Search

Multicancer detection (MCD) tests use blood specimens to detect preclinical cancers. A major concern is overdiagnosis, the detection of preclinical cancer on screening that would not have developed into symptomatic cancer in the absence of screening. Because overdiagnosis can lead to unnecessary and harmful treatments, its quantification is important. A key metric is the screen overdiagnosis fraction (SOF), the probability of overdiagnosis at screen detection. Estimating SOF is notoriously difficult because overdiagnosis is not observed. This estimation is more challenging with MCD tests because short‐term results are needed as the technology is rapidly changing. To estimate average SOF for a program of yearly MCD tests, I introduce a novel method that requires at least two yearly MCD tests given to persons having a wide range of ages and applies only to cancers for which there is no conventional screening. The method assumes an exponential distribution for the sojourn time in an operational screen‐detectable preclinical cancer (OPC) state, defined as once screen‐detectable (positive screen and work‐up), always screen‐detectable. Because this assumption appears in only one term in the SOF formula, the results are robust to violations of the assumption. An SOF plot graphs average SOF versus mean sojourn time. With lung cancer screening data and synthetic data, SOF plots distinguished small from moderate levels of SOF. With its unique set of assumptions, the SOF plot would complement other modeling approaches for estimating SOF once sufficient short‐term observational data on MCD tests become available. [ABSTRACT FROM AUTHOR]

Summary This study addresses the diagnostic challenges of identifying lymphoedema in patients with lipoedema using lymphoscintigraphy. Overdiagnosis of lymphoedema in this patient population is frequent and may result in reduced proposed surgical interventions. We retrospectively analyzed clinical data from patients followed for lipoedema, lymphoedema or lipolymphoedema and who underwent lymphoscintigraphy. All patients were assigned a clinical or lymphoscintigraphic diagnosis of lymphoedema and concordance between clinical and lymphoscintigraphic diagnosis was assessed. A modification of lymphoscintigraphic criteria interpretation was proposed to enhance the diagnosis specificity. We included 94 female patients (188 lower limbs). One hundred and thirty‐seven limbs presented with signs of lipoedema (137/188; 72.9%) and 42 with clinical signs of lymphoedema (42/188; 22.3%). Overall, 125 limbs presented with a diagnosis of lymphoedema on lymphoscintigraphy (125/188; 66.5%). Using lymphoscintigraphy to diagnose lymphoedema in patients with lipoedema resulted in low specificity (38.3%). By adjusting the interpretation criteria of the lymphoscintigraphic anomalies, we could achieve a specificity of 80.85%, reducing the risk of overdiagnosing lymphoedema in patients with lipoedema. This study contributes to the ongoing efforts to optimize the assessment and management of patients with lipoedema and potential lymphatic involvement, by modifying the interpretation of lymphoscintigraphic criteria. [ABSTRACT FROM AUTHOR]

Objective: The Type 1 and 2 systemic lupus erythematosus (SLE) Model was developed to encapsulate all signs and symptoms that patients with SLE experience. Our previous qualitative work demonstrated the model accurately reflects the lived experience of people living with SLE. The objective of this study was to present the Type 1 and 2 SLE Model to rheumatologists to understand how the model fits with their experiences treating patients with SLE. Methods: We conducted a qualitative descriptive study using semistructured interviews with rheumatologists. Rheumatologists were asked about their general impression of the Type 1 and 2 SLE Model, how the model does or does not fit within their approach to treating patients with SLE, the utility of the model in clinical practice, and any suggested changes. Applied thematic analysis identified salient themes. Results: We interviewed 13 rheumatologists. The majority of rheumatologists approved of the model and found it useful to guide therapy and clinical decision‐making. Several rheumatologists thought the model was helpful for patient education to manage expectations about differences between Type 1 and Type 2 symptoms and treatments. A few rheumatologists expressed concern that the model could lead to an overdiagnosis of SLE. Conclusion: The Type 1 and 2 SLE Model was accepted by most rheumatologists interviewed and welcomed as a useful approach to identifying and treating symptoms in patients with SLE. Future studies will determine how implementing the Type 1 and 2 SLE Model affects patient understanding, the physician–patient relationship, and clinical outcomes. [ABSTRACT FROM AUTHOR]

ABSTRACT During the illustrious career of Martin C. Mihm Jr., MD, the diagnosis of melanoma underwent significant changes, to which he made many contributions. In early descriptions, melanomas were fungating tumor masses that were obviously malignant, and highly lethal. In seminal work by Dr. Mihm and his mentor, Wallace H. Clark, Jr., MD, the early phases of development of these neoplasms were recognized and distinguished from the more advanced disease. It was generally believed that the early stage of melanoma, termed radial growth phase (RGP) and characterized by absence of vertical growth phase (VGP) and by favorable microstaging attributes could be recognized, excised, and cured, thus preventing the development of advanced disease. However, strenuous efforts in this direction over several decades have resulted in little or no change in mortality, leading to the recognition that many of these neoplasms, at least, may not be true biological malignancies, and to the conclusion that overdiagnosis commonly occurs in this disease, which is defined as representing diagnosis as melanoma of a neoplasm that would not have had the capacity to cause death or symptoms in the lifetime of the host. Although there may be other subsets of neoplasms in this category, an important category of overdiagnosis in melanomas is concentrated in T1a melanomas that lack VGP. If these neoplasms can be recognized with sensitive and specific criteria, which may already be available, changes in terminology may be appropriate, recognizing that some of them may have low malignant potential, whereas others may have no capacity at all for metastasis and may not warrant the use of the term “melanoma.” [ABSTRACT FROM AUTHOR]

Class‐based perspectives on the persistent social gradients in health within modern welfare states largely focus on the adverse consequences of unfettered neoliberalism and entrenched meritocratic socioeconomic selection. Namely, neoliberal‐driven economic inequality has fuelled resentment and stress among lower‐status groups, while these groups have become more homogeneous with regard to health behaviours and outcomes. We synthesise several sociological and historical literatures to argue that, in addition to these class‐based explanations, socioeconomic inequality may contribute to persistent social gradients in health due to elite class self‐interest—in particular elites' preferences for overdiagnosis, overprescription and costly high‐technology medical treatments over disease prevention, and for increased tolerance for regulatory capture. We demonstrate that this self‐interest provides parsimonious explanations for several contemporary trends in U.S. health inequality including (A) supply‐side factors in drug‐related deaths, (B) longitudinal trends in the social gradients of obesity and chronic disease mortality and (C) the immigrant health advantage. We conclude that sociological theories of elite class self‐interest usefully complement theories of the psychosocial effects of neoliberalism and of meritocratic social selection while answering recent calls for research on the role advantaged groups play in generating inequalities in health, and for research that moves beyond technological determinism in health sociology. [ABSTRACT FROM AUTHOR]

Background: Cow's milk allergy (CMA) overdiagnosis appears to be increasing and is associated with excessive low‐allergy formula prescription. We evaluated recent trends and regional variation in low‐allergy formula prescribing for CMA in England, and assessed potential risk factors for higher prescribing rates. Methods: Data on national and regional prescribing of low‐allergy formulas were extracted from England's electronic prescription database using R. Region‐level factors were evaluated for potential associations with regional low‐allergy formula prescription rates using multivariate linear regression. Analysis of national prescribing trends covered 2007–2023, analysis of regional variation and region‐level factors examined 2017–2019, prior to a re‐organisation of the regional healthcare structure in England. Results: Low‐allergy formula prescribing increased from 6.1 to 23.3 L per birth nationally, between 2007 and 2023. Regional prescribing rate varied from 0.8 to 47.6 L per birth in 2017–2019. We found significant associations between regional low‐allergy formula prescribing rate and regional prescribing rates for milk feed thickeners Gaviscon Infant and Carobel Instant (β = 0.10, p < 0.01), and for other anti‐reflux medications used in young children (β = 0.89 p < 0.01). Inconsistent associations were seen with prescribing junior adrenaline auto‐injectors and oral antibiotics. A model including these four variables accounted for 37% of regional variation in low‐allergy formula prescribing rate. Region‐level socio‐economic deprivation, CMA guideline recommendations and paediatric allergy service provision were not associated with low‐allergy formula prescribing. Conclusions: Low‐allergy formula prescribing in England is increasing, varies significantly by region and is consistently associated with prescribing rates for milk feed thickeners and other anti‐reflux medication for young children. Community prescribing behaviours may be important determinants of CMA overdiagnosis. [ABSTRACT FROM AUTHOR]

