracture, and the low pretest odds of a true fracture among patients with a suspected scaphoid fracture illustrate that routine MRI of suspected scaphoid fractures carries a notable risk of overdiagnosis and potential overtreatment. Two alternative strategies are supported by preliminary evidence and merit additional attention: more-selective use of MRI in people deemed at higher risk according to a clinical prediction rule and strategies for involving the patient in decisions regarding how to manage the notably small risk of future symptomatic nonunion.

LEVEL OF EVIDENCE

Level IV, diagnostic study.

Factors associated with overdiagnosis of benign pulmonary nodules as malignancy: a retrospective cohort study

OBJECTIVE

To establish a preoperative model for the differential diagnosis of benign and malignant pulmonary nodules (PNs), and to evaluate the related factors of overdiagnosis of benign PNs at the time of imaging assessments.

MATERIALS AND METHODS

In this retrospective study, 357 patients (median age, 52 years; interquartile range, 46-59 years) with 407 PNs were included, who underwent surgical histopathologic evaluation between January 2020 and December 2020. Patients were divided into a training set (n = 285) and a validation set (n = 122) to develop a preoperative model to identify benign PNs. CT scan features were reviewed by two chest radiologists, and imaging findings were categorized. The overdiagnosis rate of benign PNs was calculated, and bivariate and multivariable logistic regression analyses were used to evaluate factors associated with benign PNs that were over-diagnosed as malignant PNs.

RESULTS

The preoperative model identified features such as the absence of part-solid and non-solid nodules, absence of spiculation, absence of vascular convergence, larger lesion size, and CYFRA21-1 positivity as features for identifying benign PNs on imaging, with a high area under the receiver operating characteristic curve of 0.88 in the validation set. The overdiagnosis rate of benign PNs was found to be 50%. Independent risk factors for overdiagnosis included diagnosis as non-solid nodules, pleural retraction, vascular convergence, and larger lesion size at imaging.

CONCLUSION

We developed a preoperative model for identifying benign and malignant PNs and evaluating factors that led to the overdiagnosis of benign PNs. This preoperative model and result may help clinicians and imaging physicians reduce unnecessary surgery.

[What is overdiagnosis?]

A considerable amount of spending in health care is deemed wasteful. Overdiagnosis, i.e. the labelling of a person with a diagnosis that lacks net benefit, is an entity within the overarching concept of »too much medicine«. Overdiagnosis includes overdetection and overdefinition. Disease mongering is a type of overdefinition with economic drivers. Overtesting and overtreatment are other aspects of »too much medicine«, but are not overdiagnosis per se. Medical research tends to focus on benefits of diagnostics and therapy, whereas overdiagnosis and other harms receive less attention, leading to overestimation of benefits. The international network Choosing Wisely has been successful in changing the diagnostic mindset in several countries and a Swedish campaign is under way, yielding new possibilities to counteract »too much medicine« and the specific problem of overdiagnosis.

Data-driven overdiagnosis definitions: A scoping review

INTRODUCTION

Adequate methods to promptly translate digital health innovations for improved patient care are essential. Advances in Artificial Intelligence (AI) and Machine Learning (ML) have been sources of digital innovation and hold the promise to revolutionize the way we treat, manage and diagnose patients. Understanding the benefits but also the potential adverse effects of digital health innovations, particularly when these are made available or applied on healthier segments of the population is essential. One of such adverse effects is overdiagnosis.

OBJECTIVE

to comprehensively analyze quantification strategies and data-driven definitions for overdiagnosis reported in the literature.

METHODS

we conducted a scoping systematic review of manuscripts describing quantitative methods to estimate the proportion of overdiagnosed patients.

RESULTS

we identified 46 studies that met our inclusion criteria. They covered a variety of clinical conditions, primarily breast and prostate cancer. Methods to quantify overdiagnosis included both prospective and retrospective methods including randomized clinical trials, and simulations.

