A tailored intervention does not reduce low value MRI's and arthroscopies in degenerative knee disease when the secular time trend is taken into account: a difference-in-difference analysis.

PURPOSE: To evaluate the effectiveness of a tailored intervention to reduce low value MRIs and arthroscopies among patients ≥ 50 years with degenerative knee disease in 13 Dutch orthopaedic centers (intervention group) compared with all other Dutch orthopaedic centers (control group). METHODS: All patients with degenerative knee disease ≥ 50 years admitted to Dutch orthopaedic centers from January 2016 to December 2018 were included. The tailored intervention included participation of clinical champions, education on the Dutch Choosing Wisely recommendation for MRI's and arthroscopies in degenerative knee disease, training of orthopaedic surgeons to manage patient expectations, performance feedback, and provision of a patient brochure. A difference-in-difference analysis was used to compare the time trend before (admitted January 2016-June 2017) and after introduction of the intervention (July 2017-December 2018) between intervention and control hospitals. Primary outcome was the monthly percentage of patients receiving a MRI or knee arthroscopy, weighted by type of hospital. RESULTS: 136,446 patients were included, of whom 32,163 were treated in the intervention hospitals. The weighted percentage of patients receiving a MRI on average declined by 0.15% per month (ß = - 0.15, P < 0.001) and by 0.19% per month for arthroscopy (ß = - 0.19, P < 0.001). However, these changes over time did not differ between intervention and control hospitals, neither for MRI (ß = - 0.74, P = 0.228) nor arthroscopy (ß = 0.13, P = 0.688). CONCLUSIONS: The extent to which patients ≥ 50 years with degenerative knee disease received a MRI or arthroscopy declined significantly over time, but could not be attributed to the tailored intervention. This secular downward time trend may reflect anoverall focus of reducing low value care in The Netherlands. LEVEL OF EVIDENCE: III.

Performing a knee arthroscopy among patients with degenerative knee disease: one-third is potentially low value care.

PURPOSE: The purpose of this study was to assess in which proportion of patients with degenerative knee disease aged 50+ in whom a knee arthroscopy is performed, no valid surgical indication is reported in medical records, and to explore possible explanatory factors. METHODS: A retrospective study was conducted using administrative data from January to December 2016 in 13 orthopedic centers in the Netherlands. Medical records were selected from a random sample of 538 patients aged 50+ with degenerative knee disease in whom arthroscopy was performed, and reviewed on reported indications for the performed knee arthroscopy. Valid surgical indications were predefined based on clinical national guidelines and expert opinion (e.g., truly locked knee). A knee arthroscopy without a reported valid indication was considered potentially low value care. Multivariate logistic regression analysis was performed to assess whether age, diagnosis ("Arthrosis" versus "Meniscal lesion"), and type of care trajectory (initial or follow-up) were associated with performing a potentially low value knee arthroscopy. RESULTS: Of 26,991 patients with degenerative knee disease, 2556 (9.5%) underwent an arthroscopy in one of the participating orthopedic centers. Of 538 patients in whom an arthroscopy was performed, 65.1% had a valid indication reported in the medical record and 34.9% without a reported valid indication. From the patients without a valid indication, a joint patient-provider decision or patient request was reported as the main reason. Neither age [OR 1.013 (95% CI 0.984-1.043)], diagnosis [OR 0.998 (95% CI 0.886-1.124)] or type of care trajectory [OR 0.989 (95% CI 0.948-1.032)] were significantly associated with performing a potentially low value knee arthroscopy. CONCLUSIONS: In a random sample of knee arthroscopies performed in 13 orthopedic centers in 2016, 65% had valid indications reported in the medical records but 35% were performed without a reported valid indication and, therefore, potentially low value care. Patient and/or surgeons preference may play a large role in the decision to perform an arthroscopy without a valid indication. Therefore, interventions should be developed to increase adherence to clinical guidelines by surgeons that target invalid indications for a knee arthroscopy to improve care. LEVEL OF EVIDENCE: IV.

Effect of omission of surgery on survival in patients aged 80 years and older with early-stage hormone receptor-positive breast cancer.