The study by Dang and colleagues in this issue is a timely reminder of the need for careful consideration when it comes to the inclusion of putative new diagnoses in the diagnostic and statistical manual of mental disorders (DSM). The authors conclude that findings from their systematic review and meta‐analysis of recent literature bearing on the DSM‐5 other specified feeding and eating disorders (OSFED) category "support the conceptualization of atypical AN, PD and NES as clinically significant EDs with similar severity to full‐threshold EDs." This commentary attempts to provide some additional context, historical context in particular, that the author believes may be helpful when considering the potential implications of Dang and colleagues' findings. This is achieved through reference to the construct, well‐known in the sociology and feminist literature, of medicalization and by highlighting certain issues relevant to the determination of "clinical significance." I hope that readers approaching Dang and colleagues' research from the currently dominant, medical‐model perspective might be persuaded of the importance of considering alternative perspectives when interpreting findings from research of this kind. [ABSTRACT FROM AUTHOR]

Background: Diagnostic tests carry significant risks, and communications are needed to help lay people consider these. The development of communications has been hindered by poor knowledge about how lay people understand and negotiate testing risks. We examined lay Australians' perceptions of diagnostic testing risks and how these risks are managed. Method: We completed 12 semistructured online focus groups with 61 Australian adults (18+) between April and June 2022. Participants were divided into younger/older (> 50 years) and male/female groups. Using semistructured discussion and exploring two hypothetical scenarios, we examined attitudes to diagnostic tests, their risks and how test risks were managed. Themes were identified, subanalysed to identify age and gender differences and mapped to the COM‐B model of behaviour change. Results: The six themes provided detailed accounts of how participants considered themselves able, empowered and assertive when negotiating testing risks and of complex ways in which relationships with health workers, personal experiences and structural factors influenced negotiating testing risks. COM‐B identified multiple opportunities for leveraging these lay beliefs in health promotion. It also identified barriers, including narrow concepts of testing risks, challenges during shared decision‐making and overestimation of personal influence on testing decisions. Significance: Our findings matter because they are a novel, detailed account of testing risk beliefs, linked to a model for behaviour change. This will directly inform development of test risk/benefit communications, which are a research priority. Public Contribution: The study design enabled participants to influence the discussion agenda, and they could comment on the analysis. Participants contributed insights about their needs, beliefs and experiences related to medical testing, and these will be used to shape future patient‐centred decision tools. [ABSTRACT FROM AUTHOR]

Clinical practice guidelines aim to enhance the quality, equality and consistency of care but often demand more time than is available, rendering adherence impractical and exceeding feasible resources. The 2017 introduction of a new periodontal classification system by the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) sought to refine clinical and epidemiological practices by serving as the basis for clinical practice guidelines and epidemiological investigations around the world. Following this classification, the EFP recommends supportive periodontal care visits every 3–12 months for all periodontitis cases. Given that in Norway, approximately 72% of the adult population are identified as periodontitis cases under the current AAP/EFP case definition, this poses a significant demand on healthcare resources. We calculated that between 60% and 70% of all estimated available working hours available for adult dental care provided by dentists and dental hygienists in Norway in 2017 would be spent on supportive periodontal care visits alone if the recommendations were to be met. This situation calls for a reevaluation of disease definitions and clinical practice guidelines to ensure they are practical, financially feasible and patient‐outcome relevant. [ABSTRACT FROM AUTHOR]

Objective: To assess the added value of concurrent systematic randomised ultrasonography‐guided biopsy (SBx) to multiparametric magnetic resonance imaging (mpMRI)‐targeted biopsy and the additional rate of overdiagnosis of clinically insignificant prostate cancer (ciPCa) by SBx in a large contemporary, real‐world cohort. Patients and Methods: A total of 1552 patients with positive mpMRI and consecutive mpMRI‐targeted biopsy and SBx were enrolled. Added value and the rate of overdiagnosis by SBx was evaluated. Primary outcome: added value of SBx, defined as detection rate of clinically significant PCa (csPCa; International Society of Urological Pathology [ISUP] Grade ≥2) by SBx, while mpMRI‐targeted biopsy was negative or showed ciPCa (ISUP Grade 1). Secondary outcome: rate of overdiagnosis by SBx, defined as detection of ciPCa in patients with negative mpMRI‐targeted biopsy and PSA level of <10 ng/mL. Results: Detection rate of csPCa by mpMRI‐targeted biopsy and/or SBx was 753/1552 (49%). Added value of SBx was 145/944 (15%). Rate of overdiagnosis by SBx was 146/656 (22%). Added value of SBx did not change when comparing patients with previous prostate biopsy and biopsy naïve patients. In multivariable analysis, a Prostate Imaging‐Reporting and Data System (PI‐RADS) 4 index lesion (odds ratio [OR] 3.19, 95% confidence interval [CI] 1.66–6.78; P = 0.001), a PI‐RADS 5 index lesion (OR 2.89, 95% CI 1.39–6.46; P = 0.006) and age (OR 1.05, 95% CI 1.03–1.08; P < 0.001) were independently associated with added value of SBx. Conclusions: In our real‐world analysis, we saw a significant impact on added value and added rate of overdiagnosis by SBx. Subgroup analysis showed no significant decrease of added value in any evaluated risk group. Therefore, we do not endorse omitting concurrent SBx to mpMRI‐guided biopsy of the prostate. [ABSTRACT FROM AUTHOR]

Background: There are no reliable methods in clinical practice to diagnose adrenal insufficiency (AI) in patients with cirrhosis owing to variable cortisol‐binding protein levels. This leads to unreliable results in ACTH stimulated serum cortisol test. We aimed to estimate the long‐acting porcine (LA)ACTH‐stimulated serum and salivary cortisol levels of patients at different stages of cirrhosis using second generation electrochemiluminescence and to determine the prevalence of true adrenal insufficiency in these patients. Design, Patients and Measurements: We included 135 noncritical patients with cirrhosis (45 each from CHILD A, B and C) and 45 healthy controls. Serum and salivary samples were collected at baseline in the morning and at 1 and 2 h after LA‐ACTH injection. Results: In healthy subjects, the 2.5th centile of 2 h ACTH stimulated serum and salivary cortisol were 19.8 and 0.97 μg/dL, which were used as cut‐offs for defining AI based on serum and saliva respectively. The median (interquartile‐range) 2‐h stimulated salivary cortisol in Child A, B, C categories and controls were 1.36(1.23–2.38), 1.46(1.18–2.22), 1.72(1.2–2.2) and 2.12(1.42–2.72) μg/dL respectively. Six subjects (4.4%) were diagnosed to have AI based on stimulated salivary cortisol cut‐off, whereas 39 (28.9%) cirrhosis subjects had inadequately stimulated serum cortisol. Three patients (symptomatic) required steroid replacement therapy. Hypoalbuminemia was identified as a major risk factor for the misdiagnosis of adrenal insufficiency by serum cortisol‐based testing. Conclusions: Long‐acting porcine ACTH stimulated salivary cortisol reduces the overdiagnosis of adrenal insufficiency compared to serum cortisol in cirrhosis liver. Stimulated salivary cortisol is a promising investigation for evaluation of adrenal function in cirrhosis and more studies are required for its further validation before clinical use. [ABSTRACT FROM AUTHOR]

This document is a letter to the editor discussing patient and doctor observations regarding the reduction of unnecessary excisions and the early detection of melanomas. The letter presents a case study of a 55-year-old male with a history of melanoma and his experience with 3D total body photography and sequential digital dermoscopic imaging. The authors argue that longitudinal photographic surveillance can help reduce overdiagnosis of melanoma and facilitate the detection of evolving and de novo lesions. The letter emphasizes the importance of patient-doctor discussions and the value of anecdotal insights in refining the detection of melanoma. [Extracted from the article]

