Accuracy, Precision, and Trending Ability of Electrical Cardiometry Cardiac Index versus Continuous Pulmonary Artery Thermodilution Method: A Prospective, Observational Study.

INTRODUCTION: Evaluation of accuracy, precision, and trending ability of cardiac index (CI) measurements using the Aesculon™ bioimpedance electrical cardiometry (Aesc) compared to the continuous pulmonary artery thermodilution catheter (PAC) technique before, during, and after cardiac surgery. METHODS: A prospective observational study with fifty patients with ASA 3-4. At six time points (T), measurements of CI simultaneously by continuous cardiac output pulmonary thermodilution and thoracic bioimpedance and standard hemodynamics were performed. Analysis was performed using Bland-Altman, four-quadrant plot, and polar plot methodology. RESULTS: CI obtained with pulmonary artery thermodilution and thoracic bioimpedance ranged from 1.00 to 6.75 L min-1 and 0.93 to 7.25 L min-1, respectively. Bland-Altman analysis showed a bias between CIBIO and CIPAC of 0.52 liters min-1 m-2, with LOA of [-2.2; 1.1] liters min-1 m-2. Percentage error between the two techniques was above 30% at every time point. Polar plot methodology and 4-quadrant analysis showed poor trending ability. Skin incision had no effect on the results. CONCLUSION: CI obtained by continuous PAC and CI obtained by Aesculon bioimpedance are not interchangeable in cardiac surgical patients. No effects of skin incision were found. International clinical trial registration number is ISRCTN26732484.

Clinically node negative breast cancer patients undergoing breast conserving therapy, sentinel lymph node procedure versus follow-up: a Dutch randomized controlled multicentre trial (BOOG 2013-08).

BACKGROUND: Studies showed that axillary lymph node dissection can be safely omitted in presence of positive sentinel lymph node(s) in breast cancer patients treated with breast conserving therapy. Since the outcome of the sentinel lymph node biopsy has no clinical consequence, the value of the procedure itself is being questioned. The aim of the BOOG 2013-08 trial is to investigate whether the sentinel lymph node biopsy can be safely omitted in clinically node negative breast cancer patients treated with breast conserving therapy. METHODS: The BOOG 2013-08 is a Dutch prospective non-inferiority randomized multicentre trial. Women with pathologically confirmed clinically node negative T1-2 invasive breast cancer undergoing breast conserving therapy will be randomized for sentinel lymph node biopsy versus no sentinel lymph node biopsy. Endpoints include regional recurrence after 5 (primary endpoint) and 10 years of follow-up, distant-disease free and overall survival, quality of life, morbidity and cost-effectiveness. Previous data indicate a 5-year regional recurrence free survival rate of 99% for the control arm and 96% for the study arm. In combination with a non-inferiority limit of 5% and probability of 0.8, this result in a sample size of 1.644 patients including a lost to follow-up rate of 10%. Primary and secondary endpoints will be reported after 5 and 10 years of follow-up. DISCUSSION: If the sentinel lymph node biopsy can be safely omitted in clinically node negative breast cancer patients undergoing breast conserving therapy, this study will cost-effectively lead to a decreased axillary morbidity rate and thereby improved quality of life with non-inferior regional control, distant-disease free survival and overall survival. TRIAL REGISTRATION: The BOOG 2013-08 study is registered in ClinicalTrials.gov since October 20, 2014, Identifier: NCT02271828. https://clinicaltrials.gov/ct2/show/NCT02271828.

The value of completion axillary treatment in sentinel node positive breast cancer patients undergoing a mastectomy: a Dutch randomized controlled multicentre trial (BOOG 2013-07).