CONCLUSION

a variety of methods to quantify overdiagnosis have been published, producing widely diverging results. A standard method to quantify overdiagnosis is needed to allow its mitigation during the rapidly increasing development of new digital diagnostic tools.

Cuff Size Affects Blood Pressure Readings, Potentially Leading to Underdiagnosis or Overdiagnosis

According to this study.

Nonsebaceous Lymphadenoma of the Salivary Glands: A Potential Overdiagnosis Pitfall

Nonsebaceous lymphadenoma is a rare benign salivary tumor. It is easily misdiagnosed as lymphoepithelial carcinoma, leading to overtreatment. Some patients experience sequelae after undergoing cervical lymph node resection and adjuvant treatment, so it is critical to distinguish these entities. We describe the histopathological and immunohistochemical features of this rare entity in 3 cases and discuss the differential diagnosis and histogenesis. Nonsebaceous lymphadenoma can be distinguished from lymphoepithelial carcinoma by the following histological features: There is a lymph node-like form at low magnification, with prominent proliferating epithelial nests but no destructive growth pattern; variable numbers of tubuloglandular components are always seen in proliferating epithelial nests, which transition to cystically dilated salivary ducts; no lesion necrosis exists; and mitotic figures are absent or rare. No patients experienced recurrence during the 8- to 69-month (mean, 29 months) follow-up.

Trends in incidence and overdiagnosis of thyroid cancer in China, Japan, and South Korea

We used data from 13 cancer registries in China, Japan, and South Korea to analyze time trends in overdiagnosis of thyroid cancer between 1998 and 2012. Age-standardized and age-specific incidence and annual percentage changes were calculated. The number of thyroid cancers diagnosed and the proportion attributable to overdiagnosis were estimated, with calculations stratified by sex and age group. The Spearman method was used to analyze the correlation between thyroid cancer incidence and overdiagnosis. From 1998 to 2012, both the incidence and proportions of overdiagnoses of thyroid cancer in China, Japan, and South Korea showed an increasing trend, with higher rates in women than men. South Korea had both the highest incidence for men (10.1/105 ) and women (46.7/105 ) and the highest proportions of overdiagnosis (men, 90.3%; women, 94.9%). The fastest growth in overdiagnosis was in Chinese men and women (annual percentage changes 6.1 and 4.6, respectively). We found significant positive correlations between age-standardized incidence and proportions of overdiagnosis for both men (Spearman r = 0.98, p < 0.05) and women (Spearman r = 0.99, p < 0.05) in the three countries. Age-specific incidence curves in Chinese and South Korean individuals were of an inverted U-shape. Overdiagnosis of thyroid cancer in Japan was mainly concentrated in middle-aged and older patients, whereas in China and South Korea, it occurred primarily in the middle-aged. The incidence and overdiagnosis of thyroid cancer in China, Japan, and South Korea are increasing, necessitating the implementation of comprehensive measures to reduce these overdiagnoses.

Does mammographic density predict survival in women with invasive breast cancer? The need to account for potential confounding from cancer stage and overdiagnosis

•The negative findings from the linked study suggest breast density may not affect prognosis after a breast cancer diagnosis. •Cancer stage and overdiagnosis are potential confounders of the relationship between breast density and health outcomes. •The prognostic value of changes in mammographic density over time may be explored in future research.

Assessing and Understanding Reactance, Self-Exemption, Disbelief, Source Derogation and Information Conflict in Reaction to Overdiagnosis in Mammography Screening: Scale Development and Preliminary Validation

PURPOSE

Overdiagnosis is a concept central to making informed breast cancer screening decisions, and yet some people may react to overdiagnosis with doubt and skepticism. The present research assessed 4 related reactions to overdiagnosis: reactance, self-exemption, disbelief, and source derogation (REDS). The degree to which the concept of overdiagnosis conflicts with participants' prior beliefs and health messages (information conflict) was also assessed as a potential antecedent of REDS. We developed a scale to assess these reactions, evaluated how those reactions are related, and identified their potential implications for screening decision making.