Background and Aims: Serum prolactin levels may be elevated by venepuncture stress. We investigated the utility of a rested prolactin sample, obtained through an indwelling venous cannula, in preventing the overdiagnosis of hyperprolactinaemia. Methods: Patients at our institution undergo serial prolactin sampling, usually over 40 min, when investigating hyperprolactinaemia. We retrospectively reviewed all serial prolactin sampling performed during a 3‐year period. Patients with possible medication‐induced hyperprolactinaemia and macroprolactin interference were excluded. We assessed the effect of venepuncture‐associated stress on hyperprolactinaemia with the main outcome being normalisation of serum prolactin at the end of serial sampling. Results: Ninety‐three patients with documented hyperprolactinaemia (range 360–1690 mU/L) were included in the analysis. Prolactin decreased during serial sampling in 73 patients (78%), suggesting a prevalent effect of venepuncture stress. The final prolactin sample was normal in 50 patients (54%), consistent with stress hyperprolactinaemia rather than pathological hyperprolactinaemia. Patients with a referral prolactin result greater than two times the upper reference limit (URL) were less likely (15%) to have a normal prolactin result on serial sampling. Measurement of a single rested prolactin sample from an indwelling cannula showed the same diagnostic utility as serial sampling. Conclusion: Serum prolactin results are frequently elevated by the stress of venepuncture. Confirmation of pathological hyperprolactinaemia in a rested sample obtained from an indwelling venous cannula is recommended in patients with mild hyperprolactinaemia, particularly when the referral prolactin is less than two times the URL. [ABSTRACT FROM AUTHOR]

Lung cancer has had one of the highest incidences and mortality in the world over the last few decades, which has aided in the promotion and popularization of screening for lung ground‐glass nodules (GGNs). People have great psychological anxiety about GGN because of the chance that it will develop into lung cancer, which makes clinical treatment of GGN a generally excessive phenomenon. Overdiagnosis in screening has recently been mentioned in the literature. An important research emphasis of screening is how to reduce the incidence of overdiagnosis and overtreatment. This paper discusses from different aspects how to characterize the occurrence of overdiagnosis and overtreatment, how to reduce overdiagnosis and overtreatment, and future screening, follow‐up, and treatment approaches. [ABSTRACT FROM AUTHOR]

Once a while, disease classifications have needed revision because new knowledge has accumulated, and new technologies and better treatments have emerged. Changes made to disease classifications should be trustworthy and openly justified. The periodontitis definition and classification system was changed in 2017 by the 'World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions'. The workshop, comprising clinicians and researchers, resulted in the production of a 23‐article special issue that introduced the new definitions and classifications of periodontitis. In this narrative review, we critically review how the changes made to the periodontitis definition and classification were justified in the light of the Checklist for Modifying Disease Definitions. Under each of the eight items of the checklist, we have discussed how the item was or could have been considered in the light of the checklist and its guidance. In our view, the new definition and classification of periodontitis was presented in an understandable way, even though the changes from the previous definition were not made visible. However, the issues of (1) estimated changes in prevalence or incidence, (2) triggers for the change, (3) prognostic ability, (4) repeatability or reproducibility, (5) incremental benefits, (6) incremental harms or (7) net benefits and harms related to the introduction of new classification were not considered in the way suggested in the checklist. Thereby, a balanced assessment of potential benefits and harms associated with the new periodontitis classification system was not presented, and to a large extent it remains unknown if the use of the new classification system will provide more net benefits to patients and to the community than previous systems. It is our view that patients and societies deserve transparent and balanced assessments of the potential benefits and harms associated with the periodontitis classification. Importantly, these should reflect the values and preferences also of the patients and the wider community and consider the impact on resource usage. [ABSTRACT FROM AUTHOR]

We used data from 13 cancer registries in China, Japan, and South Korea to analyze time trends in overdiagnosis of thyroid cancer between 1998 and 2012. Age‐standardized and age‐specific incidence and annual percentage changes were calculated. The number of thyroid cancers diagnosed and the proportion attributable to overdiagnosis were estimated, with calculations stratified by sex and age group. The Spearman method was used to analyze the correlation between thyroid cancer incidence and overdiagnosis. From 1998 to 2012, both the incidence and proportions of overdiagnoses of thyroid cancer in China, Japan, and South Korea showed an increasing trend, with higher rates in women than men. South Korea had both the highest incidence for men (10.1/105) and women (46.7/105) and the highest proportions of overdiagnosis (men, 90.3%; women, 94.9%). The fastest growth in overdiagnosis was in Chinese men and women (annual percentage changes 6.1 and 4.6, respectively). We found significant positive correlations between age‐standardized incidence and proportions of overdiagnosis for both men (Spearman r = 0.98, p < 0.05) and women (Spearman r = 0.99, p < 0.05) in the three countries. Age‐specific incidence curves in Chinese and South Korean individuals were of an inverted U‐shape. Overdiagnosis of thyroid cancer in Japan was mainly concentrated in middle‐aged and older patients, whereas in China and South Korea, it occurred primarily in the middle‐aged. The incidence and overdiagnosis of thyroid cancer in China, Japan, and South Korea are increasing, necessitating the implementation of comprehensive measures to reduce these overdiagnoses. [ABSTRACT FROM AUTHOR]

Rationale: Respiratory infections in children are one of the most common causes of hospital attendances and a common cause of sepsis. Most of these infections turn out to be viral in nature. However, the overuse of antibiotics is common and with increasing problems with antimicrobial resistance, changes to antibiotic prescribing practices need to be implemented urgently. Aims and Objectives: To test our hypothesis that a significant number of children and young people are diagnosed with and treated for 'chest sepsis' unnecessarily by evaluating adherence to British Thoracic Society and National Institute of Clinical Excellence sepsis guidelines, and to implement measures to prevent overdiagnosis. Design: A baseline audit undertaken, stratified patient risk as per NICE sepsis guidelines. Data were analysed to assess adherence to these guidelines following presentation of possible lower respiratory tract infection. Questionnaires were sent to Paediatric doctors in local hospitals and focus groups were held to qualitatively evaluate the barriers and facilitators to preventing overdiagnosis. These informed implemented measures. Results: The baseline audit showed 61% of children under two, who are more likely to have a viral chest infection were treated with intravenous antibiotics. Seventy‐seven percent of children had blood tests and 88% had chest X‐rays (CXRs) which are not routinely recommended. A total of 71% with a normal CXR had been treated with intravenous antibiotics. Barriers to preventing overdiagnosis included the over‐sensitivity of the sepsis tool, anxiety and drug prescribing habits. Facilitators included visual cues and team work. Implemented changes including a revised sepsis pathway and raising awareness led to some positive changes. However, upon re‐auditing there was no significant change in the number of children being overdiagnosed. Conclusions: Initial audit results supported our hypothesis that children were being overdiagnosed, over‐investigated and over‐treated. Despite multimodal interventions aimed at understanding the drivers underpinning these issues, the re‐audit results mirrored the baseline audit despite a transient improvement following our campaign to raise awareness and further work to change physician behaviour is required. [ABSTRACT FROM AUTHOR]

India is a low‐middle income country with a population of 1.4 billion and home to one quarter of the world's children. Exclusive breastfeeding until 6 months and continued breastfeeding until at least 2 years as per global recommendations are common practice. The Indian government and associated organisations have strived to protect breastfeeding, which is important in a country with high under‐5 mortality, malnutrition and stunting. Allergic disease is under‐recognised in India, but despite the absence of a dedicated allergy medical specialty, awareness of allergy is increasing among healthcare practitioners and in the general population. In high‐income countries, overdiagnosis of allergy has become recognised as an issue in recent years. Allergy healthcare professionals have also attracted criticism for close relationships with the formula industry, which appear to have contributed to excessive use of specialised formula products and undermining of breastfeeding. Specialised formula has been used unnecessarily for preventing allergy, based on fraudulent and selectively reported science; and for managing normal infant symptoms which are mislabelled as milk allergy. This forms part of a broader formula industry corporate strategy to widen the boundaries of illness in order to expand sales and markets. In India, allergic disease management is hindered by limited understanding of the disease entity among practitioners, low access to diagnostics, limited healthcare resources, high exposure to air pollution and a large, diverse population. Data specific to India on allergic disease prevalence and interpreting allergy diagnostics are incomplete. The knowledge gaps mean allergy management in India is often extrapolated from guidance developed in high‐income countries with low breastfeeding rates. As the allergy specialty develops in India, local guidance and practice will need to recognise the threat that current allergy practice poses to India's normative infant feeding culture, and ensure that breastfeeding continues to be supported at all levels. [ABSTRACT FROM AUTHOR]

Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is a fibroinflammatory disorder that affects multiple organs. The diagnosis of IgG4-RD is challenging due to the lack of a definitive test, and both underdiagnosis and overdiagnosis are common. To improve diagnostic accuracy, a comprehensive approach that considers clinical symptoms, radiologic findings, serologic results, and pathologic features is necessary. The 2019 American College of Rheumatology and European League Against Rheumatism (ACR/EULAR) classification criteria and the 2020 revised comprehensive diagnostic (2020 RCD) criteria provide valuable guidance for identifying and exploring the disease. It is important to be aware of the typical and atypical manifestations of IgG4-RD and to closely monitor the response to treatment. In difficult cases, a multidisciplinary discussion is recommended to avoid misdiagnosis. By following these strategies, the risk of misdiagnosis and overdiagnosis of IgG4-RD can be reduced. [Extracted from the article]

Aim: There is no international consensus for the screening and diagnosis of gestational diabetes mellitus (GDM). In March 2020, modified screening and diagnostic recommendations were rapidly implemented in Queensland, Australia, in response to the COVID‐19 pandemic. How clinicians perceived and used these changes can provide insights to support high‐quality clinical practice and provide lessons for future policy changes. The aim of this study was to understand clinicians' perceptions and use of COVID‐19 changes to GDM screening and diagnostic recommendations. Methods: Queensland healthcare professionals responsible for diagnosing or caring for women with GDM were recruited for semi‐structured telephone interviews. Data analysis of transcribed interviews used inductive reflexive thematic analysis. Results: Seventeen interviews were conducted with the following participants: six midwives/nurses, three endocrinologists, two general practitioners, two general practitioners/obstetricians, two diabetes educators, one dietitian and one obstetrician. Three themes emerged: communication and implementation, perceptions and value of evidence and diversity in perceptions of GDM screening. Overall, clinicians welcomed the rapid changes during the initial uncertainty of the pandemic, but as COVID‐19 became less of a threat to the Queensland healthcare system, some questioned the underlying evidence base. In areas where GDM was more prevalent, clinicians more frequently worried about missed diagnoses, whereas others who felt that overdiagnosis had occurred in the past continued to support the changes. Conclusions: These findings highlight the challenges to changing policy when clinicians have diverse (and often strongly held) views. [ABSTRACT FROM AUTHOR]

Rationale, Aims and Objectives: Medical decision‐making processes in primary care are influenced by defensive medical practice. This involves a high possibility for negative consequences on many levels, for example, patient's health, health care system costs and a crisis of trust in the patient−doctor relationship. Aim of this review was to identify factors of defensive medicine‐based decision‐making in primary care. Methods: This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for Scoping reviews (PRISMA‐ScR) guidelines and included systematic research on MEDLINE, Google Scholar and two German databases for additional grey literature. References provided further literature. Articles in English and German published from 1 January 1982 to 15 June 2022 were assessed. Results: From 911 publications screened, 13 publications [6 qualitative studies and 7 quantitative (3 cross‐sectional) studies] were included. In these, four main categories of factors influencing defensive medical practice were identified: (social) media, patients adopting a consumer attitude, health care system based working conditions and physician's tolerance for uncertainty. Pressure deriving from these four different sources is exerted on the general practitioner and may result in a defensive medical decision behaviour. Conclusions: Four categories on influencing factors of defensive medicine could be identified. Strategies to tolerate uncertainty should be trained in under‐ and postgraduate training. [ABSTRACT FROM AUTHOR]

Background: CT head is commonly performed in the setting of delirium and altered mental status (AMS), with variable yield. We aimed to evaluate the yield of CT head in hospitalized patients with delirium and/or AMS across a variety of clinical settings and identify factors associated with abnormal imaging. Methods: We included studies in adult hospitalized patients, admitted to the emergency department (ED) and inpatient medical unit (grouped together) or the intensive care unit (ICU). Patients had a diagnosis of delirium/AMS and underwent a CT head that was classified as abnormal or not. We searched Medline, Embase and other databases (informed by PRISMA guidelines) from inception until November 11, 2021. Studies that were exclusively performed in patients with trauma or a fall were excluded. A meta-analysis of proportions was performed; the pooled proportion of abnormal CTs was estimated using a random effects model. Heterogeneity was determined via the I² statistic. Factors associated with an abnormal CT head were summarized qualitatively. Results: Forty-six studies were included for analysis. The overall yield of CT head in the inpatient/ED was 13% (95% CI: 10.2%–15.9%) and in ICU was 17.4% (95% CI: 10%–26.3%), with considerable heterogeneity (I2 96% and 98% respectively). Heterogeneity was partly explained after accounting for study region, publication year, and representativeness of the target population. Yield of CT head diminished after year 2000 (19.8% vs. 11.1%) and varied widely depending on geographical region (8.4%–25.9%). The presence of focal neurological deficits was a consistent factor that increased yield. Conclusion: Use of CT head to diagnose the etiology of delirium and AMS varied widely and yield has declined. Guidelines and clinical decision support tools could increase the appropriate use of CT head in the diagnostic etiology of delirium/AMS. [ABSTRACT FROM AUTHOR]

Trends in specialized low-allergy infant formula dispensing in Ireland: 2016-2021 2 Abbreviations: AAF, amino acid-based formula; DPS, Drugs Payment Scheme; EHF, extensively hydrolysed formula; GMS, General Medical Services scheme; NR, not reported. This national database holds information on all publicly funded prescriptions under the General Medical Services scheme (GMS) and the Drugs Payment Scheme (DPS). Keywords: cow's milk protein allergy; overdiagnosis; paediatrics; pharmacoepidemiology EN cow's milk protein allergy overdiagnosis paediatrics pharmacoepidemiology 367 371 5 03/15/23 20230301 NES 230301 Key messages We evaluated extensively hydrolysed, amino-acid and soya formula prescriptions in databases covering ~10% Irish babies. [Extracted from the article]

Background: Many assays are available on cerebrospinal fluid (CSF) for the diagnosis of neurosyphilis (NS) but there is no 'gold standard'. Objectives: The aim of this study was to evaluate different molecular and serological assays used in NS. Methods: We evaluated two PCR assays and three serological techniques in parallel on CSF samples collected between 2019 and 2020 from patients suspected of NS. Results: The study included 143 patients comprising 30 early NS, 7 late NS and 106 patients without a diagnosis of NS. All patients with NS were symptomatic and had either neurological (67.6%) or ophthalmological signs (54.1%). The qPCR and nPCR assays had overall sensitivities (Se) of 41% and 27%, respectively; with each an overall specificity (Sp) of 100%. VDRL had a Se of 51% and a Sp of 92%. Immunoblot had a Se of 62% and a Sp of 85%. Finally, treponemal tests (TT) had a Se of 96% and a Sp of 69%. Conclusions: Our study confirms the excellent specificity of molecular techniques allowing to avoid overdiagnosis of NS, and thus, unjustified intensive antibiotic therapy protocols. CSF TT, although not very specific, has an excellent Se confirming that there is almost never NS with negative CSF TT. VDRL and immunoblot tests have better overall diagnostic performance. However, none of these techniques has sufficient diagnostic performance to represent a 'gold standard'. Thus, the diagnosis of NS relies on a combination of clinical and biological parameters with the association of PCR with serology, associating VDRL and immunoblot, in CSF. [ABSTRACT FROM AUTHOR]

Accurate pathological diagnosis is the cornerstone of optimal clinical management for patients with breast disease. As non‐operative diagnosis has now become the standard of care, histopathologists encounter the daily challenge of making definitive diagnoses on limited breast core needle biopsy (CNB) material. CNB samples are carefully evaluated using microscopic examination of haematoxylin and eosin (H&E)‐stained slides and supportive immunohistochemistry (IHC), providing the necessary information to inform the next steps in the patient care pathway. Some entities may be difficult to distinguish on small tissue samples, and if there is uncertainty a diagnostic excision biopsy should be recommended. This review discusses (1) benign breast lesions that may mimic malignancy, (2) malignant conditions that may be misinterpreted as benign, (3) malignant conditions that may be incorrectly diagnosed as primary breast carcinoma, and (4) some IHC pitfalls. The aim of the review is to raise awareness of potential pitfalls in the interpretation of breast lesions that may lead to underdiagnosis, overdiagnosis, or incorrect classification of malignancy with potential adverse outcomes for individual patients. [ABSTRACT FROM AUTHOR]