BACKGROUND: Trials failed to demonstrate additional value of completion axillary lymph node dissection in case of limited sentinel lymph node metastases in breast cancer patients undergoing breast conserving therapy. It has been suggested that the low regional recurrence rates in these trials might partially be ascribed to accidental irradiation of part of the axilla by whole breast radiation therapy, which precludes extrapolation of results to mastectomy patients. The aim of the randomized controlled BOOG 2013-07 trial is therefore to investigate whether completion axillary treatment can be safely omitted in sentinel lymph node positive breast cancer patients treated with mastectomy. DESIGN: This study is designed as a non-inferiority randomized controlled multicentre trial. Women aged 18 years or older diagnosed with unilateral invasive clinically T1-2 N0 breast cancer who are treated with mastectomy, and who have a maximum of three axillary sentinel lymph nodes containing micro- and/or macrometastases, will be randomized for completion axillary treatment versus no completion axillary treatment. Completion axillary treatment can consist of completion axillary lymph node dissection or axillary radiation therapy. Primary endpoint is regional recurrence rate at 5 years. Based on a 5-year regional recurrence free survival rate of 98 % among controls and 96 % for study subjects, the sample size amounts 439 per arm (including 10 % lost to follow-up), to be able to reject the null hypothesis that the rate for study and control subjects is inferior by at least 5 % with a probability of 0.8. Results will be reported after 5 and 10 years of follow-up. DISCUSSION: We hypothesize that completion axillary treatment can be safely omitted in sentinel node positive breast cancer patients undergoing mastectomy. If confirmed, this study will significantly decrease the number of breast cancer patients receiving extensive treatment of the axilla, thereby diminishing the risk of morbidity and improving quality of life, while maintaining excellent regional control and without affecting survival. TRIAL REGISTRATION: The BOOG 2013-07 study is registered in the register of ClinicalTrials.gov since April 10, 2014, Identifier: NCT02112682 .

Pain prevalence and its determinants after spinal cord injury: a systematic review.

Pain prevalence studies are important as they illustrate the magnitude of pain problems in a certain patient population, such as patients living with a spinal cord injury (SCI). Strikingly, reported pain prevalence rates in SCI patients are found to vary greatly, while determinants for the differences between pain prevalence reports remain unclear. We here aim to identify determinants for the differences (heterogeneity) in pain prevalence reports through a systematic review of all SCI pain prevalence reporting studies. Literature search was done using Medline, Cumulative Index to Nursing and Allied Health Literature, ISI Web of Knowledge and Embase. Data abstraction was performed while blinded and was followed by meta-(regression)-analyses. We identified 82 studies. Study design-related determinants of SCI pain prevalence reports were pain definition strictness (mild, moderate or high), primary study goal (pain study or not), data source (retrospective or not), and in a limited number of cases response/attrition rates. While correcting for these items, population characteristics correlating with pain prevalence rates were both proportion of patients with a depression and average time after injury (positive correlations). Between-study heterogeneity may remain even after the identification/correction of above-mentioned causes of heterogeneity.Pain after SCI does seem to relate to the duration of the injury and depression, yet major causes of bias in reported pain prevalence are found to be related to the primary study goal (pain study or not), choice of pain definition and the use of retrospective data.

The effects of vagus nerve stimulation on tryptophan metabolites in children with intractable epilepsy.

BACKGROUND: The mechanism of action of vagus nerve stimulation (VNS) in intractable epilepsy is not entirely clarified. It is believed that VNS causes alterations in cytokines, which can lead to rebalancing the release of neurotoxic and neuroprotective tryptophan metabolites. We aimed to evaluate VNS effects on tryptophan metabolites and on epileptic seizures and investigated whether the antiepileptic effectiveness correlated with changes in tryptophan metabolism. METHODS: Forty-one children with intractable epilepsy were included in a randomized, active-controlled, double-blind study. After a baseline period of 12 weeks, all children underwent implantation of a vagus nerve stimulator and entered a blinded active-controlled phase of 20 weeks. Half of the children received high-output (therapeutic) stimulation (n=21), while the other half received low-output (active control) stimulation (n=20). Subsequently, all children received high-output stimulation for another 19 weeks (add-on phase). Tryptophan metabolites were assessed in plasma and cerebrospinal fluid (CSF) by use of liquid chromatography-tandem mass spectrometry (LC-MS/MS) and compared between high- and low-output groups and between the end of both study phases and baseline. Seizure frequency was recorded using seizure diaries. Mood was assessed using Profile of Mood States (POMS) questionnaires. RESULTS: Regarding tryptophan metabolites, anthranilic acid (AA) levels were significantly higher at the end of the add-on phase compared with baseline (p=0.002) and correlated significantly with improvement of mood (τ=-0.39, p=0.037) and seizure frequency reduction (τ=-0.33, p<0.01). No significant changes were found between high- and low-output groups regarding seizure frequency. CONCLUSION: Vagus nerve stimulation induces a consistent increase in AA, a neuroprotective and anticonvulsant tryptophan metabolite. Moreover, increased AA levels are associated with improvement in mood and reduction of seizure frequency.

Comparison of two scoring systems for diagnosing levator ani muscle damage.

