Search

Climate change is leading to a rise in heat-related illnesses, vector-borne diseases, and numerous negative impacts on patients' physical and mental health outcomes. Concurrently, healthcare contributes about 4.6% of global greenhouse gas emissions. Low-value care, such as overtesting and overdiagnosis, contributes to unnecessary emissions. In this review, we describe diagnostic excellence in the context of climate change and focus on two topics. First, climate change is affecting health, leading to the emergence of certain diseases, some of which are new, while others are increasing in prevalence and/or becoming more widespread. These conditions will require timely and accurate diagnosis by clinicians who may not be used to diagnosing them. Second, diagnostic quality issues, such as overtesting and overdiagnosis, contribute to climate change through unnecessary emissions and waste and should be targeted for interventions. We also highlight implications for clinical practice, research, and policy. Our findings call for efforts to engage healthcare professionals and policymakers in understanding the urgent implications for diagnosis in the context of climate change and reducing global greenhouse gas emissions to enhance both patient and planetary outcomes. [ABSTRACT FROM AUTHOR]

ABSTRACT 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]

Background: Giant bullous emphysema is characterized by large bullae occupying at least one-third of the hemithorax and leading to compression of the surrounding lung parenchyma. Overdiagnosis can occur because of the atypical appearance of hyperplastic type II pneumocytes, which may be mistaken for malignant cells. Case presentation: A 48-year-old male with a history of smoking and occupational exposure presented with dyspnea and drowsiness. Initial chest X-ray revealed a tension pneumothorax, and subsequent chest CT revealed extensive bullous emphysema and lung cancer in the right middle lobe (RML). Pathologic examination initially indicated resected bullae to metastatic adenocarcinoma, but upon review, it was determined that the reactive alveolar cells were misdiagnosed as malignant. Conclusions: This case emphasizes the need for thorough histopathological assessment and prudent interpretation of atypical cellular morphology. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Methods Results Conclusions 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.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.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.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 incidence of prostate, breast, and thyroid cancers has increased in China over the past few decades. Whether and how much these increases can be attributed to overdiagnosis are less understood. This study aimed to estimate the proportion of overdiagnosis among these three cancers in China during 2004–2019. The age-specific cancer incidence, cancer mortality, and all-cause mortality in China were extracted from the Global Burden of Diseases 2019. The lifetime risk of developing and that of dying from each cancer were calculated using the life table method. The proportion of overdiagnosis of a cancer was estimated as the difference between the lifetime risk of developing the cancer and that of suffering from the cancer (including death, metastasis, and symptoms caused by the cancer), further divided by the lifetime risk of developing the cancer. The highest possible values of these parameters were adopted in the estimation so as to obtain the lower bounds of the proportions of overdiagnosis. Sensitivity analyses assuming different lag periods between the diagnosis of a cancer and death from the cancer were performed. The results showed that the lifetime risk of developing prostate, breast, and thyroid cancer increased dramatically from 2004 to 2019 in China, while the increase in the lifetime risk of dying from these cancers was less pronounced. The proportions of overdiagnosis among prostate, breast, and thyroid cancers were estimated to be 7.88%, 18.99%, and 24.92%, respectively, in 2004, and increased to 18.20%, 26.25%, and 29.24%, respectively, in 2019. The increasing trends were statistically significant for all three cancers (all p < 0.001). In sensitivity analyses, the proportions of overdiagnosis decreased, but upward trends over time remained for all three cancers. In conclusion, the overdiagnosis of prostate, breast, and thyroid cancers in China increased from 2004 to 2019, with the highest proportion seen in thyroid cancer and the most rapid increase seen in prostate cancer. Multifaceted efforts by policy makers, guideline developers, and clinicians are needed to tackle this problem. [ABSTRACT FROM AUTHOR]

Early detection of cancer is considered a cornerstone of preventive medicine and is widely perceived as the gateway to reducing cancer deaths. Based on this assumption, large trials are currently underway to evaluate the accuracy of early detection tests. It is imperative, therefore, to set meaningful "success criteria" in early detection that reflect true improvements in health outcomes. This article discusses the pitfalls of measuring the success of early detection tests for cancer, particularly in the context of screening programs, and provides illustrative examples that demonstrate how commonly used metrics can be deceptive. Early detection can result in downstaging (favourable stage shift) when more early-stage cancers are diagnosed, even without reducing late-stage disease, potentially leading to overdiagnosis and overtreatment. Survival statistics, primarily cancer-specific survival, can be misleading due to lead time, where early detection simply extends the known duration of the disease without prolonging actual lifespan or improving overall survival. Additionally, the misuse of relative measures, such as proportions, ratios, and percentages, often make it impossible to ascertain the true benefit of a procedure and can distort the impact of screening as they are influenced by diagnostic practices, misleadingly improving perceived mortality reductions. Understanding these biases is crucial for accurately assessing the effectiveness of cancer detection methods and ensuring appropriate patient care. [ABSTRACT FROM AUTHOR]

Early detection decreases deaths from breast cancer. Yet, there are conflicting recommendations about screening mammography by major professional medical organizations, including the age and frequency with which women should be screened. The controversy over breast cancer screening is centered on 3 main points: the impact on mortality, overdiagnosis, and false positive results. Some studies claim that adverse psychological effects such as anxiety or distress are caused by screening mammography. The purpose of this article is to address negative breast cancer screening concerns including overdiagnosis and overtreatment, effect on mortality, false positive results, mammography-related anxiety, and fear of radiation. [ABSTRACT FROM AUTHOR]

Background: Melanoma overdiagnosis occurs when melanomas, not destined to cause morbidity or death in a patient's lifetime, are identified and treated. Objective: This study considers the causes and magnitude of melanoma overdiagnosis in Australia. We also speculate about a possible benefit of overdiagnosis in Australia; namely, a reduction in excess deaths in the geographical areas where melanoma is diagnosed most frequently. Discussion: Overdiagnosis can arguably be mitigated by factors that reduce the number of lesions treated for each melanoma identified. Data from the Australian Cancer Atlas show that there is a reduction in excess deaths from melanoma in geographical areas where diagnostic rates are higher (Pearson correlation coefficient r=-0.5978, 95% CI: -0.6243 to -0.5699, P<0.0001); this being the strongest inverse correlation observed among the 20 cancer types in the Atlas. Is early diagnosis of actual life-threatening melanomas in these geographical regions impacting survival? Further research is planned. [ABSTRACT FROM AUTHOR]

