Doing the Right Thing? General Practitioners' Considerations in Achieving a Timely Dementia Diagnosis.

OBJECTIVES: Timely detection and diagnosis of dementia are beneficial for providing appropriate, anticipatory care and preventing acute situations. However, initiating diagnostic testing is a complex and dynamic process that requires general practitioners (GPs) to balance competing priorities. Previously identified barriers, such as a lack of time, knowledge, and resources, may not fully represent the challenges involved in this process. Therefore, this study aimed to examine GPs' more implicit considerations on starting the diagnostic trajectory for dementia. METHODS: A qualitative study was conducted using semi-structured interviews with 14 Dutch GPs who were purposively selected through maximum variation sampling. The interview transcripts were inductively analyzed in multiple rounds by a multidisciplinary research team using thematic analysis. RESULTS: GPs' considerations on starting the diagnostic trajectory for dementia can be summarized in three main themes that are interconnected: (1) 'the presumed patient's willingness', that is, facing a dilemma of wanting to respect patient autonomy in cases of denial or an absence of a diagnostic request, while at the same time identifying a problem and feeling the urgency to act; (2) 'the GP's attempt not to harm', that is, balancing between not wanting to harm the patient and/or relatives with the burdensome label of dementia and with the possible negative consequences of a late diagnosis; and (3) 'time, trust, and interprofessional collaboration influence timeliness of diagnostic work-up', that is, time available for consultations, time as a diagnostic factor, GP's diagnostic confidence, and trustful physician-patient relationship. CONCLUSIONS: This study revealed that important ethical dilemmas regarding patient autonomy and the principle of doing no harm lie behind practical GP barriers to initiating diagnostic testing for dementia. Time, trust, and interprofessional collaboration were found to facilitate GPs in determining the right decision and timing with each individual patient and their relatives. Future research could explore the value of diagnostic decision aids that explicitly involve patients and their relatives in this balancing act.

The Diagnostic Value of Multifrequency Tympanometry in Patients with Ménière's Disease: A Prospective Analysis.

INTRODUCTION: Diagnosing Ménière's disease (MD) by its characteristics such as episodes of vertigo, fluctuating hearing loss, and tinnitus with aural fullness remains challenging. Available tests evaluating the presence of endolymphatic hydrops (EH) are often expensive or time assuming. An in-office quick and simple non-invasive diagnostic test is multifrequency tympanometry (MFT). It can measure conductance at 2 kHz probe tones, which was demonstrated to reflect variations in cochlear pressure. Previous studies investigating MFT as a diagnostic test for MD showed conflicting outcomes possibly biased by their retrospective design. METHODS: We prospectively collected MFT results (Y width) in patients with dizziness and compared MFT test results in affected (group 1) and unaffected (group 2) ears of 37 MD subjects and in control ears of 33 non-MD subjects (group 3). RESULTS: The mean value of the Y width in affected ears was 315.6 ± 70.2 daPa compared to 292.3 ± 98.6 daPa in unaffected ears in MD subjects and 259.4. ± 60.6 daPa in the non-MD group. A positive test result (i.e., a Y width of 235 daPa or more) was found in 35 ears in the MD group, 21 times involving the affected ear and 14 times involving the unaffected ear, compared to 16 in the non-MD group. No significant differences between the three groups could be demonstrated (p > 0.05). We found a sensitivity of 58.3% and specificity of 66.3% for detecting EH in an affected ear in MD subjects. CONCLUSION: There is a trend towards increased conductance tympanometry in affected ears. However, we noticed a high false positive rate of MFT and do not support standardized use of MFT as an additional diagnostic tool for detecting EH in MD patients. A negative test result on the contrary is unlikely related to EH.

Risk assessment for postoperative outcomes in a mixed hospitalized gynecological population by the Dutch safety management system (Veiligheidsmanagementsysteem, VMS) screening tool 'frail elderly'.

