Deciphering the tumour immune microenvironment cell by cell

Immune checkpoint inhibitors (ICIs) have rejuvenated therapeutic approaches in oncology. Although responses tend to be durable, response rates vary in many cancer types. Thus, the identification and validation of predictive biomarkers is a key clinical priority, the answer to which is likely to lie in the tumour microenvironment (TME). A wealth of data demonstrates the huge impact of the TME on ICI response and resistance. However, these data also reveal the complexity of the TME composition including the spatiotemporal interactions between different cell types and their dynamic changes in response to ICIs. Here, we briefly review some of the modalities that sculpt the TME, in particular the metabolic milieu, hypoxia and the role of cancer-associated fibroblasts. We then discuss recent approaches to dissect the TME with a focus on single-cell RNA sequencing, spatial transcriptomics and spatial proteomics. We also discuss some of the clinically relevant findings these multi-modal analyses have yielded.

Effectiveness of carbohydrate counting and Dietary Approach to Stop Hypertension dietary intervention on managing Gestational Diabetes Mellitus among pregnant women who used metformin: A randomized controlled clinical trial

BACKGROUND

Gestational diabetes mellitus (GDM) is one of the most common complication of pregnancy that has significant impacts on both mother and her offspring health. The present study aimed to examine the effect of carbohydrate counting, carbohydrate counting combined with DASH, and control dietary interventions on glycemic control, and maternal and neonatal outcomes.

METHODS

A total of 75 pregnant women with GDM at 24th - 30th week of gestation were enrolled and randomized to follow one of the three diets: control or carbohydrate counting, or carbohydrate counting combined with Dietary Approach to Stop Hypertension (DASH). Only 70 of them completed the study until delivery. Fasting blood samples were taken at baseline and the end of the study to measure fasting blood glucose (FBG), fasting insulin, glycated hemoglobin (HbA1c), and fructosamine. Homeostatic model assessment-insulin resistance (HOMA-IR) score was calculated using HOMA2 calculator program. The participants recorded at least four blood glucose readings per day. Maternal and neonatal outcomes were collected from medical records. Dietary intake was assessed by three-day food records at the baseline and the end of the study.

RESULTS

Adherence to the three dietary interventions, resulted in decreased FBG levels significantly among all the participants (P < 0.05). Consumption of the carbohydrate counting combined with the DASH diet showed significant reduction in serum insulin levels and HOMA-IR score compared to carbohydrate counting group and control group. Means of fructosamine and HbA1c did not differ significantly among the three intervention diet groups. Overall mean of 1-h postprandial glucose (1 h PG) level was significantly lower in the carbohydrate counting combined with DASH group compared with that in the carbohydrate counting group and the control group (P < 0.001). The number of women who were required to commence insulin therapy after dietary intervention was significantly lower in carbohydrate counting group and carbohydrate counting combined with DASH group (P = 0.026). There were no significant differences in other maternal and neonatal outcomes among the three dietary intervention groups.

CONCLUSIONS

The carbohydrate counting and the carbohydrate counting combined with DASH dietary interventions resulted in beneficial effects on FBG and 1 h PG compared with the control diet. The three dietary interventions produced similar maternal and neonatal outcomes in women with GDM.

TRIAL REGISTRATION

This trial was registered on ClinicalTrials.gov under the identification code: NCT03244579. https://clinicaltrials.gov/ct2/show/NCT03244579.

Prevalence of endometriosis in women undergoing laparoscopic surgery for various gynaecological indications at a Jordanian referral centre: gaining insight into the epidemiology of an important women's health problem

Background

Endometriosis is a considerable health challenge for women of reproductive age. Information about its prevalence in the Jordanian population is sparse. The objective of this research was to evaluate the presence of endometriosis in gynaecological patients undergoing laparoscopic surgery for various indications and to correlate the finding of endometriosis with variables, including patient demographics, obstetric history, type, and indication of laparoscopic procedure.

Methods

A retrospective cohort study involving 460 women who underwent different laparoscopic procedures for a variety of indications was conducted in the Department of Obstetrics and Gynaecology in Jordan University Hospital, a tertiary referral hospital in Jordan, between January 2015 and September 2020.