BACKGROUND: Surgery is increasingly being omitted in older patients with operable breast cancer in the Netherlands. Although omission of surgery can be considered in frail older patients, it may lead to inferior outcomes in non-frail patients. Therefore, the aim of this study was to evaluate the effect of omission of surgery on relative and overall survival in older patients with operable breast cancer. METHODS: Patients aged 80 years or older diagnosed with stage I-II hormone receptor-positive breast cancer between 2003 and 2009 were selected from the Netherlands Cancer Registry. An instrumental variable approach was applied to minimize confounding, using hospital variation in rate of primary surgery. Relative and overall survival was compared between patients treated in hospitals with different rates of surgery. RESULTS: Overall, 6464 patients were included. Relative survival was lower for patients treated in hospitals with lower compared with higher surgical rates (90·2 versus 92·4 per cent respectively after 5 years; 71·6 versus 88·2 per cent after 10 years). The relative excess risk for patients treated in hospitals with lower surgical rates was 2·00 (95 per cent c.i. 1·17 to 3·40). Overall survival rates were also lower among patients treated in hospitals with lower compared with higher surgical rates (48·3 versus 51·3 per cent after 5 years; 15·0 versus 19·7 per cent after 10 years respectively; adjusted hazard ratio 1·07, 95 per cent c.i. 1·00 to 1·14). CONCLUSION: Omission of surgery is associated with worse relative and overall survival in patients aged 80 years or more with stage I-II hormone receptor-positive breast cancer. Future research should focus on the effect on quality of life and physical functioning.

ANTECEDENTES: En los Países Bajos cada vez es más frecuente descartar la cirugía en pacientes mayores con cáncer de mama operable. Aunque la omisión de la cirugía puede ser adecuada en pacientes mayores frágiles, ello puede determinar peores resultados en pacientes no frágiles. Por tanto, el objetivo de este estudio fue evaluar el efecto de omitir la cirugía en la supervivencia relativa y en la supervivencia global en pacientes mayores con cáncer de mama operable. MÉTODOS: A partir del Registro de Cáncer de los Países Bajos se seleccionaron las pacientes de ≥ 80 años de edad diagnosticadas de cáncer de mama entre 2003-2009 en estadios 1-2 y con receptores hormonales positivos. Se aplicó un método de variables instrumentales para minimizar los factores de confusión utilizando la tasa de variación hospitalaria de la cirugía primaria. Se compararon las supervivencias relativa y global de las pacientes tratadas en hospitales con diferentes tasas de cirugía. RESULTADOS: Se incluyeron 6.464 pacientes. La supervivencia relativa fue menor en las pacientes tratadas en hospitales con tasas quirúrgicas más bajas en comparación con las tratadas en hospitales con tasas altas (90,2% versus 92,4% a los 5 años y 71,6% versus 88,2% a los 10 años, respectivamente). El exceso de riesgo relativo para las pacientes tratadas en hospitales con tasas quirúrgicas más bajas fue de 2,00 (i.c. del 95% 1,17-3,40). La supervivencia global también fue menor para las pacientes tratadas en hospitales con tasas quirúrgicas más bajas en comparación con las más altas (48,3% versus 51,3% a los 5 años y 15,0% versus 19,7% a los 10 años, respectivamente, cociente de riesgos instantáneos, hazard ratio, HR, ajustado 1,07) i.c. del 95% 1,00-1,14)). CONCLUSIÓN: Omitir la cirugía se asocia con una peor supervivencia relativa y global en pacientes de ≥ 80 años con cáncer de mama en estadios 1-2 y receptores hormonales positivos. Las investigaciones futuras deberían centrarse en el efecto de este enfoque en la calidad de vida y la funcionalidad física.

Preferences and beliefs of Dutch orthopaedic surgeons and patients reduce the implementation of "Choosing Wisely" recommendations in degenerative knee disease.

PURPOSE: The purpose of this study was to assess which factors were associated with the implementation of "Choosing Wisely" recommendations to refrain from routine MRI and arthroscopy use in degenerative knee disease. METHODS: Cross-sectional surveys were sent to 123 patients (response rate 95%) and 413 orthopaedic surgeons (response rate 62%) fulfilling the inclusion criteria. Univariate and multivariate logistic regression analyses were used to identify factors associated with implementation of "Choosing Wisely" recommendations. RESULTS: Factors reducing implementation of the MRI recommendation among patients included explanation of added value by an orthopaedic surgeon [OR 0.18 (95% CI 0.07-0.47)] and patient preference for MRI [OR 0.27 (95% CI 0.08-0.92)]. Factors reducing implementation among orthopaedic surgeons were higher valuation of own MRI experience than existing evidence [OR 0.41 (95% CI 0.19-0.88)] and higher estimated patients' knowledge to participate in shared decision-making [OR 0.38 (95% CI 0.17-0.88)]. Factors reducing implementation of the arthroscopy recommendation among patients were orthopaedic surgeons' preferences for an arthroscopy [OR 0.03 (95% CI 0.00-0.22)] and positive experiences with arthroscopy of friends/family [OR 0.03 (95% CI 0.00-0.39)]. Factors reducing implementation among orthopaedic surgeons were higher valuation of own arthroscopy experience than existing evidence [OR 0.17 (95% CI 0.07-0.46)] and belief in the added value [OR 0.28 (95% CI 0.10-0.81)]. CONCLUSIONS: Implementation of "Choosing Wisely" recommendations in degenerative knee disease can be improved by strategies to change clinician beliefs about the added value of MRIs and arthroscopies, and by patient-directed strategies addressing patient preferences and underlying beliefs for added value of MRI and arthroscopies resulting from experiences of people in their environment. LEVEL OF EVIDENCE: IV.