Abstract Background Giant bullous emphysema is characterized by large bullae occupying at least one-third of the hemithorax and leading to compression of the surrounding lung parenchyma. Overdiagnosis can occur because of the atypical appearance of hyperplastic type II pneumocytes, which may be mistaken for malignant cells. Case presentation A 48-year-old male with a history of smoking and occupational exposure presented with dyspnea and drowsiness. Initial chest X-ray revealed a tension pneumothorax, and subsequent chest CT revealed extensive bullous emphysema and lung cancer in the right middle lobe (RML). Pathologic examination initially indicated resected bullae to metastatic adenocarcinoma, but upon review, it was determined that the reactive alveolar cells were misdiagnosed as malignant. Conclusions This case emphasizes the need for thorough histopathological assessment and prudent interpretation of atypical cellular morphology.

The incidence of prostate, breast, and thyroid cancers has increased in China over the past few decades. Whether and how much these increases can be attributed to overdiagnosis are less understood. This study aimed to estimate the proportion of overdiagnosis among these three cancers in China during 2004–2019. The age-specific cancer incidence, cancer mortality, and all-cause mortality in China were extracted from the Global Burden of Diseases 2019. The lifetime risk of developing and that of dying from each cancer were calculated using the life table method. The proportion of overdiagnosis of a cancer was estimated as the difference between the lifetime risk of developing the cancer and that of suffering from the cancer (including death, metastasis, and symptoms caused by the cancer), further divided by the lifetime risk of developing the cancer. The highest possible values of these parameters were adopted in the estimation so as to obtain the lower bounds of the proportions of overdiagnosis. Sensitivity analyses assuming different lag periods between the diagnosis of a cancer and death from the cancer were performed. The results showed that the lifetime risk of developing prostate, breast, and thyroid cancer increased dramatically from 2004 to 2019 in China, while the increase in the lifetime risk of dying from these cancers was less pronounced. The proportions of overdiagnosis among prostate, breast, and thyroid cancers were estimated to be 7.88%, 18.99%, and 24.92%, respectively, in 2004, and increased to 18.20%, 26.25%, and 29.24%, respectively, in 2019. The increasing trends were statistically significant for all three cancers (all p < 0.001). In sensitivity analyses, the proportions of overdiagnosis decreased, but upward trends over time remained for all three cancers. In conclusion, the overdiagnosis of prostate, breast, and thyroid cancers in China increased from 2004 to 2019, with the highest proportion seen in thyroid cancer and the most rapid increase seen in prostate cancer. Multifaceted efforts by policy makers, guideline developers, and clinicians are needed to tackle this problem.

Early detection of cancer is considered a cornerstone of preventive medicine and is widely perceived as the gateway to reducing cancer deaths. Based on this assumption, large trials are currently underway to evaluate the accuracy of early detection tests. It is imperative, therefore, to set meaningful “success criteria” in early detection that reflect true improvements in health outcomes. This article discusses the pitfalls of measuring the success of early detection tests for cancer, particularly in the context of screening programs, and provides illustrative examples that demonstrate how commonly used metrics can be deceptive. Early detection can result in downstaging (favourable stage shift) when more early-stage cancers are diagnosed, even without reducing late-stage disease, potentially leading to overdiagnosis and overtreatment. Survival statistics, primarily cancer-specific survival, can be misleading due to lead time, where early detection simply extends the known duration of the disease without prolonging actual lifespan or improving overall survival. Additionally, the misuse of relative measures, such as proportions, ratios, and percentages, often make it impossible to ascertain the true benefit of a procedure and can distort the impact of screening as they are influenced by diagnostic practices, misleadingly improving perceived mortality reductions. Understanding these biases is crucial for accurately assessing the effectiveness of cancer detection methods and ensuring appropriate patient care.

Exposure to ionizing radiation, especially during childhood, is a well-established risk factor for thyroid cancer. Following the 1986 Chernobyl nuclear power plant accident the total number of cases of thyroid cancer registered between 1991 and 2015 in males and females who were less than 18 years old exceeded 19,000 (in Belarus and Ukraine, and in the most contaminated oblasts of the Russian Federation). However, as indicated by the United Nations Scientific Committee on the Effects of Atomic Radiation the fraction of the incidence of thyroid cancer attributable to radiation exposure among the non-evacuated residents of the contaminated regions of Belarus, Ukraine and Russia is of the order of 0.25. Apparently, the increased registration of thyroid neoplasms in the parts of these countries is a classical ‘screening effect’, i.e., massive diagnostic examinations of the risk-aware populations performed with modern eqipment resulting in detection of many occult neoplasms (incidentalomas). Moreover, one type of thyroid cancer previously called ‘encapsulated follicular variant of papillary thyroid carcinoma’ is non-invasive and instead of ‘carcinoma’ should now be recognized as ‘noninvasive follicular thyroid neoplasm with papillary-like nuclear features.’ Other potential causes of overdiagnosing of thyroid tumors include increase of the spontaneous incidence rate of this disease with age, iodine deficiency among children from Belarus, Russia and Ukraine, and/or consumption by these children of drinking water containing high levels of nitrates that likely coincides with the carcinogenic effect of radiation on the thyroid gland.

Abstract Background With the increasing prevalence of nonsmoking-related lung cancer in Asia, Asian countries have increasingly adopted low-dose computed tomography (LDCT) for lung cancer screening, particularly in private screening programs. This study examined how annual LDCT volume affects lung cancer stage distribution, overdiagnosis, and gender disparities using a hospital-based lung cancer database. Methods This study analyzed the annual utilized LDCT volume, clinical characteristics of lung cancer, stage shift distribution, and potential overdiagnosis. At the individual level, this study also investigated the relationship between stage 0 lung cancer (potential strict definition regarding overdiagnosis) and the clinical characteristics of lung cancer. Results This study reviewed the annual trend of 4971 confirmed lung cancer cases from 2008 to 2021 and conducted a link analysis with an LDCT imaging examination database over these years. As the volume of lung cancer screenings has increased over the years, the number and proportion of stage 0 lung cancers have increased proportionally. Our study revealed that the incidence of stage 0 lung cancer increased with increasing LDCT scan volume, particularly during the peak growth period from 2017 to 2020. Conversely, stage 4 lung cancer cases remained consistent across different time intervals. Furthermore, the increase in the lung cancer screening volume had a more pronounced effect on the increase in stage 0 lung cancer cases among females than it had among males. The estimated potential for overdiagnosis brought about by the screening process, compared to non-participating individuals, ranged from an odds ratio of 7.617 to one of 17.114. Both strict and lenient definitions of overdiagnosis (evaluating cases of stage 0 lung cancer and stages 0 to 1 lung cancer) were employed. Conclusions These results provide population-level evidence of potential lung cancer overdiagnosis in the Taiwanese population due to the growing use of LDCT screening, particularly concerning the strict definition of stage 0 lung cancer. The impact was greater in the female population than in the male population, especially among females younger than 40 years. To improve lung cancer screening in Asian populations, creating risk-based prediction models for smokers and nonsmokers, along with gender-specific strategies, is vital for ensuring survival benefits and minimizing overdiagnosis.