METHODS

Female participants aged 39 to 49 years read information about overdiagnosis in mammography screening and completed survey questions assessing their reactions to that information. We used a multidimensional theoretical framework to assess dimensionality and overall domain-specific internal consistency of the REDS and Information Conflict questions. Exploratory and confirmatory factor analyses were performed using data randomly split into a training set and test set. Correlations between REDS, screening intentions, and other outcomes were evaluated.

RESULTS

Five-hundred twenty-five participants completed an online survey. Exploratory and confirmatory factor analyses identified that Reactance, Self Exemption, Disbelief, Source Derogation, and Information Conflict represent unique constructs. A reduced 20-item scale was created by selecting 4 items per construct, which showed good model fit. Reactance, Disbelief, and Source Derogation were associated with lower intent to use information about overdiagnosis in decision making and the belief that informing people about overdiagnosis is unimportant.

CONCLUSIONS

REDS and Information Conflict are distinct but correlated constructs that are common reactions to overdiagnosis. Some of these reactions may have negative implications for making informed screening decisions.

HIGHLIGHTS

Overdiagnosis is a concept central to making informed breast cancer screening decisions, and yet when provided information about overdiagnosis, some people are skeptical.This research developed a measure that assessed different ways in which people might express skepticism about overdiagnosis (reactance, self-exemption, disbelief, source derogation) and also the perception that overdiagnosis conflicts with prior knowledge and health messages (information conflict).These different reactions are distinct but correlated and are common reactions when people learn about overdiagnosis.Reactance, disbelief, and source derogation are associated with lower intent to use information about overdiagnosis in decision making as well as the belief that informing people about overdiagnosis is unimportant.

Preventing the overdiagnosis of chest sepsis in children: A quality improvement project

RATIONALE

Respiratory infections in children are one of the most common causes of hospital attendances and a common cause of sepsis. Most of these infections turn out to be viral in nature. However, the overuse of antibiotics is common and with increasing problems with antimicrobial resistance, changes to antibiotic prescribing practices need to be implemented urgently.

AIMS AND OBJECTIVES

To test our hypothesis that a significant number of children and young people are diagnosed with and treated for 'chest sepsis' unnecessarily by evaluating adherence to British Thoracic Society and National Institute of Clinical Excellence sepsis guidelines, and to implement measures to prevent overdiagnosis.

DESIGN

A baseline audit undertaken, stratified patient risk as per NICE sepsis guidelines. Data were analysed to assess adherence to these guidelines following presentation of possible lower respiratory tract infection. Questionnaires were sent to Paediatric doctors in local hospitals and focus groups were held to qualitatively evaluate the barriers and facilitators to preventing overdiagnosis. These informed implemented measures.

RESULTS

The baseline audit showed 61% of children under two, who are more likely to have a viral chest infection were treated with intravenous antibiotics. Seventy-seven percent of children had blood tests and 88% had chest X-rays (CXRs) which are not routinely recommended. A total of 71% with a normal CXR had been treated with intravenous antibiotics. Barriers to preventing overdiagnosis included the over-sensitivity of the sepsis tool, anxiety and drug prescribing habits. Facilitators included visual cues and team work. Implemented changes including a revised sepsis pathway and raising awareness led to some positive changes. However, upon re-auditing there was no significant change in the number of children being overdiagnosed.

CONCLUSIONS

Initial audit results supported our hypothesis that children were being overdiagnosed, over-investigated and over-treated. Despite multimodal interventions aimed at understanding the drivers underpinning these issues, the re-audit results mirrored the baseline audit despite a transient improvement following our campaign to raise awareness and further work to change physician behaviour is required.