PURPOSE: Frailty is associated with a higher risk for negative postoperative outcomes. This study aimed to determine the association between the screening tool of the Dutch safety management system, Veiligheidsmanagementsysteem (VMS) 'frail elderly' and postoperative complications in a gynecological population. METHODS: This cohort study included women aged 70 years or older, who were scheduled for any kind of gynecological surgery. VMS screening data (including risk for delirium, falling, malnutrition, and functional impairment) were extracted from the electronic patient records. VMS score could range between 0 and 4 patients with a VMS score of one or more were considered frail. Data on possible confounding factors and complications within 30 days after surgery, classified with the Clavien-Dindo classification, were collected. Regression analysis was performed. RESULTS: 157 women were included with a median age of 74 years (inter quartile range 71-79). Most patients underwent prolapse surgery (52%) or hysterectomy (31%). Forty-one patients (26%) experienced any postoperative complication. Sixty-two patients (39%) were considered frail preoperatively by the VMS screening tool. Frailty measured with the VMS screening tool was not independently associated with postoperative complications in multivariable analysis (Odds ratio 1.18; 95% CI 0.49-2.82). However, a recent fall in the last 6 months (n = 208) was associated with postoperative complications (Odds ratio 3.90; 95% CI 1.57-9.66). CONCLUSION: An independent association between frailty, determined by the VMS screening tool 'Frail elderly', and postoperative complications in gynecological surgery patients could not be confirmed. A recent fall in the last 6 months seems associated with postoperative complications.

The relation between dizziness and suspected obstructive sleep apnoea.

PURPOSE: (1) To determine the prevalence of a high risk of obstructive sleep apnoea (OSA) in patients with dizziness. (2) To assess a relation between the risk of OSA and dizziness-related impairment. (3) To determine whether a high risk of OSA is associated with unexplained dizziness or with hyperventilation/anxiety disorders. METHODS: In this cross-sectional study, we included Dutch adult patients with dizziness. Patients suffering from dementia were excluded. We asked patients to complete the Dizziness Handicap Inventory (DHI) and STOP-Bang questionnaire (SBQ). Based on the SBQ, patients were subdivided into groups with a low, intermediate, and high risks of OSA. All patients were subjected to our standard examinations for the workup for dizziness. RESULTS: Among 704 included patients with a mean age of 59 years (± 17 years), 258 (37%) were male. A high risk of OSA was present in 144 (20%) of our patients of whom 120 (83%) were male. Male patients with a high risk of OSA reported an on average 9-point higher score on the DHI than male patients with a low risk of OSA (p = 0.018). We determined an independent relation between the risk of OSA and dizziness-related impairment. We observed no relation between a high risk of OSA and unexplained dizziness or hyperventilation/anxiety disorders. CONCLUSION: The prevalence of a high risk of OSA in male patients with dizziness is high and a higher risk of OSA is associated with more dizziness-related impairments. A high risk of OSA is not associated with unexplained dizziness or with hyperventilation/anxiety disorders.

The association between depressive symptoms during pregnancy and post-delivery fear of childbirth; a prospective study.

BACKGROUND: Fear of childbirth is an important reason for a caesarean section on request. OBJECTIVE: To assess the association between depressive symptoms during pregnancy and post-delivery fear of childbirth (PFOC). METHODS: We prospectively studied pregnant women from two hospitals in the Netherlands. Women completed the Edinburgh Depression Scale (EPDS), the Wijma Delivery Experience Questionnaire (W-DEQ B) and questions concerning risk factors. Depressive symptoms were assessed at baseline and six weeks post-delivery. PFOC was assessed six weeks post-delivery. Baseline characteristics and pregnancy outcomes were compared between women with and without a depression at baseline. The association between depression and PFOC was assessed with multivariable logistic regression analysis. RESULTS: 245 women participated in this study. At baseline 11% suffered from depressive symptoms. There were no differences in pregnancy outcomes. Women with depressive symptoms more often suffered from depressive symptoms six weeks post-delivery (adjusted OR 4.9, 95% CI 1.4-17). PFOC six weeks post-delivery was present in 11%. Women with depression were at increased risk of PFOC six weeks post-delivery (adjusted OR 9.2, 95% CI 2.6-32). CONCLUSION: This study shows that women with depression at baseline are at increased risk for depression and PFOC six weeks post-delivery.

The Association of Preoperative Anemia and the Postoperative Course and Oncological Outcome in Patients Undergoing Rectal Cancer Surgery: A Multicenter Snapshot Study.