PURPOSE: Indolent prostate cancer (PCa) is prevalent in the intended use population (adults age 50-79 years) for blood-based multicancer early detection (MCED) tests. We examined the detectability of PCa by a clinically validated, targeted methylation–based MCED test. METHODS: Detectability by Gleason grade group (GG), clinical stage, association of detection status with tumor methylated fraction (TMeF), and overall survival (OS) were assessed in substudy 3 of Circulating Cell-Free Genome Atlas (CCGA; ClinicalTrials.gov identifier: NCT02889978) and PATHFINDER (ClinicalTrials.gov identifier: NCT04241796) studies. RESULTS: Test sensitivity for PCa in substudy 3 of CCGA was 11.2% (47/420). The test detected 0 (0%) of 58 low-grade (GG1), 3 (1.9%) of 157 favorable intermediate-grade (GG2), 4 (5.1%) of 78 unfavorable intermediate-grade (GG3), and 36 (31.9%) of 113 high-grade (GG4 and 5) cancers and 3 (3.2%) of 95 stage I, 11 (4.7%) of 235 stage II, 7 (14.9%) of 47 stage III, and 22 (81.5%) of 27 stage IV cases. The median TMeF was higher for detected than nondetected cases (2,106.0 parts per million [PPM]; IQR, 349.8-24,376.3 v 24.4 PPM; IQR, 17.8-38.5; P <.05). Nondetected cases had better OS (P <.05; hazard ratio [HR], 0.263 [95% CI, 0.104 to 0.533]) and detected cases had similar survival (P =.2; HR, 0.672 [95% CI, 0.323 to 1.21]) compared with SEER adjusted for age, GG, and stage. Performance was similar in PATHFINDER, with no detected GG1/2 (0/13) or stage I/II (0/16) cases. CONCLUSION: This MCED test preferentially detects high-grade, clinically significant PCa. Use in population-based screening programs in addition to standard-of-care screening is unlikely to exacerbate overdiagnosis of indolent PCa. GRAIL's Galleri test preferentially detects more deadly prostate cancer over indolent cases [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]

Objectives GCA can be confirmed by temporal artery biopsy (TAB) but false negatives can occur. GCA may be overdiagnosed in TAB-negative cases, or if neither TAB nor imaging is done. We used HLA genetic association of TAB-positive GCA as an 'unbiased umpire' test to estimate historic overdiagnosis of GCA. Methods Patients diagnosed with GCA between 1990 and 2014 were genotyped. During this era, vascular imaging alone was rarely used to diagnose GCA. HLA region variants were jointly imputed from genome-wide genotypic data of cases and controls. Per-allele frequencies across all HLA variants with P  < 1.0 × 10−5 were compared with population control data to estimate overdiagnosis rates in cases without a positive TAB. Results Genetic data from 663 GCA patients were compared with data from 2619 population controls. TAB-negative GCA (n  = 147) and GCA without TAB result (n  = 160) had variant frequencies intermediate between TAB-positive GCA (n  = 356) and population controls. For example, the allele frequency of HLA-DRB1*04 was 32% for TAB-positive GCA, 29% for GCA without TAB result, 27% for TAB-negative GCA and 20% in population controls. Making several strong assumptions, we estimated that around two-thirds of TAB-negative cases and one-third of cases without TAB result may have been overdiagnosed. From these data, TAB sensitivity is estimated as 88%. Conclusions Conservatively assuming 95% specificity, TAB has a negative likelihood ratio of around 0.12. Our method for utilizing standard genotyping data as an 'unbiased umpire' might be used as a way of comparing the accuracy of different diagnostic pathways. [ABSTRACT FROM AUTHOR]

Background To assess the amount of breast cancer overdiagnosis associated with the National Health Service Breast Screening Programme (NHSBSP) that started in 1988 in England. Methods First, numbers of breast cancers in women eligible for breast screening not attending screening were estimated for the period 1995–2019, which were extrapolated to all women. A second method was based on ratios of incidence rates of breast cancers in women aged 50–69 to women aged 70 years or more in 1971–1985. The ratio was used for estimating expected numbers of cancers in 1988–2019, and 1995–2019. Results From 1995 to 2019, 506,607 non-invasive and invasive breast cancers were diagnosed among women aged 50–64 years (1995–2001) and 50–70 years (2002–2019). A first method estimated that 95,297 cancers were in excess to the number of cancers that would be expected had the NHSBSP not existed. 42,567 screen-detected non-invasive and micro-invasive cancers represented 45.8% of the total excess cancer. 18.8% of all cancers diagnosed among women invited to screening, 25.1% of cancers found in women attending screening, and 35.1% of cancers detected by screening would represent overdiagnosis. A second method estimated that, 18.0% of all cancers diagnosed in 1988–2019, and 18.2% of all cancers diagnosed in 1995–2019 among women invited to screening would represent overdiagnosis. Conclusion The two independent methods obtained similar estimates of overdiagnosis. The NHS Breast Screening Programme in England is associated with substantial amount of overdiagnosis. [ABSTRACT FROM AUTHOR]