Background: Evidence exists that escalating melanoma incidence is due in part to overdiagnosis, the diagnosis of lesions that will not lead to symptoms or death. The authors aimed to characterize subsets of melanoma patients with very‐low risk of death that may be contributing to overdiagnosis. Methods: Melanoma patients diagnosed in 2010 and 2011 with stage I lesions ≤1.0 mm thick and negative clinical lymph nodes from the Surveillance, Epidemiology, and End Results database were selected. Classification and regression tree and logistic regression models were developed and validated to identify patients with very‐low risk of death from melanoma within 7 years. Logistic models were also used to identify patients at higher risk of death among this group of stage I patients. Results: Compared to an overall 7‐year mortality from melanoma of 2.5% in these patients, a subset comprising 25% had a risk below 1%. Younger age at diagnosis and Clark level II were associated with low risk of death in all models. Breslow thickness below 0.4 mm, absence of mitogenicity, absence of ulceration, and female sex were also associated with lower mortality. A small subset of high‐risk patients with >20% risk of death was also identified. Conclusion: Patients with very‐low risk of dying from melanoma within 7 years of diagnosis were identified. Such cases warrant further study and consensus discussion to develop classification criteria, with the potential to be categorized using an alternative term such as "melanocytic neoplasms of low malignant potential." Lay summary: Although melanoma is the most serious skin cancer, most melanoma patients have high chances of survival.There is evidence that some lesions diagnosed as melanoma would never have caused symptoms or death, a phenomenon known as overdiagnosis.In this study, we used cancer registry data to identify a subset of early‐stage melanoma patients with almost no melanoma deaths.Using two statistical approaches, we identified patients with <1% risk of dying from melanoma in 7 years.Such patients tended to be younger with minimal invasion into the skin.We also identified a very small patient subset with higher mortality risk. This Surveillance, Epidemiology, and End Results analysis identified subsets of stage I melanoma patients with <1% risk of death from melanoma within 7 years of diagnosis. Clark level II invasion and younger patient age were associated with lower risk of death from melanoma. [ABSTRACT FROM AUTHOR]

We aimed to explore the underlying reasons that estimates of overdiagnosis vary across and within low‐dose computed tomography (LDCT) lung cancer screening trials. We conducted a systematic review to identify estimates of overdiagnosis from randomised controlled trials of LDCT screening. We then analysed the association of Ps (the excess incidence of lung cancer as a proportion of screen‐detected cases) with postscreening follow‐up time using a linear random effects meta‐regression model. Separately, we analysed annual Ps estimates from the US National Lung Screening Trial (NLST) and German Lung Cancer Screening Intervention Trial (LUSI) using exponential decay models with asymptotes. We conducted stratified analyses to investigate participant characteristics associated with Ps using the extended follow‐up data from NLST. Among 12 overdiagnosis estimates from 8 trials, the postscreening follow‐up ranged from 3.8 to 9.3 years, and Ps ranged from −27.0% (ITALUNG, 8.3 years follow‐up) to 67.2% (DLCST, 5.0 years follow‐up). Across trials, 39.1% of the variation in Ps was explained by postscreening follow‐up time. The annual changes in Ps were −3.5% and −3.9% in the NLST and LUSI trials, respectively. Ps was predicted to plateau at 2.2% for NLST and 9.2% for LUSI with hypothetical infinite follow‐up. In NLST, Ps increased with age from −14.9% (55‐59 years) to 21.7% (70‐74 years), and time trends in Ps varied by histological type. The findings suggest that differences in postscreening follow‐up time partially explain variation in overdiagnosis estimates across lung cancer screening trials. Estimates of overdiagnosis should be interpreted in the context of postscreening follow‐up and population characteristics. [ABSTRACT FROM AUTHOR]

The article titled "Cover Image" in the journal Digestive Endoscopy discusses two cases that highlight the issue of overdiagnosis in preoperative endoscopic ultrasonography (EUS) diagnosis. The first case involves a 12 mm elevated lesion with depressions, while the second case involves a 70 mm subcircumferential elevated lesion with nodules. In both cases, EUS indicated a suspected clinical submucosal invasive cancer (cSM-Ca) in the preoperative diagnosis, but the histopathological diagnosis of resected specimens confirmed pathological intramucosal cancer, revealing a misdiagnosis in the preoperative prediction of invasion depth. This emphasizes the need for caution in interpreting EUS findings to avoid overdiagnosis. [Extracted from the article]

Background: There is significant overdiagnosis of milk allergy in young children in some countries, leading to unnecessary use of specialized formula. This guidance, developed by experts without commercial ties to the formula industry, aims to reduce milk allergy overdiagnosis and support carers of children with suspected milk allergy. Methods: Delphi study involving two rounds of anonymous consensus building and an open meeting between January and July 2021. Seventeen experts in general practice, nutrition, midwifery, health visiting, lactation support and relevant areas of paediatrics participated, located in Europe, North America, Middle East, Africa, Australia and Asia. Five authors of previous milk allergy guidelines and seven parents provided feedback. Findings: Participants agreed on 38 essential recommendations through consensus. Recommendations highlighted the importance of reproducibility and specificity for diagnosing milk allergy in children with acute or delayed symptoms temporally related to milk protein ingestion; and distinguished between children directly consuming milk protein and exclusively breastfed infants. Consensus was reached that maternal dietary restriction is not usually necessary to manage milk allergy, and that for exclusively breastfed infants with chronic symptoms, milk allergy diagnosis should only be considered in specific, rare circumstances. Consensus was reached that milk allergy diagnosis does not need to be considered for stool changes, aversive feeding or occasional spots of blood in stool, if there is no temporal relationship with milk protein ingestion. When compared with previous guidelines, these consensus recommendations resulted in more restrictive criteria for detecting milk allergy and a more limited role for maternal dietary exclusions and specialized formula. Interpretation: These new milk allergy recommendations from non‐conflicted, multidisciplinary experts advise narrower criteria, more prominent support for breastfeeding and less use of specialized formula, compared with current guidelines. [ABSTRACT FROM AUTHOR]

Purpose: To inform overprescribing and antibiotic stewardship in nursing homes (NHs), we examined the concordance between clinicians' (NH primary care providers and registered nurses) diagnosis of suspected UTI with a clinical guideline treated as the gold standard, and whether clinician characteristics were associated with diagnostic classification. Methods: We conducted a cross‐sectional web‐based survey of a U.S. national convenience sample of NH clinicians. The survey included a discrete choice experiment with 19 randomly selected clinical scenarios of NH residents with possible UTIs. For each scenario, participants were asked if they thought a UTI was likely. Responses were compared to the guideline to determine the sensitivity and specificity of clinician judgment and performance indicators. Multivariable logistic mixed effects regression analysis of demographic, work, personality, and UTI knowledge/attitudes characteristics was conducted. Results: One thousand seven hundred forty‐eight NH clinicians responded to 33,212 discrete choice scenarios; 867 (50%) were NH primary care providers and 881 (50%) were NH registered nurses, 39% were male, and the mean age was 45 years. Participants were uncertain about diagnosis in 30% of scenarios. Correct classification occurred for 66% of all scenarios (providers: 70%; nurses: 62%). Respondent judgment had a sensitivity of 78% (providers: 81%; nurses: 74%) and specificity of 54% (providers: 59%; nurses: 49%) compared to the clinical guideline. Adjusting for covariates in multivariable models, being a nurse and having higher closemindedness were associated higher odds of false positive UTI (odds ratio [OR] 1.61, p < 0.001; and OR 1.09, p = 0.039, respectively), although higher UTI knowledge and conscientiousness were associated with lower odds of false positive UTI ratings (OR 0.80, p < 0.001; OR 0.90, p = 0.005, respectively). Conclusions: Clinicians tend to over‐diagnose urinary tract infections, necessitating systems‐based interventions to augment clinical decision‐making. Clinician type, UTI knowledge, and personality traits may also influence behavior and deserve further study. [ABSTRACT FROM AUTHOR]