Nationwide population-based study of the impact of immediate breast reconstruction after mastectomy on the timing of adjuvant chemotherapy.

BACKGROUND: Initiation of adjuvant chemotherapy within 6-12 weeks after mastectomy is recommended by guidelines. The aim of this population-based study was to investigate whether immediate breast reconstruction (IBR) after mastectomy reduces the likelihood of timely initiation of adjuvant chemotherapy. METHODS: All patients with breast cancer who had undergone mastectomy and adjuvant chemotherapy between 2012 and 2016 in the Netherlands were identified. Time from surgery to adjuvant chemotherapy was categorized as within 6 weeks or after more than 6 weeks, within 9 weeks or after more than 9 weeks, and within 12 weeks or after more than 12 weeks. The impact of IBR on the initiation of adjuvant chemotherapy for these three scenarios was estimated using propensity score matching to adjust for treatment by indication bias. RESULTS: A total of 6300 patients had undergone primary mastectomy and adjuvant chemotherapy, of whom 1700 (27·0 per cent) had received IBR. Multivariable analysis revealed that IBR reduced the likelihood of receiving adjuvant chemotherapy within 6 weeks (odds ratio (OR) 0·76, 95 per cent c.i. 0·66 to 0·87) and 9 weeks (0·69, 0·54 to 0·87), but not within 12 weeks (OR 0·75, 0·48 to 1·17). Following propensity score matching, IBR only reduced the likelihood of receiving adjuvant chemotherapy within 6 weeks (OR 0·95, 0·90 to 0·99), but not within 9 weeks (OR 0·97, 0·95 to 1·00) or 12 weeks (OR 1·00, 0·99 to 1·01). CONCLUSION: Postmastectomy IBR marginally reduced the likelihood of receiving adjuvant chemotherapy within 6 weeks, but not within 9 or 12 weeks. Thus, IBR is not contraindicated in patients who need adjuvant chemotherapy after mastectomy.

ANTECEDENTES: Las guías clínicas recomiendan iniciar la quimioterapia adyuvante entre las 6 y las 12 semanas después de la mastectomía. El objetivo de este estudio de base poblacional fue investigar si la reconstrucción inmediata de la mama (immediate breast reconstruction, IBR) tras mastectomía reduce la posibilidad de iniciar la quimioterapia adyuvante en el momento adecuado. MÉTODOS: Se identificaron todas las pacientes con cáncer de mama a las que se había realizado mastectomía y quimioterapia adyuvante entre el 2012 y el 2016 en los Países Bajos. El tiempo transcurrido entre la cirugía y la quimioterapia adyuvante se clasificó en tres grupos: ≤ 6 versus > 6 semanas, ≤ 9 versus > 9 semanas y ≤ 12 versus > 12 semanas. El impacto de la IBR en el inicio de la quimioterapia adyuvante en estos tres escenarios se estimó mediante un análisis de emparejamiento por puntaje de propensión para ajustar el tratamiento por sesgo de indicación. RESULTADOS: Se realizó una mastectomía primaria y quimioterapia adyuvante en 6.300 pacientes, de las que a 1.700 (27%) se hizo una IBR. El análisis multivariable demostró que la IBR redujo la probabilidad de recibir quimioterapia adyuvante dentro de las 6 y 9 semanas (razón de oportunidades, odds ratio, OR 0,76; i.c. del 95% 0,66-0,87 y OR 0,69; i.c. del 95% 0,54-0,87, respectivamente), pero no dentro de las 12 semanas (OR 0,75, i.c. del 95% 0,48-1,17). Al emparejar mediante el análisis de puntaje de propensión, la IBR solo redujo la probabilidad de recibir quimioterapia adyuvante dentro de las 6 semanas (OR 0,95; i.c. del 95%: 0,90 a 0,99), pero no dentro de las 9 ó 12 semanas (OR 0,97; i.c. del 95%: 0,95 a 1,00 y OR 1,00, i.c. del 95% 0,99-1,01). CONCLUSIÓN: La IBR postmastectomía disminuyó marginalmente la probabilidad de recibir quimioterapia adyuvante dentro de las 6 semanas, pero no más allá de las 9 ó 12 semanas. Por lo tanto, la IBR postmastectomía no está contraindicada en pacientes que necesitan tratamiento con quimioterapia adyuvante.