Background The recommendation for the implementation of mammography screening in women aged 45–49 and 70–74 is conditional with moderate certainty of the evidence. The aim of this study is to simulate the long-term outcomes (2020–50) of using different age range scenarios in the breast cancer screening programme of the Valencia Region (Spain), considering different programme participation rates. Methods Three age range scenarios (S) were simulated with the EU-TOPIA tool, considering a biennial screening interval: S1, 45–69 years old (y); S2, 50–69 y and S3, 45–74 y. Simulations were performed for four participation rates: A = current participation (72.7%), B = +5%, C = +10% and D = +20%. Considered benefits: number (N°) of in situ and invasive breast cancers (BC) (screen vs. clinically detected), N° of BC deaths and % BC mortality reduction. Considered harms: N° of false positives (FP) and % overdiagnosis. Results The results showed that BC mortality decreased in all scenarios, being higher in S3A (32.2%) than S1A (30.6%) and S2A (27.9%). Harms decreased in S2A vs. S1A (N° FP: 236 vs. 423, overdiagnosis: 4.9% vs. 5.0%) but also benefits (BC mortality reduction: 27.9% vs. 30.6%, N° screen-detected invasive BC 15/28 vs. 18/25). In S3A vs. S1A, an increase in benefits was observed (BC mortality reduction: 32.2% vs. 30.6%), N° screen-detected in situ B: 5/2 vs. 4/3), but also in harms (N° FP: 460 vs. 423, overdiagnosis: 5.8% vs. 5.0%). Similar trends were observed with increased participation. Conclusions As the age range increases, so does not only the reduction in BC mortality, but also the probability of FP and overdiagnosis. [ABSTRACT FROM AUTHOR]

Inflammatory arthritis may be the principal feature or one component of an inflammatory rheumatological disease. It is a clinical diagnosis, principally made based on the patient’s history and examination. Specific investigations, such as rheumatoid factor and human leucocyte antigen B27 gene, may support the diagnosis in the context of a suggestive clinical presentation, but a diagnosis cannot be made based on these tests alone because positive results may also be seen in healthy individuals. To reduce the likelihood of false positive results, laboratory and radiological investigations should be tailored to the suspected diagnosis based on pretest probability. While musculoskeletal symptoms are a common presentation in general practice, specific features that increase suspicion of an inflammatory arthritis include prolonged morning stiffness (more than 1 hour) that is improved by exercise or movement. A broad ‘rheumatological panel’ increases the likelihood of false positive results and should be avoided to prevent unnecessary further investigations and treatment, and unwarranted anxiety in both the patient and the doctor. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Urinary tract infections (UTIs) are common, but overdiagnosed, in children with spina bifida. We sought to evaluate the diagnostic test characteristics of urinalysis (UA) findings for symptomatic UTI in children with spina bifida. METHODS: Retrospective cross-sectional study using data from 2 centers from January 1, 2016, to December 31, 2021. Children with myelomeningocele aged <19 years who had paired UA (and microscopy, when available) and urine culture were included. The primary outcome was symptomatic UTI. We used generalized estimating equations to control for multiple encounters per child and calculated area under the receiver operating characteristics curve, sensitivity, and specificity for positive nitrites, pyuria ($10 white blood cells/high-powered field), and leukocyte esterase (more than trace) for a symptomatic UTI. RESULTS: We included 974 encounters from 319 unique children, of which 120 (12.3%) met our criteria for UTI. Pyuria had the highest sensitivity while nitrites were the most specific. Comparatively, nitrites were the least sensitive and pyuria was the least specific. When the cohort was limited to children with symptoms of a UTI, pyuria remained the most sensitive parameter, whereas nitrites remained the least sensitive. Nitrites continued to be the most specific, whereas pyuria was the least specific. Among all encounters, the overall area under the receiver operating characteristics curve for all components of the UA was lower in children who use clean intermittent catheterizations compared with all others. CONCLUSIONS: Individual UA findings have moderate sensitivity (leukocyte esterase or pyuria) or specificity (nitrites) but overall poor diagnostic accuracy for symptomatic UTIs in children with spina bifida. [ABSTRACT FROM AUTHOR]

Background: Thyroid cancer incidence has increased globally in recent decades, especially in females, although its trends in Taiwan have not been studied extensively. This study aimed to investigate changes in female incidence and possible causes of thyroid cancer in Taiwan. Methods: Using the Taiwan Cancer Registry (TCR) Database, age-standardized incidence rates, age-specific incidence rates and birth cohorts were calculated. Correlation between female thyroid cancer incidence and cohort fertility rates were examined. Results: Thyroid cancer incidence increased in Taiwanese female, with age-adjusted rates per 100,000 people increasing from 7.37 during 1995–1999 to 20.53 during 2015–2019; the annual percentage change (APC) was 5.9% (95% CI, 5.3–6.5). Age-specific incidence rates increased with age, with peak rates occurring at younger ages. The APCs in the 50–54 age group were the highest (6.8%, 95% CI, 6.1–7.5). Incidence rates also increased with later birth cohorts. We observed a significant negative correlation between thyroid cancer incidence and fertility rates in the same birth cohort. Conclusions: We hypothesize that overdiagnosis may be a main reason for the rapidly increasing thyroid cancer incidence in Taiwanese females. Notably, we observed a strong negative correlation between fertility and thyroid cancer incidence. However, our study is limited by the absence of individual-level cancer data in the TCR database. These associations with fertility will be an important subject for future thyroid cancer research. [ABSTRACT FROM AUTHOR]

Overdiagnosis is the concept that some cancers detected at screening would never have become clinically apparent during a woman's lifetime in the absence of screening. This could occur if a woman dies of a cause other than breast cancer in the interval between mammographic detection and clinical detection (obligate overdiagnosis) or if a mammographically detected breast cancer fails to progress to clinical presentation. Overdiagnosis cannot be measured directly. Indirect methods of estimating overdiagnosis include use of data from randomized controlled trials (RCTs) designed to evaluate breast cancer mortality, population-based screening studies, or modeling. In each case, estimates of overdiagnosis must consider lead time, breast cancer incidence trends in the absence of screening, and accurate and predictable rates of tumor progression. Failure to do so has led to widely varying estimates of overdiagnosis. The U.S. Preventive Services Task Force (USPSTF) considers overdiagnosis a major harm of mammography screening. Their 2024 report estimated overdiagnosis using summary evaluations of 3 RCTs that did not provide screening to their control groups at the end of the screening period, along with Cancer Intervention and Surveillance Network modeling. However, there are major flaws in their evidence sources and modeling estimates, limiting the USPSTF assessment. The most plausible estimates remain those based on observational studies that suggest overdiagnosis in breast cancer screening is 10% or less and can be attributed primarily to obligate overdiagnosis and nonprogressive ductal carcinoma in situ. [ABSTRACT FROM AUTHOR]