Medical overuse-defined as the provision of health services for which potential harms exceed potential benefits-constitutes a paradigm of low-value care and is seen as a threat to the quality of care. Value in healthcare implies a precise definition of disease. However, defining a disease may not be straightforward since clinical data do not show discrete boundaries, calling for some clinical judgment. And, if in time a redefinition of disease is needed, it is important to recognize that it can induce overdiagnosis, the identification of medical conditions that would, otherwise, never cause any significant symptoms or lead to clinical harm. A classic example is the impact of recommendations from professional societies in the late 1990s, lowering the threshold for abnormal total cholesterol from 240 mg/dl to 200 mg/dl. Due to these changes in risk factor definition, literally overnight there were 42 million new cases eligible for treatment in the United States. The same happened with hypertension-using either the 2019 NICE guidelines or the 2018 ESC/ECC guidelines criteria for arterial hypertension, the proportion of people overdiagnosed with hypertension was calculated to be between 14% and 33%. In this review, we will start by discussing resource overuse. We then present the basis for disease definition and its conceptual problems. Finally, we will discuss the impact of changing risk factor/disease definitions in the prevalence of disease and its consequences in overdiagnosis and overtreatment (a problem particularly relevant when definitions are widened to include earlier or milder disease). [ABSTRACT FROM AUTHOR]

Context: Prostate‐specific antigen (PSA) testing increases prostate cancer diagnoses and reduces long‐term disease‐specific mortality, but also results in overdiagnoses and treatment‐related harms. Objective: To systematically assess the benefits and harms of population‐based PSA screening and the potential net benefit to inform health policy decision‐makers in Germany. Evidence Acquisition: We performed a protocol‐guided comprehensive literature search according to the Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) statement. All steps were performed by one or two investigators; any discrepancies were resolved by consensus. To allow subgroup analyses for identifying the optimal screening parameters, the eight national trials conducted under the umbrella of the European Randomised study of Screening for Prostate Cancer (ERSPC) were included as individual trials. Evidence Synthesis: We included a total 11 randomised controlled trials (RCTs) with a total of 416 000 study participants. For all‐cause mortality, we found neither benefit nor harm. PSA screening was associated with a reduced risk of both prostate cancer mortality and the development of metastases. For the outcomes of health‐related quality of life, adverse effects and the consequences of false‐negative screening results there was no difference; however, this was due to the lack of eligible RCT data. Finally, PSA screening was associated with large numbers of overdiagnoses with adverse downstream consequences of unnecessary treatment (e.g. incontinence, erectile dysfunction) and large numbers of false‐positive PSA tests leading to biopsies associated with a small but not negligible risk of complications. Limitations of this assessment include the clinical heterogeneity and methodological limitations of the underlying studies. Conclusions: The benefits of PSA‐based prostate cancer screening do not outweigh its harms. We failed to identify eligible screening studies of newer biomarkers, PSA derivatives or modern imaging modalities, which may alter the balance of benefit to harm. Patient Summary: In the present study, we reviewed the evidence on the PSA blood test to screen men without symptoms for prostate cancer. We found that the small benefits experienced by some men do not outweigh the harms to many more men. [ABSTRACT FROM AUTHOR]

Aims: Fundic gland polyps (FGPs) arise sporadically and in combination with familial adenomatous polyposis (FAP). Criteria for distinguishing low-grade dysplasia (LGD) from regenerative atypia in FGPs are not well established. The aims of study were to determine: (i) interobserver variability in diagnosing LGD in FGPs; (ii) bias in diagnosing LGD in FAP patients; and (iii) stringent criteria for LGD in FGPs. Methods and results: Five senior pathologists who were blinded to the clinical history reviewed 72 FAPassociated FGPs and 34 sporadic FGPs. Cases were classified as negative (score = 0) or positive (score = 1) for LGD. Each case was assigned a 'combined dysplasia score' (CDS) ranging from 0 to 5 to reflect all five opinions. Fleiss' kappa showed only moderate interobserver agreement (j = 0.46). Fortyone FGPs were classified as negative for dysplasia by consensus (CDS = 0-1), including 10 (24%) originally diagnosed as LGD. In contrast, all 37 cases classified as LGD by consensus (CDS = 4-5) were originally diagnosed as LGD, indicating that overdiagnosis of dysplasia is more common than underdiagnosis (P = 0.0012). Cytological atypia in the surface epithelium and an abrupt transition between atypical and normal-appearing epithelium were the most sensitive (97% and 100%, respectively) and specific (100% and 98%, respectively) features of dysplasia (P < 0.0001 for both comparisons). Very good agreement was achieved when a diagnosis of dysplasia was based on the presence of both features (j = 0.85). Conclusions: There is high interobserver variability and a tendency to overdiagnose LGD in FGPs. Strict criteria requiring both surface atypia and abrupt transition for LGD in FGPs result in low interobserver variability. [ABSTRACT FROM AUTHOR]

Computed tomography (CT) revealed a 2.1-cm mass in the right adrenal gland with a low CT value (13 Hounsfield Units). Abbreviations ACTH adrenocortcotropic horome AHF Adreno-hepatic fusion CT Computed tomography CYP11B1 cytochrome P450 family 11 subfamily B member 1 CYP11B2 cytochrome P450 family 11 subfamily B member 2 DST dexamethasone suppression test HCC hepatocellular carcinoma PAC plasma aldosterone concentration SF-1 steroidgenic factor 1 Adreno-hepatic fusion (AHF) is defined as parenchymal adhesions between the liver and right adrenal gland. Moreover, as in the present case, ectopic bile ducts within the adrenal parenchyma sometimes showed cystic changes, and AHF-related intra-adrenal bile duct dilatation has been reported as a possible pathogenesis of right adrenal epithelial cysts.[3] We diagnosed the patient with adrenocortical adenoma arising from AHF. [Extracted from the article]

Sixty-three (90%) guidelines addressed CMA diagnosis, of which 43 (68%) reported separate criteria for non-IgE-mediated CMA, and 20 (32%) reported a single set of diagnostic criteria without discriminating non-IgE- and IgE-mediated CMA signs and symptoms. Keywords: breastfeeding; cow's milk allergy; guidelines; prescribing; primary care EN breastfeeding cow's milk allergy guidelines prescribing primary care 188 191 4 01/05/22 20220101 NES 220101 Key Messages In 2019, we identified 70 English primary care guidelines for milk allergy diagnosis and management. Milk allergy guidelines for infants in England promote over-diagnosis: A cross-sectional survey. [Extracted from the article]

Objectives: In 2010, WHO published guidelines emphasising parasitological confirmation of malaria before treatment. We present data on changes in fever case management in a low malaria transmission setting of northern Tanzania after 2010. Methods: We compared diagnoses, treatments and outcomes from two hospital‐based prospective cohort studies, Cohort 1 (2011–2014) and Cohort 2 (2016–2019), that enrolled febrile children and adults. All participants underwent quality‐assured malaria blood smear‐microscopy. Participants who were malaria smear‐microscopy negative but received a diagnosis of malaria or received an antimalarial were categorised as malaria over‐diagnosis and over‐treatment, respectively. Results: We analysed data from 2098 participants. The median (IQR) age was 27 (3–43) years and 1047 (50.0%) were female. Malaria was detected in 23 (2.3%) participants in Cohort 1 and 42 (3.8%) in Cohort 2 (p = 0.059). Malaria over‐diagnosis occurred in 334 (35.0%) participants in Cohort 1 and 190 (17.7%) in Cohort 2 (p < 0.001). Malaria over‐treatment occurred in 528 (55.1%) participants in Cohort 1 and 196 (18.3%) in Cohort 2 (p < 0.001). There were 30 (3.1%) deaths in Cohort 1 and 60 (5.4%) in Cohort 2 (p = 0.007). All deaths occurred among smear‐negative participants. Conclusion: We observed a substantial decline in malaria over‐diagnosis and over‐treatment among febrile inpatients in northern Tanzania between two time periods after 2010. Despite changes, some smear‐negative participants were still diagnosed and treated for malaria. Our results highlight the need for continued monitoring of fever case management across different malaria epidemiological settings in sub‐Saharan Africa. [ABSTRACT FROM AUTHOR]