INTRODUCTION AND HYPOTHESIS: Levator defects are risk factors for pelvic organ prolapse (POP) and its recurrence. The most widely used scoring systems for severity of defects shown on magnetic resonance imaging (MRI) and perineal ultrasound (US) are not identical. The aim of this study was to investigate the differences between these classification systems with regard to levator defects on US and their clinical relevance for recurrence after prolapse surgery. METHODS: Women with previous cystocele repair underwent transperineal 3D US. Levator defects were graded according to the scoring system described with regard to MRI (DeLancey et al.) and perineal US (Dietz et al.). The results were compared using the weighted kappa and receiver operating characteristic (ROC) curves (SPSS version 20.0). RESULTS: We assessed 152 women. On US classification, more defects were categorized as highest grade compared with MRI classification [n = 64 (42 %) vs. n = 41 (28 %), p < 0.01]. The grades of levator defects on both scoring systems showed very good agreement, with a weighted kappa of 0.82 [95 % confidence interval (CI) 0.75-0.88). The predictive value of scoring systems for cystocele recurrence after prolapse surgery showed an area under the receiver operating curve (AUC) of 0.63 and 0.64, respectively. CONCLUSIONS: Comparison of the two scoring systems showed good agreement but was lowest for the highest-grade defects. There was no difference in predictive value between scoring systems for cystocele recurrence after prolapse surgery.

Transperineal ultrasound compared to evacuation proctography for diagnosing enteroceles and intussusceptions.

INTRODUCTION: This study concerns the level of agreement between transperineal ultrasound and evacuation proctography for diagnosing enteroceles and intussusceptions. METHOD: In a prospective observational study, 50 consecutive women who were planned to have an evacuation proctography underwent transperineal ultrasound too. Sensitivity, specificity, positive (PPV) and negative predictive value, as well as the positive and negative likelihood ratio of transperineal ultrasound were assessed in comparison to evacuation proctography. To determine the interobserver agreement of transperineal ultrasound, the quadratic weighted kappa was calculated. Furthermore, receiver operating characteristic curves were generated to show the diagnostic capability of transperineal ultrasound. RESULTS: For diagnosing intussusceptions (PPV 1.00), a positive finding on transperineal ultrasound was predictive of an abnormal evacuation proctography. Sensitivity of transperineal ultrasound was poor for intussusceptions (0.25). For diagnosing enteroceles, the positive likelihood ratio was 2.10 and the negative likelihood ratio, 0.85. There are many false-positive findings of enteroceles on ultrasonography (PPV 0.29). The interobserver agreement of the two ultrasonographers assessed as the quadratic weighted kappa of diagnosing enteroceles was 0.44 and that of diagnosing intussusceptions was 0.23. CONCLUSION: An intussusception on ultrasound is predictive of an abnormal evacuation proctography. For diagnosing enteroceles, the diagnostic quality of transperineal ultrasound was limited compared to evacuation proctography.

Pain relief and quality-of-life improvement after spinal cord stimulation in painful diabetic polyneuropathy: a pilot study.

BACKGROUND: Painful diabetic polyneuropathy (PDP) is associated with high pain scores and is difficult to treat. Therefore, spinal cord stimulation (SCS) has been suggested as second-line treatment. In this study, the feasibility and efficacy of SCS in PDP were investigated, as well as the predictive value of clinical sensory testing for the treatment outcome. METHODS: Fifteen patients with intractable PDP in the lower limbs were recruited. During lead implantation, the feasibility of achieving adequate paraesthesia coverage using one stimulation lead was investigated. If trial stimulation was successful, a definitive neurostimulator was implanted. Pain intensity was scored using an 11-point numeric rating scale and patients' global impression of change scale. Additionally, neuropathic pain characteristics, quality of life, sleep quality and mood were assessed. The predictive value of clinical sensory testing for the treatment outcome was analysed. RESULTS: Adequate paraesthesia coverage was achieved in 14 out of 15 patients. Clinically relevant pain relief was present in 11 patients after trial stimulation and 10 patients at 12 months. The quality of life was significantly increased at 2 weeks and 3 months in patients with successful SCS treatment. Several neuropathic pain characteristics and quality of sleep were improved at 2 weeks and 12 months. Preoperative clinical sensory testing did not differentiate between treatment responders from non-responders. CONCLUSIONS: SCS seems to be an efficacious and feasible treatment for intractable PDP. In this exploratory study, it was not possible to predict the treatment outcome using clinical sensory testing. These results justify performing a randomized clinical trial.

