Frequency and diagnostic outcome of bilateral recall at screening mammography.

Our study was performed to determine the frequency of recall for bilateral breast lesions at screening mammography and compare its outcome with respect to unilateral recall. We included 329 132 screening mammograms (34 889 initial screens and 294 243 subsequent screens) from a Dutch screening mammography program between January 2013 and January 2018. During a 2-year follow-up, we collected radiological data, pathology reports and surgical reports of all recalled women. At bilateral recall, the lesion with the highest Breast Imaging Reporting and Data System score was used as the index lesion when comparing screening mammography characteristics at bilateral vs unilateral recall. A total of 9806 women were recalled at screening (recall rate, 3.0%). Bilateral recall comprised 2.8% (271/9806) of all recalls. Biopsy was more frequently performed after bilateral recall than unilateral recall (54.6% [148/271] vs 44.1% [4201/9535], P < .001), yielding a lower positive predictive value (PPV) of biopsy after bilateral recall (42.6% vs 51.7%, P = .029). The PPV of recall was comparable for both groups (23.2% [63/271] vs 22.8% [2173/9535], P = .85). Invasive cancers after bilateral recall were larger than those diagnosed after unilateral recall (P = .02), but histological subtype, histologic grading, receptor status and proportions of lymph node positive cancers were comparable. Bilateral recall infrequently occurs at screening mammography. Biopsy is more frequently performed following bilateral recall, but the PPV of recall is similar for unilateral and bilateral recall. Invasive cancers of both groups show comparable pathological features except of a larger tumor size after bilateral recall.

Delayed breast cancer diagnosis after repeated recall at biennial screening mammography: an observational follow-up study from the Netherlands.

BACKGROUND: Delay in detection of breast cancer may worsen tumour characteristics, with progression of tumour size and a higher risk of metastatic lymph nodes. The purpose of this study was to investigate delayed breast cancer diagnosis after repeated recall for the same mammographic abnormality at screening. METHODS: This was a retrospective study performed in two cohorts of women enrolled in a mammography screening programme in the Netherlands. All women aged 50-75 who underwent biennial screening mammography either between January 1, 1997 and December 31, 2006 (cohort 1) or between January 1, 2007 and December 31, 2016 (cohort 2) were included. RESULTS: The cohorts showed no difference in proportions of women with delayed breast cancer diagnosis of at least 2 years (2.2% versus 2.8%, P = 0.29). Most delays were caused by incorrect BI-RADS classifications after recall (74.2%). An increase in mean tumour size was seen when comparing sizes at initial false-negative recall and at diagnosis of breast cancer (P < 0.001). CONCLUSIONS: The proportion of women with a long delay in breast cancer confirmation following repeated recall at screening mammography has not decreased during 20 years of screening. These delays lead to larger tumour size at detection and may negatively influence prognosis.

Fully automated postoperative ventilation in cardiac surgery patients: a randomised clinical trial.

BACKGROUND: Ensuring that lung-protective ventilation is achieved at scale is challenging in perioperative practice. Fully automated ventilation may be more effective in delivering lung-protective ventilation. Here, we compared automated lung-protective ventilation with conventional ventilation after elective cardiac surgery in haemodynamically stable patients. METHODS: In this single-centre investigator-led study, patients were randomly assigned at the end of cardiac surgery to receive either automated (adaptive support ventilation) or conventional ventilation. The primary endpoint was the proportion of postoperative ventilation time characterised by exposure to predefined optimal, acceptable, and critical (injurious) ventilatory parameters in the first three postoperative hours. Secondary outcomes included severe hypoxaemia (Spo2 <85%) and resumption of spontaneous breathing. Data are presented as mean (95% confidence intervals [CIs]). RESULTS: We randomised 220 patients (30.4% females; age: 62-76 yr). Subjects randomised to automated ventilation (n=109) spent a 29.7% (95% CI: 22.1-37.4) higher mean proportion of postoperative ventilation time receiving optimal postoperative ventilation after surgery (P<0.001) compared with subjects receiving conventional postoperative ventilation (n=111). Automated ventilation also reduced the proportion of postoperative ventilation time that subjects were exposed to injurious ventilatory settings by 2.5% (95% CI: 1-4; P=0.003). Severe hypoxaemia was less likely in subjects randomised to automated ventilation (risk ratio: 0.26 [0.22-0.31]; P<0.01). Subjects resumed spontaneous breathing more rapidly when randomised to automated ventilation (hazard ratio: 1.38 [1.05-1.83]; P=0.03). CONCLUSIONS: Fully automated ventilation in haemodynamically stable patients after cardiac surgery optimised lung-protective ventilation during postoperative ventilation, with fewer episodes of severe hypoxaemia and an accelerated resumption of spontaneous breathing. CLINICAL TRIAL REGISTRATION: NCT03180203.