BACKGROUND: There is still controversy about the relationship between preoperative anemia and outcomes after rectal cancer surgery. OBJECTIVE: The aim of this study was to analyze the association between preoperative anemia and postoperative complications and the survival of patients undergoing surgery for rectal cancer in the era of laparoscopic surgery and modern perioperative care. DESIGN: This was a cohort study. SETTINGS: Data were gathered from 71 hospitals in The Netherlands. PATIENTS: Patients who underwent resection for rectal cancer in 2011, for whom preoperative hemoglobin level was registered, were included. INTERVENTIONS(S): There were no interventions. MAIN OUTCOME MEASURES: Short-term outcome parameters were any postoperative complication or mortality within 30 days postoperatively, and pelvic infectious complications defined as anastomotic leakage and presacral abscess. Long-term outcomes were chronic sinus diagnosed at any time during 3-year follow-up, 3-year local and distant recurrence rates, and 3-year overall survival. RESULTS: Of 2095 patients, 1857 had a registered preoperative hemoglobin level; 576 (31%) of these patients anemic and 1281 (69%) were nonanemic. Preoperative anemia was not independently associated with postoperative complications (HR, 1.1; 95% CI, 0.9-1.4; p = 0·24) or 30-day mortality (HR, 1.4, 95% CI, 0.7-2.8; p = 0·29). Preoperative anemia was associated with 3-year overall survival (HR, 2.1; 95% CI, 1.7-2.5; p < 0.0001), after multivariable analysis (HR, 1.4; 95% CI, 1.1-1.8; p = 0·008), and with local recurrence rate (HR, 1.6; 95% CI, 1.1-2.4; p = 0.026), but not with distant recurrence rate (HR, 1.2; 95% CI, 1.0-1.5; p = 0.054). LIMITATIONS: Preoperative anemia appeared to have only limited association with postoperative and disease-specific outcome after rectal cancer surgery in contrast to published meta-analysis of small historical series. CONCLUSIONS: Anemia is associated with overall survival. It might be considered as one of the warning signs in identifying high-risk patients. See Video Abstract at http://links.lww.com/DCR/A913.

The prevalence of benign paroxysmal positional vertigo in patients with osteoporosis.

BACKGROUND: Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of dizziness. There is some evidence that osteoporosis is a risk factor for BPPV. OBJECTIVE: To determine the prevalence of BPPV in patients with proven osteoporosis. MATERIALS AND METHODS: We examined 187 new consecutive patients who attended our osteoporosis clinic. All patients had proven osteoporosis (DEXA scan resulting in a T score ≤ - 2.5). Patients completed a screening questionnaire assessing the presence of episodic vertigo provoked by changes in head position. When we suspected the presence of BPPV, we performed a Dix-Hallpike manoeuvre and a supine roll test. If the diagnostic procedure was positive, a (therapeutic) canalith repositioning manoeuvre (CRM) was performed. RESULTS: Twelve out of 187 patients had a history of typical vertigo compatible with BPPV. In four patients, the presence of BPPV was confirmed by means of a positive Dix-Hallpike manoeuvre. The prevalence of BPPV in this population of patients with osteoporosis was 2.1% (95% CI 0.8-5.4%). CONCLUSION: The prevalence of BPPV in patients with osteoporosis is low. Based on this study, we suggest that there does not seem to be a relation between osteoporosis and BPPV.

Hip Resurfacing Implant Orientation Analysis: A Comparison of a Computer-Added Design Technique and Computed Tomography.

BACKGROUND: Accurate acetabular component orientation in hip resurfacing is mandatory. The aim of this study is to analyze if interpretation of pelvic radiographs with computer-added design (CAD) software is comparable to computed tomography (CT) in measurement of acetabular anteversion and inclination of a Birmingham Hip Resurfacing (BHR) hip. METHODS: A consecutive series of 49 patients (50 hips) who underwent hip resurfacing arthroplasty between 2005 and 2007 with the BHR system were retrospectively included. The surgical procedure was performed by 1 orthopedic surgeon in the beginning of his learning curve. Computer-added design software was used to measure acetabular component orientation on an anteroposterior pelvic radiograph. These measurements were compared with CT measurements. We calculated the correlation between the CAD software and CT analysis. The degree of underestimation or overestimation was determined, and a Bland-Altman plot was created to visualize the agreement between CAD software and CT results. RESULTS: We analyzed 50 BHR hips with mean inclination of 54.6° and 55.6° and mean anteversion of 24.8° and 13.3° measured by CT and CAD, respectively. Pearson correlation coefficient for inclination was 0.69 (P < .001) and for anteversion 0.81 (P < .001). Computer-added design showed a mean underestimated anteversion of 11.6° (P < .001). There was no significant underestimation or overestimation of inclination with CAD analysis compared to CT measurements. CONCLUSION: The CAD software is useful to assess acetabular inclination in hip resurfacing but underestimates anteversion.