Background: The stages of chronic kidney disease (CKD) and estimated glomerular filtration rate (eGFR) reference ranges are currently determined without considering age. Aim: To determine whether a chart that graphs age with eGFR helps GPs make better decisions about managing patients with declining eGFR. Design & setting: A randomised controlled vignette study among Australian GPs using a percentile chart plotting the trajectory of eGFR by age. Method: Three hundred and seventy-three GPs received two case studies of patients with declining renal function. They were randomised to receive the cases with the chart or without the chart, and asked a series of questions about how they would manage the cases. Results: In an older female patient with stable but reduced kidney function, use of the chart was associated with GPs in the study recommending a longer follow-up period, and longer time until repeat pathology testing. In a younger male First Nations patient with normal but decreasing kidney function, use of the chart was associated with GPs in the study recommending a shorter follow-up period, shorter time to repeat pathology testing, increased management of blood pressure and lifestyle, and avoidance of nephrotoxic medications. This represents more appropriate care in both cases. Conclusion: Having access to a chart of percentile eGFR by age was associated with more appropriate management review periods of patients with reduced kidney function, either by greater compliance with current guidelines or greater awareness of a clinically relevant kidney problem. [ABSTRACT FROM AUTHOR]

Simple Summary: The European Thyroid Imaging and Reporting Data System (EU-TIRADS) aids clinicians in determining the necessity of fine-needle aspiration biopsy (FNAB) for thyroid nodules suspected of malignancy. This study evaluated the effectiveness of EU-TIRADS criteria in real-world surgical settings. Results indicated that the EU-TIRADS demonstrates reliable diagnostic accuracy in identifying thyroid cancer, facilitating improved clinical decision-making regarding patient management. Enhanced adherence to EU-TIRADS guidelines can mitigate the risk of an overdiagnosis and overtreatment, particularly for low-risk thyroid cancer cases, thereby optimizing patient care. Background: The European Thyroid Imaging and Reporting Data System (EU-TIRADS) aims to reduce the overdiagnosis of thyroid cancer (TC) by guiding the selection of nodules for fine-needle aspiration biopsy (FNAB). This study sought to validate EU-TIRADS nodule selection criteria using data from EUROCRINE, an extensive international endocrine surgery registry. Method: We reviewed indications for FNAB among patients with TC compared to those with benign disease who underwent surgery between March 2020 and March 2022, considering preoperative EU-TIRADS scores and dominant nodule size (FNAB is recommended in Category 5 (˃10 mm or ˂10 mm with suspicious lymph nodes), 4 (˃15 mm), and 3 (˃20 mm)). Patients were categorized into three risk groups: minimal risk (patients with papillary microcarcinoma), high risk (patients with pT3b stage or higher, pN1b, or pM1), and low–moderate risk (all other patients). We conducted a Receiver Operating Characteristic (ROC) analysis to assess the diagnostic accuracy of the EU-TIRADS. Results: We analyzed 32,008 operations. Approximately 68% of the surgical records included EU-TIRADS classifications. The EU-TIRADS exhibited diagnostic accuracy across high-volume sites, with a median ROC Area Under the ROC Curve (AUC) of 0.752, indicating its effectiveness in identifying malignancy. Among the cases, 7907 patients had TC. Notably, 55% of patients with TC underwent FNAB despite not initially meeting the EU-TIRADS criteria. These patients were distributed across the minimal- (58%), low–moderate- (36%), and high-risk (5.8%) categories. Of the patients with TC recommended for FNAB, 78% were deemed low–moderate risk, 21% high risk, and only 0.7% minimal risk. Conclusion: The EU-TIRADS offers effective preoperative malignancy risk stratification. Promoting the proper use of the EU-TIRADS in clinical practice is essential to mitigate the overdiagnosis and overtreatment of low-risk TC. [ABSTRACT FROM AUTHOR]

Culture influences responses to psychological measurements in ways unrelated to target constructs, thus biasing test scores and potentially contributing to under- and over-diagnosis of mental health problems in populations for which measures have not yet been normed. We conducted a systematic review of publications addressing response style among Latinx population groups in North and South America. In a final corpus of 24 studies, Latinx/Latin American populations were generally found to exhibit higher levels of extreme response style (n = 17), acquiescent response style (n = 10), and socially desirable responding (n = 5). The few publications (n = 3) that investigated midpoint responding reported no differences. Seven publications (29%) attempted to adjust scores to mitigate response style bias, using both scale design and statistical techniques. Findings suggest that researchers and clinicians should directly assess culturally patterned response style as a construct, rather than inferring style indirectly using other measures. For clinicians, knowledge of response style represents another facet of case conceptualization. [ABSTRACT FROM AUTHOR]

Simple Summary: Lung Cancer Screening (LCS) is an evolving field presenting variations in its implementation worldwide. This manuscript is delivered by a multidisciplinary Task Force (TF) in LCS. It aims to identify and present existing evidence regarding biomarkers in LCS and form an up-to-date overview of the current evidence. Background: Lung Cancer Screening (LCS) is an evolving field with variations in its implementation in various countries. There are only scarce data from National LCS programs. Aim: We aim to provide an up-to-date overview of the current evidence regarding the use of biomarkers in LCS. Materials and Methods: A multidisciplinary Task Force experts' panel collaborated and conducted a systematic literature search, followed by screening, review and synthesis of available evidence. Results: Biomarkers in LCS could be used to improve risk stratification in high-risk participants, improve clarification regarding indeterminate lung nodules and avoid overdiagnosis in suspicious lung findings. Currently, there seem to be promising biomarkers (blood/serum/breath) that have been studied in various trials; however, there is still a lack of solid evidence in clinical validation that would pave the way for their integration into LCS programs. Conclusions: Biomarkers are the next logical step in improving the LCS pathway and its efficiency by playing an adjuvant role in a minimally invasive way. National LCS programs and pilot studies should integrate biomarkers to validate their accuracy in real-life LCS participants. [ABSTRACT FROM AUTHOR]

ABSTRACT 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.