Results

The prevalence of endometriosis in this patient group was higher than that of the general population (13.7% vs. 2.5%), and the mean age at diagnosis (31.9 years) was younger than the general population's age of peak incidence (35–45 years). It was significantly higher in women with lower numbers of pregnancies (p = 0.01) and a lower number of Caesarean sections (p = 0.05) and in those where the indication for surgery was related to decreased fertility or pelvic pain (p = 0.02). Women with high parity or where the surgery's indication suggested normal fertility, such as family planning, were less likely to have endometriosis.

Conclusion

To our knowledge, this is the first Jordanian study to assess the prevalence of endometriosis in women undergoing gynaecological laparoscopy. This study suggests that the epidemiology of endometriosis in this region follows similar trends to what has been previously documented in international literature, while emphasizing the need for further research into this important women's health issue in this part of the world.

Anesthesia for Cesarean Section: Retrospective Comparative Study

Background

Cesarean section is a widely performed surgery.

Objective

To compare anesthetic types regarding feto-maternal outcomes.

Materials and Methods

Retrospective comparative study of 3599 cesarean sections (emergency and elective categories).

Results

Mean APGAR score was statistically higher in the spinal than general anesthesia among the emergency category, P = 0.000 and 0.026, respectively, with no significant difference in the elective category. Estimated blood loss among the elective category was statistically significantly higher in the spinal than general anesthesia, P = 0.001. However, among the emergency category, it was significantly higher in the general than in spinal or epidural anesthesia, P = 0.000. Diclofenac sodium was used more after spinal than general anesthesia (P = 0.000), with no significant difference between epidural and general or between epidural and spinal anesthesia. Pethidine hydrochloride (HCL) was used more after general than after spinal anesthesia (P = 0.000). However, pethidine HCL use was not statistically significantly different between spinal and epidural anesthesia. In the elective category, paracetamol was requested more after spinal than epidural or general anesthesia, P = 0.000. No significant difference was seen between epidural and general anesthesia, P = 1.000. No statistically significant difference was found among the anesthetic types in both categories regarding tramadol HCL. Length of hospital stay, operative time and neonatal intensive care unit admission were not statistically different between anesthetic modes. In the emergency category, significantly higher percentage of patients were satisfied with and would recommend epidural anesthesia.

Conclusion

There was no statistically significant difference among the three types of anesthesia regarding neonatal intensive care admission and length of hospital stay for emergency and elective categories. APGAR score was higher with spinal than with general anesthesia in the emergency category with no significant difference in the elective category. More diclofenac sodium and paracetamol and less opioids were used after regional than after general anesthesia. Satisfaction was higher with epidural anesthesia.

Limitations

Retrospective and single centered.

Impact of Biopsy Technique on Clinically Important Outcomes for Cutaneous Melanoma: A Systematic Review and Meta-analysis

We performed a systematic review and meta-analysis to examine the relationship between the type of biopsy technique employed in the diagnosis of cutaneous melanoma and 4 clinically important outcomes: melanoma-specific mortality, all-cause mortality, Breslow tumor depth, or melanoma recurrence. Our database was obtained by searching PubMed, Ovid MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, and the Cochrane Library from inception until December 6, 2019. Studies were identified that compared biopsy techniques used to diagnose cutaneous melanoma with any of our study outcomes. We included 7 observational studies for our meta-analysis after screening 3231 titles and abstracts. Pooled data identified a significantly higher all-cause mortality in the punch biopsy group (risk ratio [RR], 1.520; P=.02). A higher, but nonsignificant, rate of melanoma-specific mortality (RR, 1.96; P=.22) and melanoma recurrence (RR, 1.20; P=.186) was also found for the punch biopsy group. Breslow tumor thickness was not significantly lower for punch incision (standardized mean difference, −0.42; P=.27). We found limited evidence for differences in clinically important outcomes across the spectrum of the most common methods employed in clinical practice for the initial diagnosis of cutaneous melanoma. A small, but significant, increase (P=.02) in all-cause mortality with punch biopsies was not seen for the other outcomes and was most likely due to small sample sizes and demographic differences in the included studies and unlikely represents a clinically important outcome. Our findings support the use of existing clinical practice guidelines for evaluating pigmented lesions suspicious for cutaneous melanoma.