Estimating Breast Cancer Overdiagnosis After Screening Mammography Among Older Women in the United States

BACKGROUND

Overdiagnosis is increasingly recognized as a harm of breast cancer screening, particularly for older women.

OBJECTIVE

To estimate overdiagnosis associated with breast cancer screening among older women by age.

DESIGN

Retrospective cohort study comparing the cumulative incidence of breast cancer among older women who continued screening in the next interval with those who did not. Analyses used competing risk models, stratified by age.

SETTING

Fee-for-service Medicare claims, linked to the SEER (Surveillance, Epidemiology, and End Results) program.

PATIENTS

Women 70 years and older who had been recently screened.

MEASUREMENTS

Breast cancer diagnoses and breast cancer death for up to 15 years of follow-up.

RESULTS

This study included 54 635 women. Among women aged 70 to 74 years, the adjusted cumulative incidence of breast cancer was 6.1 cases (95% CI, 5.7 to 6.4) per 100 screened women versus 4.2 cases (CI, 3.5 to 5.0) per 100 unscreened women. An estimated 31% of breast cancer among screened women were potentially overdiagnosed. For women aged 75 to 84 years, cumulative incidence was 4.9 (CI, 4.6 to 5.2) per 100 screened women versus 2.6 (CI, 2.2 to 3.0) per 100 unscreened women, with 47% of cases potentially overdiagnosed. For women aged 85 and older, the cumulative incidence was 2.8 (CI, 2.3 to 3.4) among screened women versus 1.3 (CI, 0.9 to 1.9) among those not, with up to 54% overdiagnosis. We did not see statistically significant reductions in breast cancer-specific death associated with screening.

LIMITATIONS

This study was designed to estimate overdiagnosis, limiting our ability to draw conclusions on all benefits and harms of screening. Unmeasured differences in risk for breast cancer and differential competing mortality between screened and unscreened women may confound results. Results were sensitive to model specifications and definition of a screening mammogram.

CONCLUSION

Continued breast cancer screening was associated with greater incidence of breast cancer, suggesting overdiagnosis may be common among older women who are diagnosed with breast cancer after screening. Whether harms of overdiagnosis are balanced by benefits and for whom remains an important question.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Patient-level information underlying overdiagnosis of urinary tract infections in nursing homes: A discrete choice experiment

The overdiagnosis of urinary tract infections (UTIs) in nursing home residents is a significant public health threat. Using a discrete choice experiment and a diagnostic guideline, we examined which patient-level information was associated with the overdiagnosis of UTIs and found that urinalysis results and lower urinary tract status were most associated.

Current Controversies in Low-Risk Differentiated Thyroid Cancer: Reducing Overtreatment in an Era of Overdiagnosis

CONTEXT

Low-risk differentiated thyroid cancer (DTC) is overdiagnosed, but true incidence has increased as well. Owing to its excellent prognosis with low morbidity and mortality, balancing treatment risks with risks of disease progression can be challenging, leading to several areas of controversy.

EVIDENCE ACQUISITION

This mini-review is an overview of controversies and difficult decisions around the management of all stages of low-risk DTC, from diagnosis through treatment and follow-up. In particular, overdiagnosis, active surveillance vs surgery, extent of surgery, radioactive iodine (RAI) treatment, thyrotropin suppression, and postoperative surveillance are discussed.

EVIDENCE SYNTHESIS

Recommendations regarding the diagnosis of DTC, the extent of treatment for low-risk DTC patients, and the intensity of posttreatment follow-up have all changed substantially in the past decade. While overdiagnosis remains a problem, there has been a true increase in incidence as well. Treatment options range from active surveillance of small tumors to total thyroidectomy followed by RAI in select cases. Recommendations for long-term surveillance frequency and duration are similarly broad.

CONCLUSION

Clinicians and patients must approach each case in a personalized and nuanced fashion to select the appropriate extent of treatment on an individual basis. In areas of evidential equipoise, data regarding patient-centered outcomes may help guide decision-making.