Correction to: Frequency and characteristics of contralateral breast abnormalities following recall at screening mammography.

The original version of this article, published on 17 April 2018, unfortunately contained a mistake.

Characteristics of screen-detected cancers following concordant or discordant recalls at blinded double reading in biennial digital screening mammography.

OBJECTIVES: To analyse which mammographic and tumour characteristics led to concordant versus discordant recalls at blinded double reading to further optimise our breast cancer screening programme. METHODS: We included a consecutive series of 99,013 screening mammograms obtained between July 2013 and January 2015. All mammograms were double read in a blinded fashion. Discordant readings were routinely recalled without consensus or arbitration. During the 2-year follow-up, relevant data of the recalled women were collected. We compared mammographic characteristics, screening outcome and tumour characteristics between concordant and discordant recalls. RESULTS: There were 2,543 concordant recalls (71.4%) and 997 discordant recalls (28.0%). The positive predictive value of a concordant recall was significantly higher (23.5% vs. 10.0%, p < 0.001). The proportion of BI-RADS 0 was significantly higher in the discordant recall group (75.7% vs. 56.3%, p < 0.001). Discordant recalls were more often an asymmetry or architectural distortion (21.8% vs. 13.2% and 9.3% vs. 6.5%, respectively, p < 0.001). There were no differences in the distribution of DCIS and invasive cancers and tumour characteristics were comparable for the two groups, except for a more favourable tumour grade in the discordant recall group (54.7% vs. 39.9% grade I tumours, p = 0.022). CONCLUSIONS: Screen-detected cancers detected by a discordant reading show a more favourable tumour grade than cancers diagnosed after a concordant recall. The higher proportion of asymmetries and architectural distortions in this group provide a possible target for improving screening programmes by additional training of screening radiologists and the implementation of digital breast tomosynthesis. KEY POINTS: • With blinded double reading of screening mammograms, screen-detected cancers detected by a discordant reading show a more favourable tumour grade than cancers diagnosed after a concordant recall. • The proportions of asymmetries and architectural distortions are higher in case of a discordant reading. • Possible improvement strategies could target additional training of screening radiologists and the implementation of digital breast tomosynthesis in breast cancer screening programmes.

Incorporation of the technologist's opinion for arbitration of discrepant assessments among radiologists at screening mammography.

PURPOSE: We determined whether the addition of the technologist's opinion may be helpful in deciding if discordant readings at blinded double reading should be recalled. METHODS: A consecutive series of 99,013 digital screening mammograms, obtained between July 2013 and January 2015, were included. All mammograms were first interpreted by a technologist and then double read in a blinded fashion by a team of 13 screening radiologists. All concordant and discordant positive readings among radiologists were recalled. RESULTS: Out of 3562 recalls, 998 women were recalled after a discordant reading. Of these women, 337 (33.8%) had a positive technologist assessment, of which 40 (11.9%) were diagnosed with breast cancer. Sixty women with a negative technologist assessment (60/661, 9.1%) were diagnosed with breast cancer (p = 0.16). Recall rate would have decreased with technologist arbitration (3.6% vs. 2.9%, p < 0.001). Cancer detection rate decreased with 8.5%, from 7.1/1000 screens to 6.5/1000 screens (p = 0.10). Among women with a positive technologist assessment, the probability of breast cancer was highest in case of suspicious microcalcifications and lowest for suspicious masses (30.4% (17/56) versus 7.0% (16/212), p < 0.001). Breast cancers were diagnosed in all groups of mammographic abnormalities, except in women with a suspicious asymmetry and a negative technologist assessment. CONCLUSIONS: Assessment by a technologist does not provide a significant discriminating ability in case of a discordant radiologist reading and, taking into account the decrease in cancer detection rate, does not appear to be a suitable arbitration strategy for discordant recalls at blinded double reading.