Variation in red cell transfusion decisions in the intensive care unit - a nationwide survey in the Netherlands.

BACKGROUND AND OBJECTIVES: Most guidelines recommend a restrictive transfusion trigger of 7 g/dl. It is unclear whether this resulted in more uniform transfusion practices. The primary objective was to uncover the extent of variation in transfusion decisions within four scenarios of critically ill patients among critical care physicians in the Netherlands. MATERIALS AND METHODS: An online survey comprising four different hypothetical clinical scenarios was sent to all members of the Dutch Society of Intensive Care. The scenarios represented patients with acute myocardial infarction (Hb 8·5 g/dl), abdominal sepsis (Hb 7·1 g/dl), traumatic brain injury (TBI) (Hb 7·9 g/dl) and post-surgical complications (Hb 7·3 g/dl). The questions explored the decision whether or not to transfuse and a ranking of clinical characteristics playing the most important role in the transfusion decision. RESULTS: A total of 224 members (22%) participated in the study of whom 188 (84%) completed all questions. The percentages of respondents that decided to transfuse ranged from 25·9% in the scenario with TBI to 81·6% in the scenario with post-surgical complications. Most controversy was seen in the scenario with sepsis for which 43·2% decided to transfuse, whereas 56·8% decided not to. Haemoglobin level, diagnosis and haemodynamics were most important for the transfusion decision in all scenarios. CONCLUSIONS: Physicians decided differently on red-blood-cell transfusion given the clinical scenarios and weighed clinical characteristics differently in their transfusion decisions. These findings suggest there still is substantial variation in critical care transfusion practice.

Erythropoietin to reduce allogeneic red blood cell transfusion in patients undergoing total hip or knee arthroplasty.

BACKGROUND AND OBJECTIVES: To determine the value of erythropoietin in reducing allogeneic transfusions, it is important to assess the effects, safety and costs for individual indications. Previous studies neither compared the effects of erythropoietin between total hip and total knee arthroplasty, nor evaluated the safety or costs. We performed a meta-analysis to assess the effects of erythropoietin in total hip and knee arthroplasty separately. Safety and costs were evaluated as secondary outcomes. MATERIALS AND METHODS: A systematic literature search was performed to identify randomized controlled trials evaluating the effect of erythropoietin in total hip and knee arthroplasty until April 2014. Study data were extracted using standardized forms and pooled using a random-effects model. Strength of the evidence was evaluated using Cochrane's Collaboration's tool for risk of bias assessment. RESULTS: Seven studies were included (2439 patients). Erythropoietin significantly reduced exposure to allogeneic transfusion in both hip (RR 0·45; 95%CI 0·33-0·61) and knee (RR 0·38; 95%CI 0·27-0·53) arthroplasty, without differences between indications (P = 0·44). Mean number of transfused red blood cell units was significantly decreased in erythropoietin-treated patients (mean difference -0·57; 95%CI -0·86 to -0·29)(unable to split). No differences in thromboembolic or adverse events were found. Only one study evaluated costs, so that no pooled cost-effectiveness estimates could be given. CONCLUSION: Erythropoietin is effective in both hip and knee arthroplasty and can be considered as safe. However, the decision to use erythropoietin on a routine base should be balanced against its costs, which may be relatively high.

Nonelective colon cancer resections in elderly patients: results from the dutch surgical colorectal audit.

AIMS: The aim of the study was to assess which factors contribute to postoperative mortality, especially in elderly patients who undergo emergency colon cancer resections, using a nationwide population-based database. METHODS: 6,161 patients (1,172 nonelective) who underwent a colon cancer resection in 2010 in the Netherlands were included. Risk factors for postoperative mortality were investigated using a multivariate logistic regression model for different age groups, elective and nonelective patients separately. RESULTS: For both elective and nonelective patients, mortality risk increased with increasing age. For nonelective elderly patients (80+ years), each additional risk factor increased the mortality risk. For a nonelective patient of 80+ years with an American Society of Anesthesiologists score of III+ and a left hemicolectomy or extended resection, postoperative mortality rate was 41% compared with 7% in patients without additional risk factors. CONCLUSIONS: For elderly patients with two or more additional risk factors, a nonelective resection should be considered a high-risk procedure with a mortality risk of up to 41%. The results of this study could be used to adequately inform patient and family and should have consequences for composing an operative team.