The value of clinical and laboratory diagnostics for chest pain patients at the emergency department.

BACKGROUND: The focus during the diagnostic process for patients with acute chest pain is to discriminate patients who can be safely discharged from those who are at risk for an acute coronary syndrome (ACS). In this study the diagnostic value of the clinical examination is compared with laboratory testing of troponin. METHODS: This study included 710 chest pain patients who presented at the ED of two hospitals in the Netherlands. Clinical examination and laboratory testing were combined in the recently developed HEART-score. The diagnostic values of clinical presentation, troponin and the HEART-score for a major adverse coronary event (MACE) and an ACS within 6 weeks were assessed. Furthermore, the improvement of HEART with the second troponin measurement after 6 h was assessed using the net reclassification improvement (NRI). RESULTS: The use of HEART (AUCMACE: 0.77; AUCACS: 0.82) obtains a higher diagnostic value than troponin (AUCMACE: 0.72; AUCACS: 0.74) or clinical evaluation (AUCMACE: 0.69; AUCACS: 0.74). Statistical significant different AUCs were obtained when HEART is compared to troponin or clinical evaluation (p<0.01). The use of the second troponin test (after 6 h of admission) within HEART resulted in an improvement of 8.0%. CONCLUSIONS: The HEART-score combines clinical evaluation and results from laboratory testing, which should be used together, to discriminate patients at risk of a cardiac event from patients who can be safely discharged. In addition, it is shown that a second troponin measurement slightly improves the discriminative ability of the HEART-score.

Quality of life after surgery for colon cancer in patients with Lynch syndrome: partial versus subtotal colectomy.

BACKGROUND: Lynch syndrome is a disorder caused by mismatch repair gene mutations. Mutation carriers have a high risk of developing colorectal cancer. In patients with Lynch syndrome in whom colon cancer has been diagnosed, in general, subtotal colectomy instead of partial colectomy is recommended because of the substantial risk of metachronous colorectal cancer. However, the effect of more extensive surgery on quality of life and functional outcome is unknown. OBJECTIVE: The aim of this study was to investigate quality of life and functional outcome in patients with Lynch syndrome after partial colectomy and subtotal colectomy. DESIGN: This is a nationwide cross-sectional study in the Netherlands. SETTINGS: Two quality-of-life questionnaires (Short Form-36 and The European Organization for Research and Treatment of Cancer Colorectal Cancer-specific Quality of Life Questionnaire Module) and a functional outcome questionnaire (Colorectal Functional Outcome) were used. PATIENTS: Patients with Lynch syndrome who underwent surgery for colon cancer were included. MAIN OUTCOME MEASURES: The primary outcomes measured were quality of life and functional outcome. RESULTS: Questionnaires were sent to 192 patients with Lynch syndrome who underwent surgery for colorectal cancer. A total of 136 patients returned the questionnaire (response rate, 71%). Eighteen patients with rectal cancer, 9 patients with a permanent ileostomy, and 5 patients with an IPAA were excluded. Fifty-one patients underwent partial colectomy, and 53 underwent subtotal colectomy. None of the scales of the Short Form-36 survey showed a significant difference. Analysis of the Colorectal Functional Outcome questionnaire revealed that, after subtotal colectomy, patients have a significantly higher stool frequency (p ≤ 0.01) and a significantly higher score on stool-related aspects (p = 0.06) and social impact (p = 0.03). The European Organization for Research and Treatment of Cancer Colorectal Cancer-specific Quality of Life Questionnaire Module presented more problems with defecation after subtotal colectomy (p ≤ 0.01). LIMITATIONS: Certain selection bias cannot be ruled out. CONCLUSIONS: Although functional outcome is worse after subtotal colectomy than after partial colectomy, generic quality of life does not differ after the 2 types of surgery in Lynch syndrome. When discussing the options for surgery with the patient, all advantages and disadvantages of both surgical procedures, including quality of life and functional outcome, should be discussed.