Psychosocial adjustment in a Dutch sample of children with cerebral palsy.

BACKGROUND: Over the last couple of years, there has been increasing interest for QoL in children with CP. Psychosocial adjustment in these children remains underrepresented in current literature. AIMS: To describe psychosocial adjustment in children with CP by means of the Psychosocial Adjustment and Role Skills Scale III (PARS-III), to describe the psychometric properties of this questionnaire, to identify a cut-off score for psychosocial maladjustment and to investigate the relationship between patient characteristics (i.e. predictive factors) and psychosocial adjustment. METHODS: The parents of 93 children with CP (59 boys, 34 girls; mean age 12.3 years, SD 3.8; 4-18; GMFCS 1: 28, GMFCS 2: 5, GMFCS 3: 19, GMFCS 4: 18, GMFCS 5: 23) completed the PARS-III and the Child Behavior Checklist (CBCL) concerning the psychosocial and behavioral functioning of their child. RESULTS: Cronbach's alpha-coefficient for the PARS-III was 0.89 indicating good internal consistency. High correlation with the CBCL was found. Confirmatory factor analysis confirmed the 6 domain structure of the PARS-III. Overall, children with CP achieved lower psychosocial adjustment scores compared to healthy children. A cut-off score (1 SD below the mean) of 78 was found. When predicting psychosocial maladjustment in children with CP, less gross motor function, hand function, communication skills and bilateral involvement of CP are the most important factors, but these can only explain 36% of variation in psychosocial adjustment. CONCLUSION: Using the by-proxy version of the PARS-III it was found that children with CP are reported to achieve lower psychosocial adjustment scores than healthy children.

Can morphine still be considered to be the standard for treating chronic pain? A systematic review including pair-wise and network meta-analyses.

OBJECTIVE: For chronic pain treatment many health care authorities consider morphine to be the reference standard for strategic decisions in pain therapy. Although morphine's effectiveness is clear and its cost is low, it's unclear whether morphine should remain the first choice or reference treatment. RESEARCH DESIGN AND METHODS: We performed a systematic review to evaluate the evidence available to support the position of morphine as the reference standard for step III opioids based on efficacy and tolerability outcomes. RESULTS: The search yielded 5,675 titles and 56 studies were included. Considerable heterogeneity precluded pair-wise meta-analysis on change of pain intensity and no difference between morphine and other opioids were found for tolerability outcomes. The network meta-analysis showed no statistically significant difference in change of pain intensity between morphine and oxycodone, methadone and oxymorphone. Compared to morphine, patients using buprenorphine are more likely to discontinue treatment due to lack of effect (OR 2.32, 95% CI 1.37 to 3.95). Patients using methadone are more likely to discontinue due to adverse events (OR 3.09, 95% CI 1.14 to 8.36), whereas this risk is decreased for patients using fentanyl (OR 0.29, 95% CI 0.17 to 0.50) or buprenorphine (OR 0.30, 95% CI 0.16 to 0.53). The most important limitation of this review is that the included studies are heterogeneous with regard to study population and intervention, which may affect the pooled effect estimates. The main strength is that we only included parallel RCTs, the strongest design for intervention studies. CONCLUSIONS: The current evidence is moderate, both in respect to the number of directly comparative studies and in the quality of reporting of these studies. No clear superiority in efficacy and tolerability of morphine over other opioids was found in pair-wise and network analyses. Based on these results, a justification for the placement of morphine as the reference standard for the treatment of severe chronic pain cannot be supported.

5% lidocaine-medicated plaster vs other relevant interventions and placebo for post-herpetic neuralgia (PHN): a systematic review.