We herein report three cases of mature teratomas with pineal gland differentiation, which is a less recognized phenomenon. Case 1 was a 6‐year‐old male with a neck mass, Case 2 was a 23‐year‐old female with a retroperitoneal mass, and Case 3 was a 45‐year‐old female with a retroperitoneal mass. Each case showed the typical macroscopic and histological findings of mature teratoma, such as solid and cystic lesions mainly lined with a mature squamous epithelium. All cases also showed glial differentiation. Small foci of lobulated cell nests were detected in the center of or adjacent to mature glial tissue. Cells had a clear to pale eosinophilic cytoplasm with small round nuclei. Immunohistochemically, cells were positive for synaptophysin, neurofilament protein with a perivascular "club‐shaped swelling" pattern, and cone‐rod homeobox protein. To the best of our knowledge, this is the first report of pineal gland differentiation arising in mature teratoma, which may be easily overlooked or misdiagnosed as somatic‐type tumors, particularly neuroendocrine tumors. To avoid overtreatment, pathologists need to be aware that pineal gland differentiation may occur in mature teratomas. [ABSTRACT FROM AUTHOR]

An excess risk of thyroid cancer has been reported in different World Trade Center (WTC)‐dust exposed cohorts. Increased surveillance of these cohorts has been suggested as a potential explanation of this reported excess thyroid cancer risk leading to an increased diagnosis of earlier‐stage thyroid cancers. However, the uncertainty to what extent surveillance or physician bias may be contributing to the reported incidence of thyroid cancer in WTC‐dust exposed populations remains, highlighting the need to investigate a potential causal link between WTC dust exposure and thyroid cancer. Future studies are therefore indicated to investigate potential consequences of WTC dust exposure on the thyroid gland. Studies of the heavily exposed populations offer the possibility to better understand the mechanisms behind the exposure to a variety of environmental contaminants, and may provide useful insights into exposures harmful to the thyroid. These can be used in risk stratification when implementing screening in high‐risk populations and may inform shared decision‐making regarding the extent of thyroid cancer treatment. [ABSTRACT FROM AUTHOR]

Overdiagnosis is a harmful consequence of screening which is particularly challenging to estimate. An unbiased setting to measure overdiagnosis in breast cancer screening requires comparative data from a screened and an unscreened cohort for at least 30 years. Such randomised data will not become available, leaving us with observational data over shorter time periods and outcomes of modelling. This collaborative effort of the International Cancer Screening Network quantified the variation in estimated breast cancer overdiagnosis in organised programmes with evaluation of both observed and simulated data, and presented examples of how modelling can provide additional insights. Reliable observational data, analysed with study design accounting for methodological pitfalls, and modelling studies with different approaches, indicate that overdiagnosis accounts for less than 10% of invasive breast cancer cases in a screening target population of women aged 50 to 69. Estimates above this level are likely to derive from inaccuracies in study design. The widely discrepant estimates of overdiagnosis reported from observational data could substantially be reduced by use of a cohort study design with at least 10 years of follow‐up after screening stops. In contexts where concomitant opportunistic screening or gradual implementation of screening occurs, and data on valid comparison groups are not readily available, modelling of screening intervention becomes an advantageous option to obtain reliable estimates of breast cancer overdiagnosis. What's new The detection of breast cancer before symptoms arise greatly increases the chance of prolonging survival or even curing malignancy. However, the assumption that asymptomatic disease progresses to symptomatic disease is a major factor in breast cancer overdiagnosis. While estimates of overdiagnosis vary substantially, the present analysis of observational data and data from modelling studies shows that overdiagnosis accounts for less than 10 percent of invasive breast cancer cases among women ages 50 to 69. The findings reaffirm the idea that observational studies require careful design to avoid methodological pitfalls and highlight the value of insight gained from well‐calibrated modelling studies. [ABSTRACT FROM AUTHOR]

Background and purpose: The aim of this study was to determine the frequency of over‐ and underdiagnosis of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and to identify related diagnostic pitfalls. Methods: We conducted a retrospective study in Dutch patients referred to the Erasmus University Medical Centre Rotterdam between 2011 and 2017 with either a diagnosis of CIDP or another diagnosis that was revised to CIDP. We used the European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) 2010 diagnostic criteria for CIDP to classify patients into three groups: overdiagnosis, underdiagnosis, or confirmed diagnosis of CIDP. Clinical and laboratory features and treatment history were compared between groups. Results: A referral diagnosis of CIDP was revised in 32% of patients (31/96; overdiagnosis). Of 81 patients diagnosed with CIDP, 16 (20%) were referred with another diagnosis (underdiagnosis). In the overdiagnosed patients, 20% of muscle weakness was asymmetric, 48% lacked proximal muscle weakness, 29% only had distal muscle weakness, 65% did not fulfil the electrodiagnostic criteria for CIDP, 74% had an elevated cerebrospinal fluid (CSF) protein level, and 97% had another type of neuropathy. In the underdiagnosed patients, all had proximal muscle weakness, 50% had a clinically atypical CIDP, all fulfilled the electrodiagnostic criteria for CIDP, and 25% had an increased CSF protein level. Conclusion: Over‐ and underdiagnosis of CIDP is common. Diagnostic pitfalls include lack of attention to proximal muscle weakness as a diagnostic hallmark of CIDP, insufficient recognition of clinical atypical phenotypes, overreliance on CSF protein levels, misinterpretation of nerve conduction studies and poor adherence to electrodiagnostic criteria, and failure to exclude other causes of polyneuropathy. [ABSTRACT FROM AUTHOR]

Summary: Low thyroid cancer mortality worldwide has not been altered by decades of increasing radiological, pathological and surgical intervention for thyroid nodules. Ultrasound‐based risk stratification of thyroid nodules, such as TIRADS, has been introduced to reduce intervention for the 'global epidemic' of thyroid cancer 'overdiagnosis'. This article illustrates the use of TIRADS at a New Zealand tertiary centre, during its introduction, with all nodules undergoing fine‐needle aspiration biopsy (FNAB) correlated with clinical referral priority and cytological Bethesda score. The correlation between TIRADS and Bethesda score was not significant but cytology had a strong association with clinical priority. Accuracy of TIRADS was poor though the risk of malignancy for TIRADS 5 nodules was 5.1 times those rated as TIRADS 3. After TIRADS was introduced, there was no significant trend in the proportion of malignant nodules diagnosed by FNAB. Despite an incomplete TIRADS programme, the ACR targets of malignancy rates were achieved. The number of patients, as well as the number of nodules per patient, referred for FNAB continues to rise. Changing papillary thyroid cancer nomenclature and other control measures by health policymakers, such as adjustments to payment systems, may be justified. Radiologists are wasting precious health resources that can be better deployed. The use of TIRADS is expensive and a symptom of health policy failure. Clear recommendations from professional societies to not report incidental small thyroid nodules may be a useful start. Whether TIRADS merits continuing use and promotion should be further investigated. [ABSTRACT FROM AUTHOR]

The diagnosis of junctional and lentiginous naevi on sun‐damaged skin of the head and neck in adults has been questioned in the literature, with the implication that these lesions should be classified as melanoma in situ. This could result in the overdiagnosis and overtreatment of non‐malignant lesions. We conducted a cross‐sectional study of the histopathological diagnosis of pigmented lesions biopsied from the head and neck of adults ≥40 years of age that were submitted to a large, Queensland‐based pathology centre over seven months. Out of 543 lesions assessed, 293 (54.0%) were flat and 250 (46.0%) were raised. Flat naevi consisted of junctional/lentiginous and compound naevi, either with or without dysplasia. Collectively, flat naevi had a prevalence slightly less than that of melanoma (15.0% versus 19.0% among flat lesions, respectively, and 8.1% versus 11.2% among all lesions, respectively). The mean age of biopsy for all junctional/lentiginous naevi was significantly greater than that of all compound naevi (65.0 years versus 52.2 years; P = 0.001). Junctional/lentiginous naevi were significantly more associated with the neck than intradermal naevi (P < 0.001). In conclusion, benign, flat naevi account for a significant proportion of head and neck lesions in adults ≥40 years of age, and their location alone should not outweigh their histopathology when reaching a diagnosis. [ABSTRACT FROM AUTHOR]

This document is a reply to a previous article by Adler et al. regarding the use of photographic surveillance in diagnosing melanoma. The authors address the concerns raised by Adler et al. and emphasize the need for controlled trials to determine the effectiveness of monitoring and imaging in melanoma diagnosis. They also discuss the differences in results between their study and others, highlighting the potential risks of delayed excision and the importance of early diagnosis. The authors argue that the use of shaves as a procedure for complete removal is widespread and supports early diagnosis. They also address concerns about histopathological overdiagnosis and the need for further research to determine the impact of imaging on metastasis and mortality. The article concludes by acknowledging the funding source and declaring no conflicts of interest. [Extracted from the article]