Heart failure mortality prediction using PRISM score and development of a classification and regression tree model to refer patients for palliative care consultation

INTRODUCTION

We sought to assess one-year mortality in heart failure (HF) patients by using (Placement Resource Indicator for Systems Management) PRISM, a disease nonspecific risk stratification score, and use it along with modified Seattle Heart Failure Model (SHFM) to guide patient selection for palliative care consultation.

METHODS

A retrospective study design was used to examine 1-year mortality in 689 HF patients admitted from 2012 to 2014. One-year mortality was calculated using Pmort30/PRISM and modified SHFM scores, and the predicted scores were validated using the area under the ROC curve. CART was used to develop an algorithm to classify patients based on their mortality risk.

RESULTS

The discriminatory ability of PRISM categorical score (AUC = 0.701) was not significantly different than the discriminatory ability of modified SHFM (AUC = 0.686) (DeLong's test p = 0.56) but improved significantly with the combination of PRISM (categorical) score + modified SHFM (AUC = 0.740) (p = 0.002). The predictive capability of the CART tree model after cross-validation was 72.2% (AUC 0.631).

CONCLUSION

Our study suggests PRISM score performed as well as modified SHFM for one-year mortality prediction. Moreover, the addition of modified SHFM to PRISM score increases discriminatory ability in predicting 1-year mortality in heart failure patients compared to either of the two models alone. Together, when combined in a CART model, they can be used to identify the population subset with the highest mortality risk and hence guide goals of care discussion.

Treatment Options for Hirsutism: A Systematic Review and Network Meta-Analysis

BACKGROUND

Several pharmacologic treatments for hirsutism are used in practice; however, their relative efficacy is unclear.

METHODS

We searched MEDLINE, EMBASE, and CENTRAL through January 2017 for randomized controlled trials (RCTs) with follow-up of at least 6 months that evaluated antiandrogens, insulin sensitizers, and oral contraceptives in women with hirsutism. Independent pairs of reviewers selected and appraised trials. Random-effects network meta-analysis was used to compare individual drugs and classes.

RESULTS

We included 43 trials. Estrogen-progestin oral contraceptives pills (OCPs), antiandrogens, and insulin sensitizers were superior to placebo, with standardized mean reductions (95% confidence intervals) of -0.94 (-1.49 to -0.38), -1.29 (-1.80 to -0.79), and -0.62 (-1.00 to -0.23), respectively. Antiandrogen monotherapy, the combination of OCP and antiandrogen, the combination of OCPs and insulin sensitizer, and the combination of antiandrogen and insulin sensitizer were superior to insulin sensitizer monotherapy. The combination of OCPs and antiandrogen was superior to OCPs. Antiandrogen monotherapy with flutamide, finasteride, and spironolactone were each superior to placebo but similar to each other in efficacy. OCPs containing levonorgestrel, cyproterone acetate, or drospirenone were similar in effectiveness to other OCPs or had trivial differences. The certainty in comparisons with placebo was moderate and for head-to-head comparisons was low.

CONCLUSIONS

Estrogen-progestin OCPs, antiandrogens, and insulin sensitizers are superior to placebo for the treatment of hirsutism.