Frequency and characteristics of contralateral breast abnormalities following recall at screening mammography.

PURPOSE: To determine the frequency and characteristics of contralateral, non-recalled breast abnormalities following recall at screening mammography. METHODS: We included a series of 130,338 screening mammograms performed between 1 January 2014 and 1 January 2016. During the 1-year follow-up, clinical data were collected for all recalls. Screening outcome was determined for recalled women with or without evaluation of contralateral breast abnormalities. RESULTS: Of 3,995 recalls (recall rate 3.1%), 129 women (3.2%) underwent assessment of a contralateral, non-recalled breast abnormality. Most lesions were detected at clinical mammography and/or breast tomosynthesis (101 women, 78.3%). The biopsy rate was similar for recalled lesions and contralateral, non-recalled lesions, but the positive predictive value of biopsy was higher for recalled lesions (p = 0.01). A comparable proportion of the recalled lesions and contralateral, non-recalled lesions were malignant (p = 0.1). The proportion of ductal carcinoma in situ was similar for both groups, as well as invasive cancer characteristics and type of surgical treatment. CONCLUSIONS: About 3% of recalled women underwent evaluation of contralateral, non-recalled breast lesions. Evaluation of the contralateral breast after recall is important as we found that 15.5% of contralateral, non-recalled lesions were malignant. Contralateral cancers and screen-detected cancers show similar characteristics, stage and surgical treatment. KEY POINTS: • 3% of recalled women underwent evaluation of contralateral, non-recalled lesions • One out of seven contralateral, non-recalled lesions was malignant • A contralateral cancer was diagnosed in 0.5% of recalls • Screen-detected cancers and non-recalled, contralateral cancers showed similar histological characteristics • Tumour stage and surgical treatment were similar for both groups.

Severe arterial thromboembolism in patients with Covid-19.

INTRODUCTION: The novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has emerged early December 2019 and was recently confirmed by the World Health Organization (WHO) to be a public health emergency of international concern. Earlier reports have shown coagulopathy in patients with severe coronavirus disease 2019 (Covid-19). MAIN SYMPTOMS AND IMPORTANT CLINICAL FINDINGS: We present four critically ill Covid-19 patients, who were admitted to our hospital. They were treated with supportive care, oral chloroquine, and standard 2500 or 5000 International Units (IU) of dalteparine subcutaneously once daily. Two patients died during the course of their stay as a consequence of severe large vessel arterial thromboembolism. The other two patients survived but symptoms of paralysis and aphasia persisted after cerebral ischemia due to large vessel arterial thromboembolism. Patients showed no signs of overt disseminated intravascular coagulation (DIC) in their laboratory analysis. CONCLUSION: This case series suggest that even in absence of overt DIC, arterial thromboembolic complications occur in critically ill patients with Covid-19. Further studies are needed to determine which parameters are useful in monitoring coagulopathy and which dose of anti-thrombotic therapy in Covid-19 patients is adequate, even when overt DIC is not present.

Tumour characteristics of bilateral screen-detected cancers and bilateral interval cancers in women participating at biennial screening mammography.