The perceived quality of video consultations in geriatric outpatient care by early adopters.

PURPOSE: The COVID-19 pandemic caused rapid implementation and upscaling of video consulting. This study examined the perceived quality of care delivered through video consulting at a geriatric outpatient clinic, and how this related to adoption issues and barriers early adopting professionals found themselves confronted with. METHODS: We performed a qualitative study using semi-structured interviews with healthcare professionals complemented by the views of geriatric patients, family caregivers and medical secretaries. Participants from five academic centers and six teaching hospitals were included. Three researchers conducted the interviews, coded the data, and used thematic analysis. RESULTS: Interviews were conducted with 13 healthcare professionals, 8 patients, 7 family caregivers, and 4 medical secretaries. From these early adopters, we infer five criteria positively contributing to perceived quality of care provided by video consulting: (1) the patient has an intact cognitive function; (2) a family caregiver with digital literacy can be present; (3) doctor and patient already have an established relationship; (4) no immediate need for physical examination or intervention; and (5) the prior availability of a comprehensive and concise medical history. Overall, the uptake of video consulting in geriatric outpatient care appeared to be slow and laborious due to several implementation barriers. CONCLUSION: The implementation of video consulting use among geriatricians and geriatric patients at the geriatric outpatient clinic was slow due to the absence of many facilitating factors, but video consulting might be offered as an alternative to face-to-face follow-up to suitable patients in geriatric outpatient clinics.

PREsurgery thoughts - thoughts on prehabilitation in oncologic gynecologic surgery, a qualitative template analysis in older adults and their healthcare professionals.

PURPOSE: This study aimed to reveal information that can be used for composing a prehabilitation program tailored to elderly gynecological oncological patients and is applicable to healthcare professionals. We investigated possible content and indications for prehabilitation, and what potential barriers might exist. MATERIALS AND METHODS: Because of the primary exploratory study aim, inductive thematic template analysis on semi-structured interviews with gynecologic oncological patients aged ≥60 years and healthcare professionals were used. RESULTS: 16 patients and 20 healthcare professionals were interviewed. Three themes important for prehabilitation were found: (1) "Motivation," (2) "Practical issues and facilitators," and (3) "Patient-related factors." A short time interval between diagnosis and surgery was reported as a potential barrier for prehabilitation. Given components for a tailor-made prehabilitation program are: (1) The first contact with a nurse who screens the patients, gives tailor-made advice on prehabilitation and keeps patients motivated and supports them mentally; (2) If patients are referred to a more extensive/supervised program, this should preferably be arranged close to a patients' home. CONCLUSION: Based on our findings, an outline of a patient-tailored prehabilitation program was developed. The main important themes for prehabilitation were "Motivation," "Practical issues and facilitators," and "Patient-related factors."IMPLICATIONS FOR REHABILITATIONPatients and healthcare professionals are positive about prehabilitation.Main themes for designing a prehabilitation program are "Motivation," "Practical issues and facilitators," and "Patient-related factors."Nursing staff can play a key role in prehabilitation.It is important to screen patients for specific impairments to obtain a tailor-made prehabilitation program.For some patients, general advice on prehabilitation might be sufficient, while others may need more supervision.The time interval between diagnosis and surgery is often short and is perceived as a potentially significant barrier for an effective prehabilitation program.

Experiences of patients and health care professionals on the quality of telephone follow-up care during the COVID-19 pandemic: a large qualitative study in a multidisciplinary academic setting.