Melanoma screening: A plan for improving early detection

Malignant melanoma ranks fifth in the number of new cases annually in the United States (US). Despite increasing incidence and lack of recent improvement in mortality, national melanoma screening guidelines are currently not in existence. Our purpose was to review the evidence regarding screening whole-body skin examinations for early detection and a possible mortality benefit for malignant melanoma. Data sources for our review were MEDLINE Complete, PubMed, Cochrane Library, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov. Study selection included: epidemiologic data from the US and European cancer surveillance registries, population-based case-control screening trials, computer-simulated Markov model trials, and survey trials. Studies were limited to those published in the English language. Data was extracted using a dual extraction method. Data from studies have shown that the mortality of malignant melanoma is highly predicated on the tumor thickness at the time of diagnosis. Our data review is in support of the implementation of whole-body skin examinations, performed by primary care physicians, for the purpose of early detection of melanoma. A large national population-based, case-control, skin cancer screening trial in Germany has shown a reduction in melanoma-specific mortality. In conclusion, our review of the evidence supports physicians performed whole-body skin examination can lead to the detection of earlier stage melanomas as well as to a reduction in disease-specific mortality. We found a paucity of randomized trials to be a limitation of screening studies for many cancers, including melanoma. To improve screening rates and early detection of malignant melanoma, we propose making skin cancer education part of the curriculum in US primary care residency programs to become the genesis for widespread melanoma screening. Our study had no funding.

Bone turnover markers in Paget's disease of the bone: A Systematic review and meta-analysis

The aim of this systematic review and meta-analysis is to study the utility of the commonly used bone turnover markers in evaluating disease activity in patients with Paget's disease of bone before and after treatment with bisphosphonates. We found good correlation between the bone turnover marker concentrations and disease activity assessed by bone scintigraphy.

INTRODUCTION

Paget's disease of bone is a common skeletal disorder of the elderly. Bone turnover marker concentrations are used for diagnosis and follow-up. We aimed to compare the available bone turnover markers and determine their utility in assessing disease activity when compared to quantitative bone scintigraphy.

METHODS

We conducted a systematic review and meta-analysis searching MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus. We evaluated total alkaline phosphatase (total ALP), bone-specific alkaline phosphatase (bone ALP), procollagen type 1 amino-terminal propeptide (P1NP), serum, and urine C-terminal telopeptide (uCTx and sCTx, respectively), and urine N-terminal telopeptide (uNTx). The main outcome of interest was the correlation of disease activity with concentrations of bone turnover markers in Paget's disease patients before and after treatment with bisphosphonates. Correlation coefficients were pooled across studies using the random effects model.

RESULTS

We included 17 observational studies and one trial reporting on 953 patients. Prior to treatment, all studied bone turnover markers had moderate to strong correlation with scintigraphic indices (correlation coefficients ranging from 0.58 to 0.80) with no statistically significant difference between the bone turnover markers overall (p = 0.08). P1NP, uNTx, and bone ALP tend to have higher correlation with scintigraphy. After starting treatment with bisphosphonate, there was moderate to strong correlation with disease activity with all markers except bone ALP (correlation coefficients ranging from 0.43 to 0.70).

CONCLUSION

The findings of this meta-analysis suggest the Paget's disease activity is best monitored by following P1NP levels. However, total ALP, bone ALP, and uNTx are good alternatives as markers of disease activity in untreated patients. Total ALP and uNTx can be useful in following patients with Paget's disease after treatment if P1NP is not available. Clinicians, however, should take availability, cost, and the presence of liver disease into consideration when deciding which bone turnover marker is most appropriate when evaluating patients with Paget's disease.

Charged particle therapy versus photon therapy for paranasal sinus and nasal cavity malignant diseases: a systematic review and meta-analysis

BACKGROUND

Malignant tumours arising within the nasal cavity and paranasal sinuses are rare and composed of several histological types, rendering controlled clinical trials to establish the best treatment impractical. We undertook a systematic review and meta-analysis to compare the clinical outcomes of patients treated with charged particle therapy with those of individuals receiving photon therapy.

METHODS

We identified studies of nasal cavity and paranasal sinus tumours through searches of databases including Embase, Medline, Scopus, and the Cochrane Collaboration. We included treatment-naive cohorts (both primary and adjuvant radiation therapy) and those with recurrent disease. Primary outcomes of interest were overall survival, disease-free survival, and locoregional control, at 5 years and at longest follow-up. We used random-effect models to pool outcomes across studies and compared event rates of combined outcomes for charged particle therapy and photon therapy using an interaction test.