Several pharmacological treatments are used to manage post-herpetic neuralgia (PHN). The use of topical analgesics, such as 5% lidocaine-medicated plaster (5% LMP), may be preferable to systemic treatments in that they are formulated to produce a local pain relieving effect with minimal systemic absorption. However, direct head-to-head comparisons are relatively few, and a rigorous assessment of the relative efficacy and safety of the various treatment options is lacking. The objective of this study was to compare 5% LMP for the relief of PHN with other relevant interventions and placebo. Six databases were searched up to May 2010. Quantitative methods for data synthesis were used, and a network meta-analysis was conducted. Twenty unique studies (32 publications) were included. Placebo-controlled studies showed 5% LMP to be effective in providing pain relief and reducing allodynia while adverse event rates were generally low. A comparison between 5% LMP and pregabalin indicated the non-inferiority of 5% LMP for pain reduction and showed greater improvement of quality of life for 5% LMP. Adverse events (AE) were significantly fewer with 5% LMP. In the network meta-analysis, only 5% LMP and gabapentin were associated with a greater change in pain from baseline than placebo [-15.50 (95% CI -18.85 to -12.16) and -7.56 (95% CI -12.52 to -2.59) respectively]. 5% LMP was shown to be more effective than capsaicin [-16.45 (95% CI -20.04 to -12.86)], gabapentin [-7.95 (95% CI -13.29 to -2.61)] and pregabalin [-13.45 (95% CI -19.19 to -7.71)]. For pain relief, two comparators were more effective than placebo [mean pain relief, gabapentin: 32.77 (95% CI 15.57-49.97); 5% LMP: 26.77 (95% CI 9.11-44.43)]. 5% LMP was shown to be comparable to gabapentin [-6.00 (95% CI -25.32-13.32)]. The results suggest that 5% LMP and gabapentin have similar effects on pain relief and that 5% LMP is more effective than capsaicin and pregabalin (change in pain from baseline). Topical agents, such as 5% LMP, are associated with fewer and less clinically significant AE than is the case for systemic agents. However, small numbers, and limited size and quality of included studies should be taken into account. Further studies are needed.

A patient-centred instrument for assessment of quality of breast cancer care: results of a pilot questionnaire.

BACKGROUND: In several breast cancer research environments, there was a need to develop a questionnaire that would (1) provide data on how breast cancer patients experience healthcare services, (2) address issues corresponding with patients' needs and expectations and (3) produce useful data for quality assessment and improvement projects aimed at breast cancer care. This article describes the first part of the quantitative process of item selection, instrument construction and optimisation based on the results of a pilot questionnaire. METHODS: Based on qualitative research, a pilot questionnaire with items formulated as "performance" and "importance" statements was developed and sent to all breast cancer patients operated on in the previous 3-15 months in five participating hospitals. Reduction criteria, exploratory factor analysis and reliability analysis were used as part of the process of instrument optimisation. RESULTS: Of the 637 questionnaires sent out, 299 (47%) were returned and 276 (43%) were used for analyses. Out of the 72 quality items included in the pilot questionnaire, 42 items did not meet the inclusion criteria for the revised version. The remaining items refer to the factors patient education regarding aspects related to postoperative treatment, services by the breast nurse, services by the surgeon, patient education regarding activities at home and patient education regarding aspects related to preoperative treatment (Cronbach α = 0.70-0.89). CONCLUSIONS: In this study, the number of items to be included in the self-administered questionnaire was reduced. The resulting set of items that determines patients' perceptions on quality of breast cancer care is easy to complete and enables anonymous responses. Further research can be aimed at establishing the reliability of the current questionnaire.

Association between guideline adherence and clinical outcome for patients referred for diagnostic breast imaging.

OBJECTIVE: To assess the adherence to a guideline for additional breast ultrasonography in a cross-sectional survey among hospitals in The Netherlands. Furthermore, consequences of current practice non-adherence for the patient outcome of diagnostic breast imaging were studied. METHODS: Current practice was compared with a guideline made up of three recommendations for the use of ultrasonography after mammography and three recommendations for not using ultrasonography. All patients referred for mammography to the radiology departments of the participating hospitals during 2 months in 2004 were eligible for the study. No data on the gold standard for breast cancer were analysed, but clinical consequences were estimated by using a probability model based on the data of a former prospective clinical study. RESULTS: In total, 17 of the 66 hospitals approached were participating in the study. Of the 13,694 patients assessed for eligibility, 6457 were included. High adherence rates (81-97%, mean 94%) were observed for the recommendations, which indicate additional ultrasonography, whereas lower adherence rates (68-94%, mean 83%) were seen for the recommendations which do not advise additional ultrasonography. Overall, in all included hospitals, non-adherence would result in 27.2 false-positive and 1.1 false-negative imaging results. CONCLUSION: Current daily practice of diagnostic breast imaging in the hospitals in this survey corresponds to a great extent to the guideline proposed. Non-adherence in current practice results in a relatively small number of false-positive and false-negative imaging results.

Diagnostic performance of breast technologists in reading mammograms in a clinical patient population.