OBJECTIVE: To evaluate the perceived quality of follow-up telephone consultations (TCs) from the perspective of patients and healthcare professionals (HCPs) of multiple medical disciplines during the COVID-19 pandemic. DESIGN: A qualitative study using semi-structured interviews and reflexive thematic analysis. SETTING: Seven medical disciplines (general dermatology, dermato-oncology, head and neck oncology, internal medicine, medical oncology, gynaecological oncology and surgical oncology) at a large university hospital in the Netherlands. PARTICIPANTS: Patients who received and HCPs who provided TCs as a substitute for outpatient follow-up appointments during the COVID-19 pandemic. RESULTS: Eighty-two patients and 58 HCPs were interviewed. Predominantly, patients and HCPs were satisfied with the quality of care by TCs. They regarded TCs as efficient, accessible and of acceptable quality, provided there was an established patient-HCP relationship, medical complaints were absent and physical examination was not indicated. However, most patients were worried about the accuracy of their health assessment in the absence of physical examination and non-verbal communication. Both patients and HCPs wish to use TCs in the future alternatively with face-to-face consultations. CONCLUSION: This study concludes that TCs seem a valuable contribution to the context of follow-up care and could partially replace face-to-face consultations. TCs can be performed in stable, chronic patients with whom a doctor-patient relationship has already been established. Face-to-face consultations are considered more appropriate in the case of new patients, challenging or emotionally charged consultations and when clinically relevant physical examination is indicated. Due to the context-dependent nature of experiences of patients and HCPs, TCs should be used with an individually customised approach based on patient and disease specifics, in which shared decision-making plays an extensive role. Before major implementation is considered, sufficient data on the safety regarding missed diagnoses or cancer recurrences should be assembled first.

The Dutch Yips Study: Results of a Survey Among Golfers.

Background: The yips in golf is currently regarded as a task-specific movement disorder, with variable phenomenology and of unclear etiology. There is some overlap with task-specific dystonia (TSD), which has also been reported in other sports. The objective was to further characterize the yips in terms of its prevalence and related factors. Methods: Recreational golfers from one of the larger golf clubs in the Netherlands aged 18 years or older, filled in an anonymous, web-based questionnaire with items on demographic, medical and lifestyle factors, specific yips-relevant items, as well as fanaticism, familial presence of yips, obsessive-compulsive traits, and a dystonia questionnaire. Results: In total, 234 golfers (26%) completed the questionnaire, among whom 52 (22%, 95% CI: 17-28%) reported to suffer from the yips. In comparison to their non-yips counterparts, the yips group was characterized by a larger proportion of men, more current or past smoking, better golf skills, longer history of playing golf, and more familial yips occurrence. Discussion: Golfer's self-reported yips may be very frequent in a group of responding amateur golfers and associated factors seems to include male gender, current or past smoking, extensive golf experience and skills, and a positive family history of the yips. Further work to better understand the origin and nature of the yips is needed.

Association between postoperative muscle wasting and survival in older patients undergoing surgery for non-metastatic colorectal cancer.

BACKGROUND: Preoperative sarcopenia in older patients is a risk factor for adverse outcomes after colorectal cancer (CRC) surgery. Longitudinal changes in muscle mass in this group have not been studied previously although muscle wasting may have prognostic significance regarding survival. We aimed to determine the association between muscle wasting and overall survival (OS) in older patients who underwent surgery for CRC. METHODS: Patients ≥70 years who underwent surgery for non-metastatic CRC in Gelre hospitals, The Netherlands, between 2011 and 2015 were included. Cross-sectional area of skeletal muscle was measured at the level of the 3rd lumbar vertebra on preoperative and postoperative abdominal CT-scans. Patients who had >1 standard deviation decrease in muscle mass were considered to have muscle wasting. Cox regression analysis was used to evaluate associations between muscle wasting and OS. RESULTS: 233 patients were included (40% female, median age 76 years). Thirty-four patients had muscle wasting. After a median follow-up of 4.7 years, 53 (23%) patients died. The 3-year mortality rate was higher in patients with muscle wasting (27% vs 14%, p = .05). In multivariable analysis adjusted for age, recurrent disease and preoperative muscle mass, muscle wasting was associated with reduced OS (HR 2.8, 95% CI 1.5-5.4, p = .002). CONCLUSION: Muscle wasting predicted poorer survival in older patients who underwent CRC surgery. Measuring changes in muscle mass may improve risk prediction in this patient group. Future studies should address the etiology of muscle wasting in older patients with CRC. Whether perioperative exercise interventions can prevent muscle wasting also warrants further study.

SURvival PRediction In SEverely Ill Patients Study-The Prediction of Survival in Critically Ill Patients by ICU Physicians.