FINDINGS

43 cohorts from 41 non-comparative observational studies were included. Median follow-up for the charged particle therapy group was 38 months (range 5-73) and for the photon therapy group was 40 months (14-97). Pooled overall survival was significantly higher at 5 years for charged particle therapy than for photon therapy (relative risk 1·51, 95% CI 1·14-1·99; p=0·0038) and at longest follow-up (1·27, 1·01-1·59; p=0·037). At 5 years, disease-free survival was significantly higher for charged particle therapy than for photon therapy (1·93, 1·36-2·75, p=0·0003) but, at longest follow-up, this event rate did not differ between groups (1·51, 1·00-2·30; p=0·052). Locoregional control did not differ between treatment groups at 5 years (1·06, 0·68-1·67; p=0·79) but it was higher for charged particle therapy than for photon therapy at longest follow-up (1·18, 1·01-1·37; p=0·031). A subgroup analysis comparing proton beam therapy with intensity-modulated radiation therapy showed significantly higher disease-free survival at 5 years (relative risk 1·44, 95% CI 1·01-2·05; p=0·045) and locoregional control at longest follow-up (1·26, 1·05-1·51; p=0·011).

INTERPRETATION

Compared with photon therapy, charged particle therapy could be associated with better outcomes for patients with malignant diseases of the nasal cavity and paranasal sinuses. Prospective studies emphasising collection of patient-reported and functional outcomes are strongly encouraged.

FUNDING

Mayo Foundation for Medical Education and Research.

Patient engagement in research: a systematic review

BACKGROUND

A compelling ethical rationale supports patient engagement in healthcare research. It is also assumed that patient engagement will lead to research findings that are more pertinent to patients' concerns and dilemmas. However; it is unclear how to best conduct this process. In this systematic review we aimed to answer 4 key questions: what are the best ways to identify patient representatives? How to engage them in designing and conducting research? What are the observed benefits of patient engagement? What are the harms and barriers of patient engagement?

METHODS

We searched MEDLINE, EMBASE, PsycInfo, Cochrane, EBSCO, CINAHL, SCOPUS, Web of Science, Business Search Premier, Academic Search Premier and Google Scholar. Included studies were published in English, of any size or design that described engaging patients or their surrogates in research design. We conducted an environmental scan of the grey literature and consulted with experts and patients. Data were analyzed using a non-quantitative, meta-narrative approach.

RESULTS

We included 142 studies that described a spectrum of engagement. In general, engagement was feasible in most settings and most commonly done in the beginning of research (agenda setting and protocol development) and less commonly during the execution and translation of research. We found no comparative analytic studies to recommend a particular method. Patient engagement increased study enrollment rates and aided researchers in securing funding, designing study protocols and choosing relevant outcomes. The most commonly cited challenges were related to logistics (extra time and funding needed for engagement) and to an overarching worry of a tokenistic engagement.

CONCLUSIONS

Patient engagement in healthcare research is likely feasible in many settings. However, this engagement comes at a cost and can become tokenistic. Research dedicated to identifying the best methods to achieve engagement is lacking and clearly needed.

Screening for gestational diabetes: a systematic review and meta-analysis

CONTEXT

Gestational diabetes mellitus (GDM) is defined as any degree of hyperglycemia with first recognition during pregnancy. The optimal time to screen for GDM that would maximize the yield and benefits remains unclear.

OBJECTIVE

Our objective was to appraise the evidence regarding screening for GDM (accuracy, correlation with adverse outcomes, and harms).

DATA SOURCES

We searched Ovid Medline, OVID EMBASE, OVID Cochrane Library, Web of Science, Scopus, PsycInfo, and CINAHL through May 2011.

STUDY SELECTION

We included randomized controlled trials and observational studies that enrolled pregnant woman who were evaluated using different GDM screening tests.

DATA EXTRACTION

Two reviewers working independently abstracted the data.

RESULTS

We did not find any randomized controlled trials of GDM screening that measured feto-maternal outcomes. A 1-hour 50-g glucose challenge test with a cutoff point at 140 mg/dL was the most commonly used screening method. The results of this test were statistically associated with feto-maternal outcomes (P < .001), even though only 11% of individuals with a positive test (according to Carpenter and Coustan criteria) developed GDM. Positive Carpenter and Coustan criteria were associated with macrosomia (odds ratio [OR] = 2.4, 95% confidence interval [CI] = 1.9-3.1, P < .001) and gestational hypertension (OR = 1.7, CI = 1.3-2.1, P < .001). Positive National Diabetes Data Group criteria were also associated with macrosomia (OR = 3.2, CI = 2.3-4.4, P < .001) and gestational hypertension (OR = 2.1, CI = 1.6-2.8, P < .001).