PURPOSE: In the setting of an increasing workload for radiologists, this study focuses on the feasibility of skill mixing in breast imaging in a hospital radiology department. METHODS: Two radiological technologists with more than 10 years of experience in performing mammograms were trained in prereading mammograms to select the cases that require further evaluation by a radiologist. Mammograms of consecutive patients were independently evaluated by the technologists, next to the standard clinical interpretation by the radiologist on duty. Mammographic findings were recorded and a BI-RADS classification was assigned for each breast. Different prereading scenarios were analysed using clinical decision rules. Two different cut-off points of BI-RADS classifications were applied to the data. Analysis was performed for the overall clinical patient population as well as for a subgroup of patients with no immediate indication for further work-up. RESULTS: Mammograms of 1994 patients were evaluated. In total, 93 breast cancers were found in 91 patients (prevalence 4.6%). Sensitivity and specificity in selecting mammographic findings (cut-off point between BI-RADS 1 and BI-RADS 0, 2-5 and the radiologist's diagnosis as reference standard) was 98% and 74% for technologist 1 and 98% and 78% for technologist 2. In distinguishing normal and benign mammograms from those with abnormalities that are probably benign, suspicious or highly suggestive for malignancy (cut-off point BI-RADS 1-2 and BI-RADS 0, 3-5 and pathology results as reference standard), sensitivity decreased to 89% and 91% respectively. Specificity increased to 82% for both technologists. In a subgroup of 1389 patients with no immediate indication for additional imaging with the involvement of a radiologist, technologists obtained a mean sensitivity and specificity of 98% and 77% in detecting mammographic findings, and a mean sensitivity and specificity of 78% and 88% in detecting suspicious abnormalities. CONCLUSIONS: The employment of technologists in prereading mammograms seems to be an effective working strategy in daily clinical practice. However, its position in clinical practice remains indistinct as a continuous availability of radiologists still needs to be guaranteed. Nevertheless, as a substantial proportion of mammograms could be evaluated without the attention of a radiologist, the employment of technologists in prereading mammograms seems a promising new working strategy.

Urinary tract infection in male general practice patients: uropathogens and antibiotic susceptibility.

OBJECTIVES: To evaluate uropathogens and their antibiotic susceptibility in male general practitioner (GP) patients presenting with an uncomplicated urinary tract infection (UTI). MATERIAL AND METHODS: A population-based study was conducted among males, 18 years and older, general practice patients, who had symptoms indicative of an uncomplicated UTI. A UTI was defined as >/=10(3) colony-forming units/mL (CFU/mL). The etiology of the infection, antimicrobial susceptibility, and treatment strategies used by the GP were determined. RESULTS: Escherichia coli was most frequently isolated (48%), followed by other enterobacteriaceae (24%) and enterococci (9%). The etiology of infection was age-dependent; E. coli was more frequently isolated in younger patients and Pseudomonas aeruginosa in the elderly. The overall susceptibility rates were low for amoxicillin (63%) and trimethoprim (70%), and high for fluoroquinolones (91%) and amoxicillin-clavulanic acid (90%), which is similar to susceptibility rates in females with UTIs from the same population. Antibiotics were prescribed to 59% of the males with symptoms of UTI. Fluoroquinolones were given to 33% of the patients and trimethoprim-sulfamethoxazole to 24%. No difference in antibiotic prescription, nor in duration of therapy, was found between the different age groups. CONCLUSIONS: In the male presenting with complaints of an acute uncomplicated UTI at the GP, E. coli, followed by other Gram-negative bacteria were the most frequently isolated uropathogens. Susceptibility rates in uncomplicated male and female UTIs were similar, indicating that data from UTI susceptibility studies in females from the same geographic region can be useful in the choice of empirical therapy in males.

Patients' opinions on quality of care before and after implementation of a short stay programme following breast cancer surgery.

PURPOSE: To assess breast cancer patients' opinions on quality of care during an implementation study on short hospital stay, and to formulate patient inspired targets for further quality improvement based on results of the QUOTE (Quality of Care Through the Patients' Eyes) breast cancer instrument. RESULTS: Quality of patient education regarding activities at home was in need of improvement in both measurements. Quality of services delivered by the surgeon improved somewhat after implementation. Although quality of waiting and process times improved after implementation, there was still room for further improvement on these aspects. CONCLUSION: A breast cancer care programme in short stay was introduced while, on average, preserving quality of care as perceived by the patient. However, aspects regarding education on drains, prosthesis, exercises after surgery, survival rates, and waiting and process times require continuing attention to enhance patients' assessment of quality of care.