The surprise question, "Would I be surprised if this patient died in the next 12 months?" is a tool to identify patients at high risk of death in the next year. Especially in the situation of an ICU admission, it is important to recognize patients who could and could not have the benefits of an intensive treatment in the ICU department. DESIGN AND SETTING: A single-center, prospective, observational cohort study was conducted between April 2013 and April 2018, in ICU Gelre hospitals, location Apeldoorn. PATIENTS: A total of 3,140 patients were included (57% male) with a mean age of 63.5 years. Seven-hundred thirteen patients (23%) died within 1 year. INTERVENTIONS: The physician answered three different surprise question's with either "yes" or "no": "I expect that the patient is going to survive the ICU admission" (surprise question 1), "I expect that the patient is going to survive the hospital stay" (surprise question 2), and "I expect that the patient is going to survive one year after ICU admission" (surprise question 3). We tested positive and negative predicted values of the surprise questions, the mean accuracy of the surprise questions, and kappa statistics. MEASUREMENTS AND MAIN RESULTS: The positive and negative predictive values of the surprise questions for ICU admission, hospital admission, and 1-year survival were, respectively, 64%/94%, 59%/92%, and 60%/86%. Accordingly, the mean accuracy and kappa statistics were 93% (95% CI, 92-94%), κ equals to 0.43, 89% (95% CI, 88-90%), κ equals to 0.40, and 81% (95% CI, 80-82%), κ equals to 0.43. CONCLUSIONS: The frequently overlooked simple and cheap surprise question is probably an useful tool to evaluate the prognosis of acutely admitted critically ill patients.

Effectiveness of Canal Occlusion for Intractable Posterior Canal Benign Paroxysmal Positional Vertigo: A Systematic Review.

OBJECTIVES: A last resort for therapy for intractable benign paroxysmal positional vertigo (BPPV) is mechanical occlusion of the posterior semicircular canal. The aim of this review was to assess the effect of posterior canal occlusion for intractable posterior canal BPPV on vertigo and to determine the risk of loss of auditory or vestibular function. DATA SOURCES: A systematic literature search according to the PRISMA statement was performed on PubMed, the Cochrane Library, Embase, Web of Science, and CINAHL. The last search was conducted in June 2018. REVIEW METHODS: Cohort studies with original data and case reports describing >5 cases were included if they analyzed the effect of posterior semicircular canal obliteration in adults with intractable posterior BPPV on vertigo. Two authors screened titles and abstracts for eligibility. The first author screened full texts and analyzed the data. RESULTS: Eight retrospective studies met the eligibility criteria. The quality of all individual studies was rated fair. Canal occlusion was performed on 196 patients. All studies reported complete resolution of BPPV in all patients (100%). Among postoperatively tested patients, total loss of auditory function and vestibular function was reported in 2 of 190 (1%) and 9 of 68 (13%), respectively. CONCLUSION: Posterior semicircular canal plugging resulted in 100% resolution of BPPV in patients with intractable BPPV in all studies. However, the strength of evidence was weak. Potential serious complications, such as deafness and loss of vestibular function, should be taken into account.

Smooth or attached solid indeterminate nodules detected at baseline CT screening in the NELSON study: cancer risk during 1 year of follow-up.

PURPOSE: To retrospectively determine whether baseline nodule characteristics at 3-month and 1-year volume doubling time (VDT) are predictive for lung cancer in solid indeterminate noncalcified nodules (NCNs) detected at baseline computed tomographic (CT) screening. MATERIALS AND METHODS: The study, conducted between April 2004 and May 2006, was institutional review board approved. Patient consent was waived for this retrospective evaluation. NCNs between 5 and 10 mm in diameter (n = 891) were evaluated at 3 months and 1 year to assess growth (VDT < 400 days). Baseline assessments were related to growth at 3 months and 1 year by using chi(2) and Mann-Whitney U tests. Baseline assessments and growth were related to the presence of malignancy by using univariate and multivariate logistic regression analyses. RESULTS: At 3 months and at 1 year, 8% and 1% of NCNs had grown, of which 15% and 50% were malignant, respectively. One-year growth was related to morphology (P < .01), margin (P < .0001), location (P < .001), and size (P < .01). All cancers were nonspherical and purely intraparenchymal, without attachment to vessels, the pleura, or fissures. In nonsmooth unattached nodules, a volume of 130 mm(3) or larger was the only predictor for malignancy (odds ratio, 6.3; 95% confidence interval [CI]: 1.7, 23.0). After the addition of information on the 3-month VDT, large volume (odds ratio, 4.9; 95% CI: 1.2, 20.1) and 3-month VDT (odds ratio, 15.6; 95% CI: 4.5, 53.5) helped predict malignancy. At 1 year, only the 1-year growth remained (odds ratio, 213.3; 95% CI: 18.7, 2430.9) as predictor for malignancy. CONCLUSION: In smooth or attached solid indeterminate NCNs, no malignancies were found at 1-year follow-up. In nonsmooth purely intraparenchymal NCNs, size is the main baseline predictor for malignancy. When follow-up data are available, growth is a strong predictor for malignancy, especially at 1-year follow-up.