Presence of hyperemic islets in human donor-pancreata results in reduced islet isolation yield.

When studying histological characteristics of human donor-pancreata, a remarkably high number of hyperemic islets (HIs) were encountered. The abnormalities in these HIs ranged from single/multiple dilated vessels to hemorrhages extending into the exocrine tissue. We aimed to determine the relevance of the presence of HIs in human donor-pancreata for isolation outcome and to identify donor and procurement factors associated with the occurrence of HIs. The presence of HIs was scored semi-quantitatively (HI-, HI+) in 102 human donor-pancreata. Islet isolation was performed in 40 cases. Donor and procurement factors were retrospectively analyzed in 94 donors. HIs were found in 54.6% of all donor-pancreata. However, only 4.5% of all islets in the affected pancreata was hyperemic. The affected pancreata contained slightly more endocrine tissue, but produced significantly lower yields. When corrected for other factors known to influence isolation outcome, the presence of HIs and endocrine content were the only factors significantly influencing isolation outcome. Prolonged ICU stay and pre-procurement hypertension were associated with the presence of HIs. This study is a first indication that the presence of HIs in human donor-pancreata are associated with reduced isolation outcomes and suggest an impact of the procurement procedure and pre-procurement hemodynamic status of the donor on the islet quality. It is tempting to speculate that this contributes to the generally experienced difficulties in obtaining sufficient amounts of human islets.

Reduced porcine islet isolation yield in the presence of hyperemic islets.

When studying histological characteristics of porcine pancreata in relation to islet isolation, a remarkably high number of hyperemic islets (HIs) was encountered. The abnormalities observed in these HIs ranged from a single dilated vessel to hemorrhages extending into the surrounding exocrine tissue. The aim of the present study was to compare pancreata with and without HI on islet isolation outcomes. This study involved a histological examination of 143 purebred (74 juvenile and 69 adult) and 47 crossbred (only juvenile) porcine pancreata. Islet isolation was performed in 48 purebred adult pigs and in 25 crossbred pigs. Tissue samples were stained with Aldehyde Fuchsine. The presence of HIs was scored semi-quantitatively (HI-, HI+). We observed HIs in 48% of the purebred and in 68% of the crossbred pigs. However, only 3.3±3.1% and 3.1±4.7% of all assessed islets was hyperemic in HI+ pancreata in purebred and crossbred pigs, respectively. In both groups, significantly higher endocrine cell mass was found in the HI+ pancreata (p<0.01). When the higher endocrine cell mass was taken into account, we found significantly lower yields in the HI+ pancreata in both purebred and crossbred pigs (p=0.03 in both groups). The presence of HIs occurs frequently in porcine donor-pancreata and is associated with reduced isolation outcomes.

Variation in red cell transfusion practice in the intensive care unit - An international survey.

PURPOSE: Unclear recommendations in transfusion guidelines may possibly lead to inconsistency in treatment of patients admitted to the intensive care unit. This study aimed to uncover variation in red blood cell (RBC) transfusion decisions in the ICU worldwide. METHODS: Members of the European Society of Intensive Care Medicine (ESICM) were requested to complete an online questionnaire which included four different hypothetical clinical scenarios. The scenarios represented patients with acute myocardial infarction (AMI), abdominal sepsis, traumatic brain injury (TBI) and post-surgical complications. Hemoglobin level was 7∙3 g/dL in all scenarios. The questionnaire explored the physicians' transfusion decision in each clinical scenario and identified patient characteristics that were most influential in the transfusion decision. RESULTS: In total 211 members participated in the study, of whom 142 (67%) completed the entire survey. Most variation was observed in the clinical scenario of sepsis, in which 49% decided to transfuse and 51% decided not to. In the clinical scenarios of AMI, TBI and post-surgical complications this was respectively; 75/25%, 35/65% and 66/34%. CONCLUSIONS: Critical care physicians differed in outcome of RBC transfusion decisions and weighed patient characteristics differently. These findings indicate that variation in transfusion practice amongst critical care physicians exists.