Diagnostic error can be defined as deviation from a gold standard diagnosis, typically defined in terms of expert opinion, although sometimes in terms of unexpected events that might occur in follow-up (such as progression and death from disease). Although diagnostic error does exist for melanoma, deviations from gold standard diagnosis, certainly among appropriately trained and experienced practitioners, are likely to be the result of uncertainty and lack of specific criteria, and differences of opinion, rather than lack of diagnostic skills. In this review, the concept of diagnostic error will be considered in relation to diagnostic uncertainty, and the concept of overdiagnosis in melanoma will be presented and discussed.

Abstract Objective To analyse the latest evidence on the relative harms and benefits of screening and diagnostic pathways with close examination of (i) men aged 50 years or older, (ii) men whose ethnicity places them at higher risk and (iii) men with a family history. Methods We conducted a literature search using PubMed and Cochrane Central Register of Controlled Trials (CENTRAL) databases and other sources, from January 1990 to 25 January 2023. Two independent reviewers selected for randomised controlled trials (RCTs) and cohort studies which met our inclusion criteria. Results Twenty‐eight articles were selected, from six trials, including the Göteborg trial—reported separately from European Randomised Study of Screening for Prostate Cancer (ERSPC). Prostate‐specific antigen (PSA)‐based screening led to the increased detection of low‐grade cancer and reduction of advanced/metastatic disease but had contradictory effects on prostate cancer (PCa)‐specific mortality (no difference or reduced), possibly due to issues of contamination or compliance. Screening men from a relatively young age (50–55) reduced risk of PCa‐specific mortality in a subanalysis of an 18‐year follow‐up study and in a 17‐year cohort study from the main Göteborg trial. Moreover, one Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial analysis reported a trend of reduced risk of PCa‐specific mortality for men with a family history who were screened. [Correction added on 05 March 2024, after first online publication: “Cancer Screening Trial” has been added to the preceding sentence.] However, we did not find relevant studies for ethnicity. Conclusion Under current UK practice, the choice to conduct a PSA test relies on a shared decision‐making approach guided by known risk factors. However, we found there was a lack of strong evidence on the harms and benefits of PSA screening by socio‐clinical risk factors and suggest further research is required to understand the long‐term impact of screening on high‐risk populations in the current diagnostic setting.

Abstract Background Healthcare costs are rising worldwide. At the same time, a considerable proportion of care does not benefit or may even be harmful to patients. We aimed to explore attitudes towards low-value care and identify the most important barriers to the de-implementation of low-value care use in primary care in high-income countries. Methods Between May and June 2022, we email surveyed primary care physicians in six high-income countries (Austria, Finland, Greece, Italy, Japan, and Sweden). Physician respondents were eligible if they had worked in primary care during the previous 24 months. The survey included four sections with categorized questions on (1) background information, (2) familiarity with Choosing Wisely recommendations, (3) attitudes towards overdiagnosis and overtreatment, and (4) barriers to de-implementation, as well as a section with open-ended questions on interventions and possible facilitators for de-implementation. We used descriptive statistics to present the results. Results Of the 16,935 primary care physicians, 1,731 answered (response rate 10.2%), 1,505 had worked in primary care practice in the last 24 months and were included in the analysis. Of the respondents, 53% had read Choosing Wisely recommendations. Of the respondents, 52% perceived overdiagnosis and 50% overtreatment as at least a problem to some extent in their own practice. Corresponding figures were 85% and 81% when they were asked regarding their country’s healthcare. Respondents considered patient expectations (85% answered either moderate or major importance), patient’s requests for treatments and tests (83%), fear of medical error (81%), workload/lack of time (81%), and fear of underdiagnosis or undertreatment (79%) as the most important barriers for de-implementation. Attitudes and perceptions of barriers differed significantly between countries. Conclusions More than 80% of primary care physicians consider overtreatment and overdiagnosis as a problem in their country’s healthcare but fewer (around 50%) in their own practice. Lack of time, fear of error, and patient pressures are common barriers to de-implementation in high-income countries and should be acknowledged when planning future healthcare. Due to the wide variety of barriers to de-implementation and differences in their importance in different contexts, understanding local barriers is crucial when planning de-implementation strategies.

Abstract Objective This work aims to examine the latest evidence on the impact of pre‐biopsy MRI, in addition to prostate‐specific antigen (PSA) testing, on health outcomes and quality of life. Methods We conducted a literature search including PubMed and Cochrane Central Register of Controlled Trials (CENTRAL) databases, with a limited scan of (i) guidelines and (ii) references from trial reports, from January 2005 to 25th January 2023. Two independent reviewers selected randomised controlled trials (RCT) and cohort studies which met our inclusion criteria. Results One hundred thirty‐seven articles were identified, and seven trial articles were selected. Trial interventions were as follows: (i) PSA blood test, (ii) additional tests such as pre‐biopsy multiparametric magnetic resonance imaging (mpMRI) and Biparametric MRI (bpMRI), and (iii) MRI targeted biopsy and standard biopsy. Compared with standard biopsy, MRI‐based interventions led to increased detection of clinically significant cancers in three studies and decreased detection of clinically insignificant cancer (Gleason grade 3 + 3) in four studies. However, PROstate Magnetic resonance Imaging Study (PROMIS) and Stockholm3 with MRI (STHLM3‐MRI) studies reported different trends depending on the scenario studied in PROMIS (MRI triage and MRI directed biopsy vs. MRI triage and standard biopsy) and thresholds used in STHLM3‐MRI (≥0·11 and ≥0·15). MRI also helped 8%–49% of men avoid biopsy, in six out of seven studies, but not in STHLM3‐MRI at ≥0.11. Interestingly, the proportion of men who experienced sepsis and UTI was low across studies. Conclusion This review found that a combination of approaches, centred on the use of pre‐biopsy MRI, may improve the detection of clinically significant cancers and reduce (i) the diagnosis of clinically insignificant cancers and (ii) unnecessary biopsies, compared with PSA testing and standard biopsy alone. However, the impact of such interventions on longer term outcomes such as prostate cancer‐specific mortality has not yet been assessed.