CONCLUSIONS

Indirect evidence supports the use of contemporary screening tests for GDM to identify pregnancies at increased risk of adverse feto-maternal outcomes. It also suggests that use of these tests will place some women under unnecessary treatment for GDM.

Glucose targets in pregnant women with diabetes: a systematic review and meta-analysis

BACKGROUND

Glucose-lowering treatments are used during pregnancy to reduce the risk for complications in the mother and offspring, yet treatment targets have not been established.

OBJECTIVE

Our objective was to appraise and summarize the available evidence regarding the association between different blood glucose targets during pregnancy and fetal and maternal outcomes.

METHODS

We searched Medline, EMBASE, Cochrane Library, Web of Science, Scopus, PsycInfo, and CINAHL through May 2011 for randomized trials and observational studies that enrolled women with diabetes during pregnancy and reported planned or achieved glucose targets. We used random-effects meta-regression models to estimate the odds ratio for the association of outcomes of interest and glucose targets. When possible, we adjusted for diabetes type, trimester, and diabetes treatment.

RESULTS

We included 34 studies enrolling 9433 women. The studies had moderate to high risk of bias due to evidence of reporting bias and insufficient adjustment for important covariates, particularly maternal body mass index. A fasting glucose target of <90 mg/dL was the most commonly reported and the one most strongly associated with reduced risk of macrosomia (odds ratio = 0.53, 95% confidence interval = 0.31-0.90, P = .02) for women with gestational diabetes during the third trimester. For type 1 and type 2 diabetes, and for pre- and postprandial targets, data were sparse and inconclusive.

CONCLUSIONS

Evidence warranting very low confidence in the estimates suggests that a fasting glucose target of <90 mg/dL is associated with a lower risk of macrosomia and other outcomes of different importance in women with gestational diabetes. Whether this target can be extrapolated to women with pregestational diabetes or whether targets above or below this threshold offer a better benefit/risk balance remains unclear.

Patient and service user engagement in research: a systematic review and synthesized framework

BACKGROUND

There is growing attention towards increasing patient and service user engagement (PSUE) in biomedical and health services research. Existing variations in language and design inhibit reporting and indexing, which are crucial to comparative effectiveness in determining best practices.

OBJECTIVE

This paper utilizes a systematic review and environmental scan to derive an evidence-based framework for PSUE.

DESIGN

A metanarrative systematic review and environmental scan/manual search using scientific databases and other search engines, along with feedback from a patient advisory group (PAG).

ELIGIBLE SOURCES

English-language studies, commentaries, grey literature and other sources (including systematic and non-systematic reviews) pertaining to patient and public involvement in biomedical and health services research.

DATA EXTRACTED

Study description (e.g. participant demographics, research setting) and design, if applicable; frameworks, conceptualizations or planning schemes for PSUE-related endeavours; and methods for PSUE initiation and gathering patients'/service users' input or contributions.

RESULTS

Overall, 202 sources were included and met eligibility criteria; 41 of these presented some framework or conceptualization of PSUE. Sources were synthesized into a two-part framework for PSUE: (i) integral PSUE components include patient and service user initiation, reciprocal relationships, colearning and re-assessment and feedback, (ii) sources describe PSUE at several research stages, within three larger phases: preparatory, execution and translational.

DISCUSSION AND CONCLUSIONS

Efforts at developing a solid evidence base on PSUE are limited by the non-standard and non-empirical nature of much of the literature. Our proposed two-part framework provides a standard structure and language for reporting and indexing to support comparative effectiveness and optimize PSUE.

The relationship of the intensity of posttreatment prostate-specific antigen surveillance and prostate cancer outcomes: results from a population-based cohort

OBJECTIVE

To determine whether higher intensity of prostate-specific antigen (PSA) surveillance was associated with earlier detection of biochemical recurrence (BCR) or survival.