Hospital transfer after a breast cancer diagnosis: A population-based study in the Netherlands of the extent, predictive characteristics and its impact on time to treatment.

PURPOSE: Patients may transfer of hospital for clinical reasons but this may delay time to treatment. The purpose of this study is to provide insight in the extent of hospital transfer in breast cancer care; which type of patients transfer and what is the impact on time to treatment. METHODS: We included 41,413 breast cancer patients registered in the Netherlands Cancer Registry between 2014 and 2016. We investigated transfer of hospital between diagnosis and first treatment being surgery or neoadjuvant chemotherapy (NAC). Co-variate adjusted characteristics predictive for hospital transfer were determined. To adjust for possible treatment by indication bias we used propensity score matching (PSM). Time to treatment in patients with and without hospital transfer was compared. RESULTS: Among 41,413 patients, 8.5% of all patients transferred to another hospital between diagnosis and first treatment; 4.9% before primary surgery and 24.8% before NAC. Especially young (aged <40 years) patients and those who underwent a mastectomy with immediate breast reconstruction (IBR) were more likely to transfer. The association of mastectomy with IBR with hospital transfer remained when using PSM. Hospital transfer after diagnosis significantly prolonged time to treatment; breast-conserving surgery by 5 days, mastectomy by 7 days, mastectomy with IBR by 9 days and NAC by 1 day. CONCLUSIONS: While almost 5% of Dutch patients treated with primary surgery transfer hospital after diagnosis and up to 25% for patients treated with NAC, our findings suggest that especially those treated with primary surgery are at risk for additional treatment delay by hospital transfer.

Surgical adverse outcomes and patients' evaluation of quality of care: inherent risk or reduced quality of care?

BACKGROUND: Previous research has shown that sicker patients are less satisfied with their healthcare, but specific effects of adverse health outcomes have not been investigated. The present study aimed to assess whether patients who experience adverse outcomes, in hospital or after discharge, differ in their evaluation of quality of care compared with patients without adverse outcomes. METHOD: In-hospital adverse outcomes were prospectively recorded by surgeons and surgical residents as part of routine care. Four weeks after discharge, patients were interviewed by telephone about the occurrence of post-discharge adverse outcomes, and their overall evaluation of quality of hospital care and specific suggestions for improvements in the healthcare provided. RESULTS: Of 2145 surgical patients admitted to the Leiden University Medical Center in 2003, 1876 (88%) agreed to be interviewed. Overall evaluation was less favourable by patients who experienced post-discharge adverse outcomes only (average 19% lower). These patients were also more often dissatisfied (OR 2.02, 95% CI 1.24 to 3.31) than patients without adverse outcomes, and they more often suggested that improvements were needed in medical care (OR 2.07, 1.45 to 2.95) and that patients were discharged too early (OR 3.26, 1.72 to 6.20). The effect of in-hospital adverse outcomes alone was not statistically significant. Patients with both in-hospital and post-discharge adverse outcomes also found the quality of care to be lower (on average 33% lower) than patients without adverse outcomes. CONCLUSIONS: Post-discharge adverse outcomes negatively influence patients' overall evaluation of quality of care and are perceived as being discharged too early, suggesting that patients need better information at discharge.

[How does a surgeon decide that surgery is the best option?Assessing whether or not to operate]. / Hoe besluit de chirurg dat opereren het beste is?

All abdominal surgical procedures have a certain risk/benefit ratio. Recently, the way surgeons come to a decision whether to operate, or not, was discussed in the Annals of Surgery. First, the assessment of the decision for an operative versus a non-operative strategy was addressed on the basis of clinical vignettes. The perceptions concerning risk/benefit balance varied considerably between surgeons and these perceptions predicted the decision to operate. In a second paper, surgeons were randomized to either an arm in which they were exposed to a risk calculator or to a control arm. The decisions of the risk-calculator arm were less varied, but did not alter the likelihood of recommending an operation. Perhaps surgeons decide to operate or not rather intuitively, based on clinical and laboratory information. Alternatively, they may consider the statistically significant difference in risk/benefit to be less relevant. A better insight into surgeons' decision making and the way in which they weigh benefits against risks is very useful, but it is proving to be a considerable research challenge.

Fixation and clinical outcome of uncemented peri-apatite-coated versus cemented total knee arthroplasty : five-year follow-up of a randomised controlled trial using radiostereometric analysis (RSA).

