Do we more often opt for conservative management of ovarian tumors after changing the Dutch national guideline on enlarged ovaries? A nationwide cohort study.

INTRODUCTION: Increasing evidence shows that conservative management of ovarian tumors classified as benign, based on ultrasound assessment, is safe. Therefore, conservative management has been adopted as the preferred strategy for certain ovarian tumors assessed as benign in the Dutch national guideline on enlarged ovaries in 2013. The aim of this study was to examine whether implementation of this guideline has led to changes in the number of women/100 000 women undergoing surgery for an ovarian tumor in the Netherlands. MATERIAL AND METHODS: Histopathology reports were requested for all examinations of ovarian and fallopian tube specimens (including cyst enucleations) registered in Palga, the Dutch nationwide pathology databank, from 2011 (before guideline adaptation) and 2019 (after guideline adaptation). Reports on prophylactically removed adnexa, removal for other primary tumors (eg endometrial carcinoma), and for patients under 18 years of age, were excluded from the analysis. Interobserver agreement for the inclusion and classification of reports was assessed using Cohen's Kappa analysis. RESULTS: A total of 34 932 reports were retrieved, 13 917 of which were included in the analysis. In 2011 and 2019, respectively, 96.3/100 000 vs 68.8/100 000 women aged ≥18 underwent surgery for benign ovarian tumors, and 19.6/100 000 vs 18.3/100 000 for borderline and malignant tumors combined. The number of women/100 000 who had surgery for a benign ovarian tumor per 100 000 women declined by 28.5% (p < 0.001) between 2011 and 2019. The largest difference between 2011 and 2019 was observed in the number of women per 100 000 women who underwent surgery for a serous cystadenoma (-40.7%; 20.8/100 000 vs. 12.3/100 000), followed by endometrioma (-33.2%; 14.7/100 000 vs. 9.8/100 000), simple epithelial cyst (-57.3%; 8.4/100 000 vs. 3.6/100 000), and corpus luteum cyst (-57.0%; 4.0/100 000 vs. 1.7/100 000). Cohen's Kappa for the interobserver agreement was 0.96. CONCLUSIONS: The number of women/100 000 undergoing surgery for a benign ovarian tumor has substantially decreased in the Netherlands when comparing data before and after implementation of the national guideline in 2013, while the number of women/100 000 undergoing surgery for a malignant or borderline tumor remained the same. These findings suggest successful implementation of the updated guideline, and a measurable effect on increased adoption of conservative management for benign-looking ovarian tumors.

Timing of Preoperative Antibiotic Prophylaxis and Surgical Site Infection: TAPAS, An Observational Cohort Study.

OBJECTIVE: To test the hypothesis that surgical site infection (SSI) risk differs, after administration of surgical antibiotic prophylaxis (SAP) within 60-30 or 30-0 minutes before incision. BACKGROUND: The importance of appropriate timing of SAP before surgery has long been recognized. However, available evidence is contradictive on the best timing within a 60-0 minutes time interval before incision. Here, we aim to evaluate previous contradictions with a carefully designed observational cohort. METHODS: An observational cohort study was conducted in a Dutch tertiary referral center. For 2 years, consecutive patients with SAP indication undergoing general, orthopedic, or gynecologic surgery were followed for the occurrence of superficial and deep SSI as defined by the Center of Disease Control and Prevention. The association between timing of SAP and SSI was assessed using multivariable logistic regression. RESULTS: After 3001 surgical procedures, 161 SSIs were detected. In 87% of the procedures, SAP was administered within 60 minutes before incision. Only antibiotics with short infusion time were used. Multivariable logistic regression indicated there was no conclusive evidence of a difference in SSI risk after SAP administration 60-30 minutes or 30-0 minutes before incision [odds ratio: 0.82; 95% confidence interval (0.57-1.19)]. CONCLUSIONS: For SAP with short infusion time no clear superior timing interval within the 60-minute interval before incision could be identified in this cohort. We were unable to reproduce differences in SSI risk found in earlier studies.

Analysis of computer-aided diagnostics in the preoperative diagnosis of ovarian cancer: a systematic review.

OBJECTIVES: Different noninvasive imaging methods to predict the chance of malignancy of ovarian tumors are available. However, their predictive value is limited due to subjectivity of the reviewer. Therefore, more objective prediction models are needed. Computer-aided diagnostics (CAD) could be such a model, since it lacks bias that comes with currently used models. In this study, we evaluated the available data on CAD in predicting the chance of malignancy of ovarian tumors. METHODS: We searched for all published studies investigating diagnostic accuracy of CAD based on ultrasound, CT and MRI in pre-surgical patients with an ovarian tumor compared to reference standards. RESULTS: In thirty-one included studies, extracted features from three different imaging techniques were used in different mathematical models. All studies assessed CAD based on machine learning on ultrasound, CT scan and MRI scan images. Per imaging method, subsequently ultrasound, CT and MRI, sensitivities ranged from 40.3 to 100%; 84.6-100% and 66.7-100% and specificities ranged from 76.3-100%; 69-100% and 77.8-100%. Results could not be pooled, due to broad heterogeneity. Although the majority of studies report high performances, they are at considerable risk of overfitting due to the absence of an independent test set. CONCLUSION: Based on this literature review, different CAD for ultrasound, CT scans and MRI scans seem promising to aid physicians in assessing ovarian tumors through their objective and potentially cost-effective character. However, performance should be evaluated per imaging technique. Prospective and larger datasets with external validation are desired to make their results generalizable.

Prevalence of left and balanced coronary arterial dominance decreases with increasing age of patients at autopsy. A postmortem coronary angiograms study.

BACKGROUND: In patients presenting with an acute coronary syndrome, left over right coronary dominance appears to be independently associated with increased long-term mortality. This could lead to decreasing numbers of patients with a left dominant coronary artery system in older age groups. METHODS: We assessed the type of coronary dominance in different age groups in postmortem angiograms that were routinely performed at autopsy between 1993 and 2007. Coronary dominance was determined by identifying the origin of the posterior descending artery and posterolateral branches on postmortem angiography. Age, gender, and cause of death were recorded from the autopsy database. The prevalence of left dominant, right dominant, and codominant systems was determined in three increasing age categories, with cutoffs based on tertiles. RESULTS: A total 1620 coronary angiograms were assessed; 167 were excluded because it was not possible to determine coronary dominance. The median age of all patients was 71 years; 56% were male. Of all deaths, 40% were classified as cardiac. Regarding coronary dominance, 81.2% was right, 9.1% was left, and 9.7% was codominant. Overall, a decrease in prevalence of left and codominant coronary systems was observed with increasing age in the three age cohorts (≤ 63 years, 64-75 years, and ≥ 76 years) (P=.001 for overall comparison). CONCLUSIONS: In this large autopsy cohort, the prevalence of a left dominant or codominant coronary system decreased with increasing age. These findings could relate to a slightly higher risk of mortality in case of left versus right coronary artery occlusion.