Background: Community awareness of the harms of overdiagnosis remains low. Objective: To evaluate community responses to a public health campaign designed for health service waiting rooms that focuses on the harms of unnecessary diagnostic imaging for low back pain. Methods: We conducted two focus groups of 19 community members with or without low back pain in Sydney, Australia. This study formed the fourth and final stage of the development process of a public health campaign: (a) initial design, (b) expert review and revision, (c) online experiment and (d) community views & revision. We evaluated reactions to components of the campaign that included digital posters and an information leaflet using strong imagery and messaging about the risk of overdiagnosis. We conducted a qualitative thematic analysis to identify main themes. Results: Community members reacted with surprise, initial mistrust, and occasionally anger towards imagery and messaging that suggested diagnostic imaging tests could be unnecessary and harmful. With further reflection and discussion, and after reading longer format information about overdiagnosis, the participants found some of the messages informative and useful. Participants appeared to gain a better understanding of the concept of overdiagnosis and the importance of not rushing to imaging. Conclusions: Public health campaigns including posters and leaflets displayed in waiting rooms could raise awareness about overuse of diagnostic imaging and the harms of overdiagnosis more broadly. However, negative reactions are possible and must be managed carefully. Patient or Public Contribution: We involved a community participation manager who provided advice on the focus group discussion guide, participant recruitment and manuscript presentation. [ABSTRACT FROM AUTHOR]

Interval cancers are cancers detected symptomatically between screens or after the last screen. A mathematical model for the development of interval cancers can provide useful information for evaluating cancer screening. In this regard a useful quantity is MIC, the mean duration in years of progressive preclinical cancer (PPC) that leads to interval cancers. Estimation of MIC involved extending a previous model to include three negative screens, invoking the multinomial‐Poisson transformation to avoid estimating background cancer trends, and varying screening test sensitivity. Simulations show that when the true MIC is 0.5, the method yields a reasonably narrow range of estimated MICs over the range of screening test sensitivities from 0.5 to 1.0. If the lower bound on the screening test sensitivity is 0.7, the method performs considerably better even for larger MICs. The application of the method involved annual lung cancer screening in the Prostate, Lung, Colorectal, and Ovarian trial. Assuming a normal distribution for PPC duration, the estimated MIC (95% confidence interval) ranged from 0.00 (0.00 to 0.34) at a screening test sensitivity of 1.0 to 0.54 (0.03, 1.00) at a screening test sensitivity of 0.5 Assuming an exponential distribution for PPC duration, which did not fit as well, the estimated MIC ranged from 0.27 (0.08, 0.49) at a screening test sensitivity of 0.5 to 0.73 (0.32, 1.26) at a screen test sensitivity of 1.0 Based on these results, investigators may wish to investigate more frequent lung cancer screening. [ABSTRACT FROM AUTHOR]

Background: There are reports of an increasing thyroid cancer mortality rate. This study aimed to analyze the latest trends in this rate over time and compare findings from different cancer registries. Methods: Thyroid cancer incidence‐based mortality (IBM) rates were obtained from the Surveillance, Epidemiology, and End Results (SEER) program, including SEER‐9, SEER‐13, and SEER‐18. The National Center for Health Statistics (NCHS) thyroid cancer mortality rate was acquired for comparison. Statistical analysis was performed using the JoinPoint software. Results: NCHS data revealed an overall annual percent change (APC) over 1987 to 2017 of 0.61 (P <.01), and the value was nearly four times greater for males compared to females. The overall IBM APC values for SEER‐9, SEER‐13, and SEER‐18 were also positive and statistically significant (P <.01). Conclusions: The increased thyroid cancer mortality rate observed in previous studies continues to be statistically significant based on updated NCHS and SEER IBM data. [ABSTRACT FROM AUTHOR]

Overdiagnosis is a major potential harm of lung cancer screening; knowing its potential magnitude helps to optimize screening eligibility criteria. The German Lung Screening Intervention Trial ("LUSI") is a randomized trial among 4052 long‐term smokers (2622 men), 50.3 to 71.9 years of age from the general population around Heidelberg, Germany, comparing five annual rounds of low‐dose computed tomography (n = 2029) with a control arm without intervention (n = 2023). After a median follow‐up of 9.77 years postrandomization and 5.73 years since last screening, 74 participants were diagnosed with lung cancer in the control arm and 90 in the screening arm: 69 during the active screening period; of which 63 screen‐detected and 6 interval cancers. The excess cumulative incidence in the screening arm (N = 16) represented 25.4% (95% confidence interval: −11.3, 64.3] of screen‐detected cancer cases (N = 63). Analyzed by histologic subtype, excess incidence in the screening arm appeared largely driven by adenocarcinomas. Statistical modeling yielded an estimated mean preclinical sojourn time (MPST) of 5.38 (4.76, 5.88) years and a screen‐test sensitivity of 81.6 (74.4%, 88.8%) for lung cancer overall, all histologic subtypes combined. Based on modeling, we further estimated that about 48% (47.5% [43.2%, 50.7%]) of screen‐detected tumors have a lead time ≥4 years, whereas about 33% (32.8% [28.4%, 36.1%]) have a lead time ≥6 years, 23% (22.6% [18.6%, 25.7%]) ≥8 years, 16% (15.6% [12.2%, 18.3%]) ≥10 years and 11% (10.7% [8.0%, 13.0%]) ≥12 years. The high proportions of tumors with relatively long lead times suggest a major risk of overdiagnosis for individuals with comparatively short remaining life expectancies. What's new? The reduced lung cancer mortality achieved through low‐dose computed tomography screening must be balanced against the risk of overdiagnosis. In this randomized screening trial with 5 annual screening rounds and a median post‐screening follow‐up of 5.73 years, excess lung cancer incidence represented 25.4% of the screen‐detected cases. The mean pre‐clinical sojourn time was 5.38 years. The probabilities for screen‐detected tumors to have remained asymptomatic for 4 and 12 years in the absence of screening were 48% and 11%, respectively. The findings suggest that individuals with short remaining lifetime are at high risk of being overdiagnosed by low‐dose computed tomography screening. [ABSTRACT FROM AUTHOR]

Background: Cow's milk allergy (CMA) overdiagnosis in young children appears to be increasing and has not been well characterised. We used a clinical trial population to characterise CMA overdiagnosis and identify individual-level and primary care practice-level risk factors., Methods: We analysed data from 1394 children born in England in 2014-2016 (BEEP trial, ISRCTN21528841). Participants underwent formal CMA diagnosis at ≤2 years. CMA overdiagnosis was defined in three separate ways: parent-reported milk reaction; primary care record of milk hypersensitivity symptoms; and primary care record of low-allergy formula prescription., Results: CMA was formally diagnosed in 19 (1.4%) participants. CMA overdiagnosis was common: 16.1% had parent-reported cow's milk hypersensitivity, 11.3% primary care recorded milk hypersensitivity and 8.7% had low-allergy formula prescription. Symptoms attributed to cow's milk hypersensitivity in participants without CMA were commonly gastrointestinal and reported from a median age of 49 days. Low-allergy formula prescriptions in participants without CMA lasted a median of 10 months (interquartile range 1, 16); the estimated volume consumed was a median of 272 litres (26, 448). Risk factors for CMA overdiagnosis were high practice-based low-allergy formula prescribing in the previous year and maternal report of antibiotic prescription during pregnancy. Exclusive formula feeding from birth was associated with increased low-allergy formula prescription. There was no evidence that practice prescribing of paediatric adrenaline auto-injectors or anti-reflux medications, or maternal features such as anxiety, age, parity and socioeconomic status were associated with CMA overdiagnosis., Conclusion: CMA overdiagnosis is common in early infancy. Risk factors include high primary care practice-based low-allergy formula prescribing and maternal report of antibiotic prescription during pregnancy., (© 2024 The Author(s). Allergy published by European Academy of Allergy and Clinical Immunology and John Wiley & Sons Ltd.)

The article reports that PoCUS found its place as an invaluable tool in a number of clinical scenarios as one, in helping guide the resuscitation of critically ill patients and determining underlying etiology and two, in supplementing clinical history and findings to help narrow a differential diagnosis; and three, to provide procedural guidance for common bedside procedures including vascular access, thoracentesis, lumbar puncture, and endotracheal intubation.