Abstract Background Thyroid cancer overdiagnosis is a major public health issue in South Korea, which has the highest incidence rate. The accessibility of information through the Internet, particularly on YouTube, could potentially impact excessive screening. This study aimed to analyze the content of thyroid cancer-related YouTube videos, particularly those from 2016 onwards, to evaluate the potential spread of misinformation. Methods A total of 326 videos for analysis were collected using a video search protocol with the keyword “thyroid cancer” on YouTube. This study classified the selected YouTube videos as either provided by medical professionals or not and used topic clustering with LDA (latent dirichlet allocation), sentiment analysis with KoBERT (Korean bidirectional encoder representations from transformers), and reliability evaluation to analyze the content. The proportion of mentions of poor prognosis for thyroid cancer and the categorization of advertising content was also analyzed. Results Videos by medical professionals were categorized into 7 topics, with “Thyroid cancer is not a ‘Good cancer’” being the most common. The number of videos opposing excessive thyroid cancer screening decreased gradually yearly. Videos advocating screening received more favorable comments from viewers than videos opposing excessive thyroid cancer screening. Patient experience videos were categorized into 6 topics, with the “Treatment process and after-treatment” being the most common. Conclusion This study found that a significant proportion of videos uploaded by medical professionals on thyroid cancer endorse the practice, potentially leading to excessive treatments. The study highlights the need for medical professionals to provide high-quality and unbiased information on social media platforms to prevent the spread of medical misinformation and the need for criteria to judge the content and quality of online health information.

Abstract Overdiagnosis is a growing health issue, yet our understanding of medical students’ exposure to this concept within medical education is limited. Our aim was to explore students’ experience of diagnostic learning to identify how overdiagnosis may be understood by students. During in-person and online semi-structured interviews throughout 2021, we explored the education experience of twelve Western Sydney University medical students in years 3–5. Through inductive thematic analysis we identified four themes. These themes encompassed student commitment to learning about diagnosis, lack of certainty surrounding diagnosis and emotional factors of medical care, overdiagnosis as seen through the lens of high and low-value care during clinical placements and student-identified missed learning opportunities related to overdiagnosis. This study found that medical students develop inherent knowledge of overdiagnosis through an interplay of personal factors, medical school curriculum and the setting in which their training takes place. Our findings allow insight for future improvement of medical curriculum to produce exceptional medical graduates.

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

The national lung screening trial (NLST) demonstrated a reduction in lung cancer mortality with lowdose CT (LDCT) compared to chest x-ray (CXR) screening. Overdiagnosis was high (79%) among bronchoalveolar carcinoma (BAC) currently replaced by adenocarcinoma in situ (AIS), minimally invasive adenocarcinoma (MIA) and adenocarcinoma of low malignant potential (LMP) exhibiting 100% disease specific survival (DSS). Compare the outcomes and proportions of BAC, AIS, MIA, and LMP among NLST screendetected stage IA NSCLC with overdiagnosis rate. Whole slide images were reviewed by a thoracic pathologist from 174 of 409 NLST screen-detected stage IA LUAD. Overdiagnosis rates were calculated from follow-up cancer incidence rates. Most BAC were reclassified as AIS/MIA/LMP (20/35 = 57%). The 7-year DSS was 100% for AIS/MIA/LMP and 94% for BAC. Excluding AIS/MIA/LMP, BAC behaved similarly to NSCLC (7-year DSS: 86% vs. 83%, p= 0.85) The overdiagnosis rate of LDCT stage IA NSCLC was 16.6% at 11.3-years, matching the proportion of AIS/MIA/LMP (16.2%) but not AIS/MIA (3.5%) or BAC (22.8%). AIS/MIA/LMP proportionally matches the overdiagnosis rate among stage IA NSCLC in the NLST, exhibiting 100% 7-year DSS. Biomarkers designed to recognize AIS/MIA/LMP preoperatively, would be useful to prevent overtreatment of indolent screen-detected cancers. [ABSTRACT FROM AUTHOR]

Background: Healthcare costs are rising worldwide. At the same time, a considerable proportion of care does not benefit or may even be harmful to patients. We aimed to explore attitudes towards low-value care and identify the most important barriers to the de-implementation of low-value care use in primary care in high-income countries. Methods: Between May and June 2022, we email surveyed primary care physicians in six high-income countries (Austria, Finland, Greece, Italy, Japan, and Sweden). Physician respondents were eligible if they had worked in primary care during the previous 24 months. The survey included four sections with categorized questions on (1) background information, (2) familiarity with Choosing Wisely recommendations, (3) attitudes towards overdiagnosis and overtreatment, and (4) barriers to de-implementation, as well as a section with open-ended questions on interventions and possible facilitators for de-implementation. We used descriptive statistics to present the results. Results: Of the 16,935 primary care physicians, 1,731 answered (response rate 10.2%), 1,505 had worked in primary care practice in the last 24 months and were included in the analysis. Of the respondents, 53% had read Choosing Wisely recommendations. Of the respondents, 52% perceived overdiagnosis and 50% overtreatment as at least a problem to some extent in their own practice. Corresponding figures were 85% and 81% when they were asked regarding their country's healthcare. Respondents considered patient expectations (85% answered either moderate or major importance), patient's requests for treatments and tests (83%), fear of medical error (81%), workload/lack of time (81%), and fear of underdiagnosis or undertreatment (79%) as the most important barriers for de-implementation. Attitudes and perceptions of barriers differed significantly between countries. Conclusions: More than 80% of primary care physicians consider overtreatment and overdiagnosis as a problem in their country's healthcare but fewer (around 50%) in their own practice. Lack of time, fear of error, and patient pressures are common barriers to de-implementation in high-income countries and should be acknowledged when planning future healthcare. Due to the wide variety of barriers to de-implementation and differences in their importance in different contexts, understanding local barriers is crucial when planning de-implementation strategies. [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]

