Magnetic Resonance Imaging and Multivariable Risk-stratification in Prostate Cancer Screening and Active Surveillance

Prostate cancer screening is controversial as it saves lives, but is also associated with the harms of unnecessary testing (i.e. prostate biopsies) and overdiagnosis of clinically insignificant prostate cancer. Within this thesis it is shown that the use of magnetic resonance imaging and multivariable risk-stratification can significantly reduce these harms of prostate cancer screening. Nowadays, men who are diagnosed with clinically insignificant prostate cancer are often followed-up according to a strict protocol (active surveillance) instead of receiving surgery or radiotherapy, thereby preventing or delaying potential side-effects of these treatments. However, the repeated prostate biopsies during follow-up on active surveillance are also considered burdening by patients. Within this thesis it is shown that the use of magnetic resonance imaging and risk-stratification can result in an improved selection of patients who are suitable for active surveillance and can safely reduce the number of follow-up biopsies during surveillance

Distribution of Prostate Imaging Reporting and Data System score and diagnostic accuracy of magnetic resonance imaging–targeted biopsy: comparison of an Asian and European cohort

Background: This study aimed to compare the distribution of Prostate Imaging Reporting and Data System (PI-RADS) score and the diagnostic accuracy of magnetic resonance imaging (MRI)–targeted biopsy and systematic biopsy between a Chinese and a Dutch cohort. Materials and methods: Our study includes 316 men from Shanghai Changhai Hospital, China, and 266 men from the Erasmus University Medical Center, Rotterdam, the Netherlands. All men had a suspicion for prostate cancer (PCa) and were offered an multiparametric MRI (mpMRI) scan. Results: The distribution of the PI-RADS score was different between the two cohorts (P = 0.008). In the Chinese cohort of PI-RADS ≥3, the detection rate for high-grade PCa (Gleason ≥7) was 37.3% by systematic biopsy and 35.5% by MRI-targeted biopsy. The sensitivity of systematic biopsy was 0.80 for PCa and 0.75 for high-grade PCa. MRI-targeted biopsy achieved slightly higher sensitivity for PCa (0.82) and high-grade PCa (0.76). In the Dutch cohort of PI-RADS ≥3, the high-grade PCa detection rate was 44.4% and 54.5% for systematic biopsy and MRI-targeted biopsy. The sensitivity of systematic biopsy was 0.93 for PCa and 0.81 for high-grade PCa. By MRI-targeted biopsy, the sensitivity was 0.85 for PCa and 0.97 for high-grade PCa. Conclusions: The distribution of the PI-RADS score was different with more PI-RADS 4/5 in the Chinese cohort. Applying a PI-RADS ≥3 cutoff resulted in a favorable overall sensitivity. MRI-targeted biopsy showed a higher sensitivity in the detection of high-grade PCa than systematic biopsy. The sensitivity of MRI-targeted biopsy and systematic biopsy for both PCa and high-grade PCa in the Dutch cohort was superior to those in the Chinese cohort

Prevention of postoperative delirium in elderly patients planned for elective surgery: systematic review and meta-analysis

Introduction: Vulnerable or “frail” patients are susceptible to the development of delirium when exposed to triggers such as surgical procedures. Once delirium occurs, interventions have little effect on severity or duration, emphasizing the importance of primary prevention. This review provides an overview of interventions to prevent postoperative delirium in elderly patients undergoing elective surgery. Methods: A literature search was conducted in March 2018. Randomized controlled trials (RCTs) and before-and-after studies on interventions with potential effects on postoperative delirium in elderly surgical patients were included. Acute admission, planned ICU admission, and cardiac patients were excluded. Full texts were reviewed, and quality was assessed by two independent reviewers. Primary outcome was the incidence of delirium. Secondary outcomes were severity and duration of delirium. Pooled risk ratios (RRs) were calculated for incidences of delirium where similar intervention techniques were used. Results: Thirty-one RCTs and four before-and-after studies were included for analysis. In 19 studies, intervention decreased the incidences of postoperative delirium. Severity was reduced in three out of nine studies which reported severity of delirium. Duration was reduced in three out of six studies. Pooled analysis showed a significant reduction in delirium incidence for dexmedetomidine treatment, and bispectral index (BIS)-guided anaesthesia. Based on sensitivity analyses, by leaving out studies with a high risk of bias, multicomponent interventions and antipsychotics can also significantly reduce the incidence of delirium. Conclusion: Multicomponent interventions, the use of antipsychotics, BIS-guidance, and dexmedetomidine treatment can successfully reduce the incidence of postoperative delirium in elderly patients undergoing elective, non-cardiac surgery. However, present studies are heterogeneous, and high-quality studies are scarce. Future studies should add these preventive methods to already existing multimodal and multidisciplinary interventions to tackle as many precipitating factors as possible, starting in the pre-admission period