AIMS: The optimal method of tibial component fixation remains uncertain in total knee arthroplasty (TKA). Hydroxyapatite coatings have been applied to improve bone ingrowth in uncemented designs, but may only coat the directly accessible surface. As peri-apatite (PA) is solution deposited, this may increase the coverage of the implant surface and thereby fixation. We assessed the tibial component fixation of uncemented PA-coated TKAs versus cemented TKAs. PATIENTS AND METHODS: Patients were randomised to PA-coated or cemented TKAs. In 60 patients (30 in each group), radiostereometric analysis of tibial component migration was evaluated as the primary outcome at baseline, three months post-operatively and at one, two and five years. A linear mixed-effects model was used to analyse the repeated measurements. RESULTS: After five years of follow-up, one (cemented) component was revised due to ligament instability. Overall, uncemented PA-coated tibial components migrated significantly more (p = 0.003), with the mean maximum total point motion (MTPM) at five years being 0.62 mm (95% confidence intervals (CI) 0.49 to 0.76) for cemented tibial components and 0.97 mm (95% CI 0.81 to 1.15) for PA-coated tibial components in TKA. However, between three months and five years the cemented TKAs migrated significantly more (p = 0.02), displaying a MTPM of 0.27 mm (95% CI, 0.19 to 0.36) versus 0.13 mm (95% CI, 0.01 to 0.25) for PA-coated tibial components. One implant in each group was considered at risk for aseptic loosening due to continuous migration after five years of follow-up, albeit with different migration patterns for each group (i.e. higher initial migration but diminishing over time for the PA-coated component versus gradually increasing migration for the cemented component). CONCLUSION: The tibial components of PA-coated TKAs showed more overall migration compared with the tibial components of cemented TKAs. However, post hoc analysis showed that this difference was caused by higher migration of PA-coated components in the first three months, after which a stable migration pattern was observed. Clinically, there was no significant difference in outcome between the groups. Cite this article: Bone Joint J 2017;99-B:1467-76.

Surgery groups differed in adverse outcome probabilities and can be used to adjust hospital comparisons.

BACKGROUND AND OBJECTIVE: In the Netherlands, all procedures in general surgery are categorized into 12 surgery groups by the Association of Surgeons of the Netherlands. The purpose of this study was to assess whether surgery groups differ in adverse outcome probabilities, to decide whether hospital comparisons on adverse outcomes should be adjusted for differences in surgery groups. METHODS: All surgical patients in one hospital discharged in 1997-1999 were included. Only the first operation during admission was included, with the assumption that successive operations were treatment of adverse outcomes. To avoid bias, only operations with procedures from the same surgery group were included. A total of 6,025 admissions were included and analyzed by a two-step multilevel analysis. RESULTS: Four surgery groups had fewer admissions with adverse outcomes than expected, and two groups had more. After adjustment for patient and operation characteristics, the remaining variance between surgery groups is still large. Similar results were found when differences in mortality were analyzed. CONCLUSION: Surgery group can therefore be used to adjust hospital comparisons for differences in surgical procedure mix.

Long term effects of extended adjuvant endocrine therapy on quality of life in breast cancer patients.

OBJECTIVES: The standard treatment for hormone-receptor positive, postmenopausal early breast cancer patients is 5 years of adjuvant endocrine therapy. Previous studies demonstrate that prolonging adjuvant endocrine therapy may improve disease-free survival. However, endocrine therapy is known for its adverse events, which may negatively affect Quality of Life (QoL). The aim of this study is to assess the impact of extended adjuvant endocrine therapy on long-term QoL outcomes. METHODS: 471 patients selected from the IDEAL trial were invited to complete a questionnaire 1-1.5 years after starting with extended therapy. The questionnaire consisted of the EORTC QLQ-C30 and QLQ-BR23 questionnaires. Mean QoL outcomes were compared with EORTC reference values for stage I and II breast cancer patients and the general population. Furthermore, QoL outcomes were compared between different treatment regimens. A difference of eight points was considered clinically relevant. RESULTS: IDEAL patients receiving extended adjuvant endocrine therapy have significantly and clinically relevant better global QoL compared with reference values for stage I and II breast cancer patients (79.6 versus 64.6; p < 0.01) and the general population (79.6 versus 71.2; p < 0.01). Similar results were found for emotional function, pain, appetite loss, diarrhea and financial problems. Between treatment regimens prior to extended adjuvant endocrine therapy, differences were only found on specific QoL domains (e.g. arm symptoms). CONCLUSION: Breast cancer patients on extended adjuvant endocrine therapy have significantly and clinically relevant better global QoL compared with other stage I-II breast cancer patients and the general population, 6-8.5 years after diagnosis.