BACKGROUND: Unilateral interval breast cancers show less favourable prognostic features than unilateral screen-detected cancers, but data on tumour characteristics of bilateral interval cancers in a systematically screened population are sparse. Therefore, we compared tumour characteristics of bilateral interval cancers with those of bilateral screen-detected cancers. METHODS: We included all 468,720 screening mammograms of women who underwent biennial screening mammography in the South of the Netherlands between January 2005 and January 2015. We collected breast imaging reports, biopsy results and surgical reports of all recalled women and of all women who presented with interval breast cancer. In women with synchronous bilateral breast cancer, the tumour with the highest tumour stage was defined as the index cancer. For comparison of data between both groups Fisher exact test and Chi-square test were used. RESULTS: Synchronous bilateral cancer was diagnosed in 2.2% of screen-detected cancers (64/2947) and in 3.2% of interval cancers (24/753) (P = 0.1). Index tumours of bilateral screen-detected cancers and interval cancers showed similar characteristics, except for a larger proportion of T-stage 2 or worse (T2+) cancers among interval cancers (16/24 (66.7%) versus 23/58 (39.7%) (P = 0.03). Index cancers, compared to contralateral cancers, were less frequently stage T1 in both bilateral screen-detected cancers and bilateral interval cancers (35/64 (60.3%) versus 40/64 (88.9%) (P = 0.001) and 8/24 (33.3%) versus 18/24 (85.7%) (P < 0.001), respectively). In bilateral screen-detected cancers, contralateral cancers were more often stage 1a-c (P < 0.001) compared to index cancers. In bilateral index cancers, index cancers were more often of the lobular subtype (P < 0.001). CONCLUSION: Index cancers of bilateral screen-detected cancers and bilateral interval cancers show significant differences in tumour size, whereas nodal status, receptor status and final surgical treatment are comparable. In bilateral screen-detected cancer, index cancers had a significantly higher tumour stage. In bilateral screen-detected cancer, index cancers were more often the ductal invasive subtype compared to contralateral cancers.

Combined intravenous, topical and oral tranexamic acid administration in total knee replacement: Evaluation of safety in patients with previous thromboembolism and effect on hemoglobin level and transfusion rate.

BACKGROUND: The aims of this study were to investigate the safety of combined intravenous, oral and topical tranexamic acid (TXA) in primary total knee replacement. We assessed dose-related efficacy on hemoglobin level, transfusion, length of stay and thromboembolic complications. In addition, TXA safety in patients with previous history of thromboembolism >12months ago was monitored specifically. METHODS: From January 2013 until January 2016, 922 patients were included who received TXA after primary total knee replacement. Patients without TXA administration or with thromboembolic events <12months ago were excluded. TXA dosage groups were divided into ≤10mg/kg, >10-25mg/kg and >25-50mg/kg. RESULTS: Between the three TXA groups no significant difference was found in thromboembolic complications (deep venous thrombosis (DVT) and pulmonary embolism (PE)), wound leakage and transfusion rate. For patients with DVT or PE in their history >12months ago specifically, no more complications were noted in higher-TXA-dosage groups compared to the low-dosage group. Length of stay was shorter in the highest-TXA-dosage group compared with lower-dosage groups (median two vs three days). With high TXA dose a smaller difference between pre- and postoperative Hb was found: the >25-50mg/kg TXA group had a 0.419mmol/l smaller decrease in postoperative hemoglobin compared to the lowest-dosage group (P<0.05). CONCLUSION: Combined intravenous, oral and topical TXA is effective in knee replacement and can safely be given to patients with a thromboembolic history >12months ago. High dosage (>25-50mg/kg) TXA resulted in the smallest decrease in postoperative hemoglobin.

Incidence of cardiovascular complications in knee arthroplasty patients before and after implementation of a ropivacaine local infiltration analgesia protocol: A retrospective study.

BACKGROUND: Local infiltration analgesia (LIA) during total knee arthroplasty has been shown to give statistically significant reduction in post-operative pain. The effects of using high volumes of ropivacaine combined with adrenaline as LIA on cardiovascular parameters in knee replacement have not been described before. The objective of this study was to investigate the cardiovascular safety of ropivacaine as part of high volume local infiltration analgesia (LIA) in total knee replacement surgery. METHODS: This is a retrospective observational comparative cohort study conducted in two independent cohorts, one treated without and one treated with a local infiltration analgesia protocol, containing a total of 744 patients with a mean age of 68years (42 to 89) and 68years (21 to 88) respectively with a follow-up of 12months. RESULTS: No statistical difference in bradycardia during surgery, post-operative cardiovascular complications, and mortality was found after use of LIA. A statistically significant lower incidence of hypotension was found in the LIA group (P<0.01). This result has to be interpreted with care, due to the use of adrenaline in the LIA mixture, which could mask possible hypotension. No statistical difference was found in the occurrence of hypertension or tachycardia, despite the addition of adrenaline to the LIA mixture. No difference in mortality was found between the two groups (P=0.11). CONCLUSION: These results show safe use of high volume ropivacaine with adrenaline as local infiltration analgesia during total knee replacement surgery.