Negative Predictive Value of Non-Echo-Planar Diffusion Weighted MR Imaging for the Detection of Residual Cholesteatoma Done at 9 Months After Primary Surgery Is not High Enough to Omit Second Look Surgery.

OBJECTIVES: To evaluate non echo-planar diffusion weighted magnetic resonance imaging (non-EP DW MRI) at 9 months after primary surgery to rule out residual cholesteatoma in patients scheduled before second-look-surgical exploration. STUDY DESIGN: Prospective observational study. SETTING: Secondary teaching hospital. PATIENTS/INTERVENTIONS: Patients who were scheduled for second-look-surgery after primary canal wall up repair of cholesteatoma underwent 1.5 T MRI including non-EP DWI and high-resolution coronal T1 and T2-FS SE sequences. MAIN OUTCOME MEASURES: Imaging studies were evaluated for the presence of cholesteatoma by three independent observers. Intraoperative observations were regarded the standard of reference. Ear, nose, throat (ENT) surgeons were blinded for imaging findings. The primary outcome was the negative predictive value (NPV) of MR imaging, secondary outcomes were sensitivity, specificity, and positive predictive value. RESULTS: Thirty-three patients underwent both MRI and surgery, among whom 22 had a cholesteatoma. Mean time between primary surgery and MRI was 259 days (standard deviation [SD] 108). NPV of non-EP DW MRI in detecting recurrent cholesteatoma was 53% (95% CI: 32-73%). Sensitivity and specificity were 59% (39-77%) and 91% (62-98%), respectively. The positive predictive value was 93% (69-99%). In five out of nine false-negative cases, recurrent cholesteatoma measured 3 mm or less. Using a 3 mm detection threshold, NPV increased to 79%. CONCLUSION: Non-EP DW MRI cannot replace second look surgery in ruling-out residual cholesteatoma at 9 months after primary surgery. It could be used in a follow-up strategy in low risk patients. Further research is needed which types of residual cholesteatoma are not revealed by MRI.

Physical and Emotional Burden of the Epley Maneuver in the Elderly.

OBJECTIVE: To analyze and compare experiences of anxiety and discomfort caused by the Epley maneuver and the willingness for a potential retreatment between younger (≤70 yr) and older (>70 yr) patients. STUDY DESIGN: Prospective, observational cohort study. SETTING: Tertiary referral center. METHODS: Dutch adults, diagnosed with posterior canal benign paroxysmal positional vertigo, were included. Patients with dementia or subjected to an Epley maneuver ≤4 months before the hospital visit were excluded. Patients were asked about their experiences with the Epley maneuver directly after the maneuver, after 2 weeks and after 2 months. Differences in experiences between the age groups were tested with the Fisher's exact test and subgroup analyses were performed using multivariable logistic regression. RESULTS: Out of 179 included patients, 115 (64%) were aged ≤70 and 134 (75%) were female. In both groups, 25% reported anxiety directly after the Epley maneuver. Two weeks later, 19 and 27%, respectively (p = 0.26) reported anxiety. In the young group, 30% expressed discomfort directly after treatment compared with 45% in the elderly (OR 1.98, 95% CI 1.05-3.75, p = 0.04). Two weeks later, this was 36 and 38%, respectively (p = 0.87). This decreased to 24 and 33%, respectively (p = 0.37), after 2 months. There was no significant difference in willingness for potential retreatment between both groups after 2 weeks (93 and 95%, respectively, p = 0.75) nor after 2 months (97 and 92%, respectively, p = 0.13). CONCLUSION: The Epley maneuver results in little anxiety and discomfort both in young and in elderly patients. Most patients show willingness for potential retreatment in case symptoms recur.