Are women more sensitive to smoking than men? Findings from the Renfrew and Paisley study.

BACKGROUND: Prescott et al. found that the relative risks associated with smoking for respiratory and vascular deaths were higher for women who inhale than for inhaling men, and found no gender differences in relative risks of smoking-related cancers. The purpose of the present study was to assess whether these findings are reproducible, using data from the Renfrew and Paisley study. METHODS: Age-standardized mortality rate differences and age-adjusted mortality rate ratios (using Cox's proportional hazard model) were calculated for male and female smokers by amount smoked compared with never smokers. These analyses were repeated after excluding non-inhalers. RESULTS: The all-cause mortality rate ratio was higher for men than for women in all categories of amount smoked, although this difference was only statistically significant in the light smokers (1.83 [95% CI : 1.61-2.07] for men and 1.41 [95% CI : 1.28-1.56] for women, P = 0.001). The cause-specific mortality rate ratios tended to be higher for men than for women, and this difference was most substantial for neoplasms (2.57 [95% CI : 2.01-3.29] for male light smokers and 1.35 [95% CI : 1.14-1.61] for female light smokers, P < 0.001) and, in particular, for lung cancer (11.10 [95% CI : 5.89-20.92] for male light smokers and 4.73 [95% CI : 2.99-7.50] for female light smokers, P = 0.03). Furthermore, looking at the rate differences the effects of smoking were uniformly greater in men than in women. These results were virtually unchanged after excluding non-inhalers. CONCLUSION: We found similar results to Prescott et al. when all smokers were considered, but could not reproduce their findings when non-inhalers were excluded. Given the fact that we showed greater rate differences in men than in women, we think that it is too early to conclude that women may be more sensitive than men to some of the deleterious effects of smoking.

Getting insurance after genetic screening on familial hypercholesterolaemia; the need to educate both insurers and the public to increase adherence to national guidelines in The Netherlands.

Heterozygous familial hypercholesterolaemia (FH) is a common autosomal dominant inherited metabolic disease with a prevalence of 1 in 500 in most Western countries. People with FH experience an increased risk for coronary artery disease (CAD) and excess mortality especially at a young age. Until recently the diagnosis of FH was based on clinical signs and symptoms alone. These included increased cholesterol concentrations, in particular of LDL-cholesterol, in combination with the presence of tendon xanthoma, corneal arcus, xanthelasmata and a history of early CAD. Frequently FH was diagnosed after a first cardiac event.

Socioeconomic differentials in mortality among men within Great Britain: time trends and contributory causes.

STUDY OBJECTIVE: To assess the size of mortality differentials in men by social class in Scotland as compared with England and Wales, and to analyse the time trends in these differentials. SUBJECTS: Men from England and Wales and Scotland around each census from 1951 to 1981. METHODS: Poisson regression analysis was used to calculate relative indices of inequality for disease specific and all cause mortality as a measure of mortality differentials between social classes. This measure is not dependent on the size of the social class groups, so it can be used to compare the magnitude of differentials over time periods during which the relative sizes of social class groups change. MAIN RESULTS: While overall death rates were higher in Scotland than in England and Wales around the 1951, 1961, and 1971 censuses the relative indices of inequality indicated smaller mortality differences between social classes in Scotland. Inequality, as indexed by the relative index of inequality, increased over time in both Scotland and England and Wales, but to a greater degree in Scotland, resulting in greater social class mortality differentials for Scotland in 1981 (the relative index of inequality increased from 1.40 to 2.43 for England and Wales, and from 1.22 to 2.57 for Scotland between 1951 and 1981). This greater increase in the magnitude of inequalities in all cause mortality in Scotland seemed to result from increasing social class differentials in cardiovascular disease, accidents and external causes, and "all other causes of death". Examining the trends in overall death rates, it seems that the greater increase in social class differences in Scotland occurred because of the greater decrease in death rates among the privileged social groups, in combination with a smaller decrease (or a greater increase) in the death rates in the lower social class groups. CONCLUSIONS: This study has shown that trends in mortality and in inequalities in mortality differ within Great Britain. Although death rates were higher in Scotland than in England and Wales, smaller mortality differentials by social class were found in Scotland over the period 1951 to 1971. By 1981, however, social class mortality differentials were greater in Scotland than in England and Wales. The greater increase in the social class differentials over time in Scotland, may have contributed to the worsening overall mortality profile in Scotland as compared with England and Wales that occurred between 1971 and 1981.