PATIENTS AND METHODS

We identified a population-based cohort of 832 men diagnosed with nonmetastatic prostate cancer between January 1, 1995, and July 31, 2006. These men were treated with radical prostatectomy (RP), brachytherapy or external beam radiation therapy (RT), or primary androgen deprivation therapy or chose watchful waiting. To test the associations of intensity in PSA surveillance with study outcomes, we used a 2-year landmark analysis to assess whether the number of PSA tests during the first 2 years after treatment was associated with earlier detection of BCR, prostate cancer-related mortality, and all-cause mortality. We used landmark analysis to assess the association of PSA intensity, adjusting for clinicopathologic covariate, with outcome.

RESULTS

Median follow-up time for the entire cohort was 6.7 years. Higher Gleason score was the only clinicopathologic variable associated with higher PSA frequency in multivariable analysis for both the RP and RT groups (P value of .001 and .05, respectively). After adjustment for other covariates, the frequency of PSA tests during the first 2 years after RP did not increase the ability to detect BCR (hazard ratio, 1.00; 95% confidence interval, 0.84-1.19) or all-cause mortality (hazard ratio, 0.95; 95% confidence interval, 0.70-1.30) in the landmark analysis.

CONCLUSION

Higher intensity of PSA surveillance during the 2 years after RP or RT did not improve earlier detection of BCR or survival. Evidence-based guidelines for PSA surveillance after primary treatment are needed.

What is preventable harm in healthcare? A systematic review of definitions

Background

Mitigating or reducing the risk of harm associated with the delivery of healthcare is a policy priority. While the risk of harm can be reduced in some instances (i.e. preventable), what constitutes preventable harm remains unclear. A standardized and clear definition of preventable harm is the first step towards safer and more efficient healthcare delivery system. We aimed to summarize the definitions of preventable harm and its conceptualization in healthcare.

Methods

We conducted a comprehensive electronic search of relevant databases from January 2001 to June 2011 for publications that reported a definition of preventable harm. Only English language publications were included. Definitions were coded for common concepts and themes. We included any study type, both original studies and reviews. Two reviewers screened the references for eligibility and 28% (127/460) were finally included. Data collected from studies included study type, description of the study population and setting, and data corresponding to the outcome of interest. Three reviewers extracted the data. The level of agreement between the reviewers was calculated.

Results

One hundred and twenty seven studies were eligible. The three most prevalent preventable harms in the included studies were: medication adverse events (33/127 studies, 26%), central line infections (7/127, 6%) and venous thromboembolism (5/127, 4%). Seven themes or definitions for preventable harm were encountered. The top three were: presence of an identifiable modifiable cause (58/132 definitions, 44%), reasonable adaptation to a process will prevent future recurrence (30/132, 23%), adherence to guidelines (22/132, 16%). Data on the validity or operational characteristic (e.g., accuracy, reproducibility) of definitions were limited.

Conclusions

There is limited empirical evidence of the validity and reliability of the available definitions of preventable harm, such that no single one is supported by high quality evidence. The most common definition is “presence of an identifiable, modifiable cause of harm”.

Adherence to preventive recommendations: experience of a cohort presenting for executive health care

Adherence to recommended preventive services and immunizations in adults is suboptimal and often associated with socioeconomic status, race, and access to care. The aim of this study is to evaluate adherence in a cohort without these barriers to ascertain realistically optimal adherence rates and to examine remaining barriers among relatively advantaged individuals. Specifically, it employed a sample of 6889 patients presenting for executive health care from 2005 to 2009. Adherence varied across colorectal cancer screening (79%), mammography (89%), cervical cancer screening (91%), tetanus immunization (82%), and pneumococcal vaccination (62%). Multivariate logistic regressions revealed that age, education, alcohol use concerns, and being married were positively associated with adherence to certain services. Individuals without the usual barriers to care have variable, less-than-ideal rates of adherence to preventive services, which correlate with some health behaviors and demographics. Understanding the predictors of adherence may inform quality improvement processes aimed at optimizing disease prevention.