Vascular calcifications as a marker of increased cardiovascular risk: a meta-analysis.

BACKGROUND: Several imaging techniques may reveal calcification of the arterial wall or cardiac valves. Many studies indicate that the risk for cardiovascular disease is increased when calcification is present. Recent meta-analyses on coronary calcification and cardiovascular risk may be confounded by indication. Therefore, this meta-analysis was performed with extensive subgroup analysis to assess the overall cardiovascular risk of finding calcification in any arterial wall or cardiac valve when using different imaging techniques. METHODS AND RESULTS: A meta-analysis of prospective studies reporting calcifications and cardiovascular end-points was performed. Thirty articles were selected. The overall odds ratios (95% confidence interval [CI]) for calcifications versus no calcifications in 218,080 subjects after a mean follow-up of 10.1 years amounted to 4.62 (CI 2.24 to 9.53) for all cause mortality, 3.94 (CI 2.39 to 6.50) for cardiovascular mortality, 3.74 (CI 2.56 to 5.45) for coronary events, 2.21 (CI 1.81 to 2.69) for stroke, and 3.41 (CI 2.71 to 4.30) for any cardiovascular event. Heterogeneity was largely explained by length of follow up and sort of imaging technique. Subgroup analysis of patients with end stage renal disease revealed a much higher odds ratio for any event of 6.22 (CI 2.73 to 14.14). CONCLUSION: The presence of calcification in any arterial wall is associated with a 3-4-fold higher risk for mortality and cardiovascular events. Interpretation of the pooled estimates has to be done with caution because of heterogeneity across studies.

Local recurrence in rectal cancer can be predicted by histopathological factors.

AIM: The main cause of local recurrence (LR) in rectal cancer is involvement of the circumferential resection margin (CRM). However, patients with a negative CRM can also develop LR, suggesting that additional factors are important for LR. The aim of this study was to identify histopathological factors predictive for the development of LR after primary rectal cancer treatment. METHODS: T x N x M0 patients treated for locally recurrent rectal cancer at the Catharina hospital from 1994 to 2006 (n=92) were matched with a control group of patients who did not develop LR after primary rectal cancer treatment for at least 2 years (n=185) based on the type of neoadjuvant treatment in a 1:2 ratio. The pathology of all primary rectal cancers was reviewed. Patient, treatment and histopathological characteristics were studied in relation to the development of LR with logistic regression. RESULTS: Logistic regression indicated the presence of lymphovascular invasion (LVI, OR 4.66, P<0.001), extramural venous invasion (EMVI, OR 4.54, P<0.001), positive CRM (OR 2.56, P=0.032), serosal involvement (OR 6.74, P=0.035) and poor differentiation (OR 2.59, P=0.012) as factors with an increased risk to develop LR. Older age was a protective factor (OR 0.95, CI 0.93-0.98, P=0.001). CONCLUSION: Apart from a positive CRM and serosal involvement, LVI, EMVI and poor differentiation are important independent predictive factors for the development of LR. Adjuvant therapy may be considered in the presence of these features in order to decrease the risk of a local recurrence.

To eat or not to eat: facilitating early oral intake after elective colonic surgery in the Netherlands.

BACKGROUND & AIMS: It was shown that patients in the Netherlands remain exposed to unnecessarily prolonged starvation after abdominal surgery. The present study examined whether a structured collaborative effort would help to implement the early start of oral nutrition after colorectal surgery. METHODS: In 2006, twenty-six Dutch hospitals signed up to a "breakthrough project" concerning the implementation of the enhanced recovery after surgery (ERAS) programme with early oral feeding as one of the key elements. Each hospital determined the usual start of food intake by analyzing 50 patients who underwent a colorectal resection in 2004 (n=1126). Subsequently, over the course of one year 861 colorectal surgery patients were treated according to the ERAS programme. The first day that patients were eating before and after the breakthrough project was compared using Kaplan-Meier analyses and Cox regression models. RESULTS: Patients treated according to the ERAS programme were eating 3 days earlier than the patients traditionally treated (p<0.000). Two days after surgery 65% of the ERAS patients were eating normal food versus 7% of the pre-ERAS patients. CONCLUSIONS: The present nationwide collaborative effort was successful in implementing a change towards an early start of oral nutrition after abdominal surgery.