Simple Summary: The COVID-19 pandemic caused a noticeable decrease in the number of cases of breast, prostate, renal, and thyroid cancers newly diagnosed in 2020 in the Russian Federation. There was no visible impact on mortality from these diseases. Mortality did not change during the pandemic and has remained at pre-pandemic levels until now. The detection rate returned to pre-pandemic levels during 2021–2022. One could speculate that the decrease in the number of newly diagnosed cases is due to cancer tests skipped during the lockdown. This is further evidence of the overdiagnosis of breast, prostate, renal, and thyroid cancers, which is linked to the mass testing of healthy populations. Overdiagnosis, associated with mass testing in healthy populations, is a significant issue for breast, prostate, renal, and thyroid cancers. During the lockdowns caused by the COVID-19 pandemic, the intensity of cancer screening was expected to go down. In this study, we analyzed the impact of the expected reduction in screening intensity on morbidity and mortality from certain malignancies. Cumulative data from the Russian National Cancer Registry available from 2000 to 2022 were analyzed. It was noted that there has been no noticeable effect of the COVID-19 lockdowns on mortality rates from breast, prostate, renal, or thyroid cancers. At the same time, the detectable incidence decreased markedly in 2020 at the time of the lockdowns and then returned to pre-pandemic levels in 2022. At the moment, there is no sufficient reason to believe that skipping screening tests in 2020 could have any impact on breast, prostate, renal, or thyroid cancer mortality two years later (2022). The data presented further confirm that the overdiagnosis of these types of malignancies is caused by widespread screening among a generally healthy population. [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]

In Denmark, people are expected to take responsibility for their health, not least as their bodies age and they experience signs of physical or mental decline. Drawing on fieldwork among older Danes, I illustrate that an excessive focus on health gives rise to social and structural controversies and disparities, linking ideas of healthy behavior at the individual level with the societal framing of disease and aging. I argue that this emphasis contributes to the unwarranted diagnosis of bodily variations that naturally occur in the aging process, a phenomenon referred to as overdiagnosis, adding to a broader medicalization of old age. [ABSTRACT FROM AUTHOR]

• The 1-hour glucose in the 3 point OGTT, contributes only small numbers of GDM cases and a high number needed to screen (67 for 1 additional case in a selective high risk GDM screening strategy). • Omitting the 1 and/or 2-hour glucose measurements from the mid-trimester OGTT may reduce costs and burdens on pregnant women and the healthcare system, with only a marginal reduction in diagnostic yield. • The 2-hour and 1-hour glucose concentrations contributed only 7.4 % and 4.7 % to GDM diagnoses. The WHO 2013 guidelines recommend screening for gestational diabetes mellitus (GDM) by 3-point oral glucose tolerance test (OGTT). The objective of this retrospective cohort study was to evaluate GDM diagnosed by an isolated high glucose. We included pregnant women deemed at risk for GDM were offered GDM screening. We examined the records of 1939 consecutively screened pregnancies at two teaching hospitals in Amsterdam during 2016–2020. Using the WHO 2013 diagnostic criteria, we calculated the proportion of GDM cases diagnosed by isolated abnormal glucose values. Among those screened in our high risk cohort, GDM incidence was 31.5%. Of the GDM diagnoses, 57.0% were based on an isolated fasting glucose value, 30.9% based on multiple raised glucose measurements, 7.4% on an isolated raised 2-hour glucose and 4.7% on an isolated raised 1-hour glucose. For 1-hour glucose, the number needed to screen was 67 persons for one additional GDM case. The 1-hour glucose in the 3 point OGTT, as suggested by the WHO 2013 guidelines for GDM, contributes only small numbers of GDM cases and a high number needed to screen (67 for 1 additional case in a selective high risk GDM screening strategy), and is likely even less effective in universally screened populations. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the accuracy of intraoperative frozen section (FS) diagnosis for predicting the permanent section (PS) diagnosis of mucinous ovarian tumors and evaluate the factors affecting the diagnostic discordance. Patients and Methods: This retrospective cohort study was performed in Tianjin Medical University General Hospital. All women who underwent ovarian surgery with FS between January 2011 and December 2022 were identified, and those with a diagnosis of mucinous ovarian tumor (MOT) by FS or PS were reviewed. Clinical and pathologic data were extracted. Results: A total of 180 women were included, of which 141 (78.33%) had diagnostic concordance between FS and PS, yielding a sensitivity of 83.43% and a positive predictive value (PPV) of 92.76%. Under- and over-diagnosis occurred in 28 cases (15.56%) and 11 cases (6.11%). Tumor size > 13cm (OR 3.79, 95% CI 1.12– 12.73) was an independent risk factor for under-diagnosis, and tumor size ≤ 13cm (OR 16.78, 95% CI 0.01– 0.49), laparoscopic surgery (OR 0.14, 95% CI 0.02– 0.92), the combination of other tumor components (including serous, Brenner tumor, and chocolate cyst; OR 7.00, 95% CI 1.19– 41.12) were independently associated with over-diagnosis. The Kaplan-Meier survival curves and the Log rank test showed no significant difference between misdiagnosed and accurately diagnosed patients (all P > 0.05). Conclusion: Intraoperative frozen pathology of MOT is problematic for under- and over-diagnosis. The incorrect diagnosis of FS was related to determining the extent of surgery but had no impact on the patients' long-term recurrence and survival outcomes. In future clinical practice, surgeons need to obtain material accurately and enhance communication with pathologists during the operation to improve the accuracy of FS diagnosis. [ABSTRACT FROM AUTHOR]

Injuries to extremities are a common presentation to emergency departments and may be associated with multiple abnormalities. Patients may be referred for X-ray imaging of multiple adjacent regions, but the diagnostic outcomes of these X-ray examinations have not been fully explored. The aim of this study was to assess the diagnostic efficacy of X-ray examinations of adjacent body regions in the upper limb. Upper limb X-rays examinations performed over six months were collected from two hospitals, and all patients who had adjacent regions X-rayed were included. Using the radiology reports as a reference standard, the diagnostic yield of these additional adjacent X-ray examinations was assessed. Descriptive statistics and Pearson's Chi Square were used for data analysis. 591 patients had 1455 X-ray examinations, ranging from two to six X-ray requests. More than 80% of X-ray examinations were due to an injury, but less than 60% had symptoms mentioned in the clinical history. Overall, 39.1% of initial examinations reported a new finding but only 1.5% of all subsequent imaging had a new abnormality detected. Examinations with symptoms specified in the clinical history were more likely to detect new findings (p=<0.001). Imaging is an essential diagnostic tool in medical settings, but all radiographic tests should be justified, and adjacent imaging has a low diagnostic yield, hence, all limbs should be carefully assessed individually to assess the need for imaging. Every request should be justified based on presentation and symptoms, particularly when multiple areas may be impacted. Radiographic imaging is easily accessible but adherence to guidelines and assessing the diagnostic yield of common examinations is important to ensure benefits to patients. [ABSTRACT FROM AUTHOR]