The significance of isolated de novo red patches in the bladder in patients referred with suspected urinary tract cancer: Results from the IDENTIFY study

ObjectivesTo assess the contemporary malignancy rate in isolated de novo red patches in the bladder and associated risk factors for better selection of red patch biopsy. PatientsPatients from the IDENTIFY dataset; Patients referred to secondary care with suspected urinary tract cancer and found to have isolated de novo red patches on cystoscopy. MethodsWe reported the unadjusted cancer prevalence in isolated de novo red patches that were biopsied; multivariable logistic regression was used to explore cancer-associated risk factors including age, sex, smoking, type of haematuria, LUTS, UTIs and a suspicious-looking red patch (as reported by the cystoscopist). Sub-analysis of these by clinical role and experience was performed. ResultsA total of 1110 patients with isolated de novo red patches were included. 41.5% (n = 461) were biopsied, with a malignancy rate of 12.8% (59/461), which was significantly higher in suspicious versus non-suspicious red patches (19.1% vs. 2.81%, p < 0.01). There was a significant association between bladder cancer and age (OR 1.04, 95% CI 1.01-1.07, p = 0.01), smoking history (OR 2.62, 95% CI 1.09-6.27, p = 0.03) and suspicious-looking patch (OR 6.50, 95% CI 2.47-17.1, p < 0.01). The majority of malignancies were in over 60-year-olds. Malignancy rates in suspicious versus non-suspicious red patches did not differ significantly between clinical roles or experiences. Limitations included subjectivity in classifying a suspicious patch and selection bias as not all patches were biopsied. ResultsA total of 1110 patients with isolated de novo red patches were included. 41.5% (n = 461) were biopsied, with a malignancy rate of 12.8% (59/461), which was significantly higher in suspicious versus non-suspicious red patches (19.1% vs. 2.81%, p < 0.01). There was a significant association between bladder cancer and age (OR 1.04, 95% CI 1.01-1.07, p = 0.01), smoking history (OR 2.62, 95% CI 1.09-6.27, p = 0.03) and suspicious-looking patch (OR 6.50, 95% CI 2.47-17.1, p < 0.01). The majority of malignancies were in over 60-year-olds. Malignancy rates in suspicious versus non-suspicious red patches did not differ significantly between clinical roles or experiences. Limitations included subjectivity in classifying a suspicious patch and selection bias as not all patches were biopsied. ConclusionsMany patients still undergo unnecessary biopsies under general anaesthetic for isolated de novo red patches. Clinicians should consider the patient's age, smoking status and how suspicious-looking the patch is, before deciding on surveillance versus biopsy to improve cancer diagnostic yield

The IDENTIFY study: the investigation and detection of urological neoplasia in patients referred with suspected urinary tract cancer - a multicentre observational study

Objective To evaluate the contemporary prevalence of urinary tract cancer (bladder cancer, upper tract urothelial cancer [UTUC] and renal cancer) in patients referred to secondary care with haematuria, adjusted for established patient risk markers and geographical variation. Patients and Methods This was an international multicentre prospective observational study. We included patients aged ≥16 years, referred to secondary care with suspected urinary tract cancer. Patients with a known or previous urological malignancy were excluded. We estimated the prevalence of bladder cancer, UTUC, renal cancer and prostate cancer; stratified by age, type of haematuria, sex, and smoking. We used a multivariable mixed-effects logistic regression to adjust cancer prevalence for age, type of haematuria, sex, smoking, hospitals, and countries. Results Of the 11 059 patients assessed for eligibility, 10 896 were included from 110 hospitals across 26 countries. The overall adjusted cancer prevalence (n = 2257) was 28.2% (95% confidence interval [CI] 22.3–34.1), bladder cancer (n = 1951) 24.7% (95% CI 19.1–30.2), UTUC (n = 128) 1.14% (95% CI 0.77–1.52), renal cancer (n = 107) 1.05% (95% CI 0.80–1.29), and prostate cancer (n = 124) 1.75% (95% CI 1.32–2.18). The odds ratios for patient risk markers in the model for all cancers were: age 1.04 (95% CI 1.03–1.05; P < 0.001), visible haematuria 3.47 (95% CI 2.90–4.15; P < 0.001), male sex 1.30 (95% CI 1.14–1.50; P < 0.001), and smoking 2.70 (95% CI 2.30–3.18; P < 0.001). Conclusions A better understanding of cancer prevalence across an international population is required to inform clinical guidelines. We are the first to report urinary tract cancer prevalence across an international population in patients referred to secondary care, adjusted for patient risk markers and geographical variation. Bladder cancer was the most prevalent disease. Visible haematuria was the strongest predictor for urinary tract cancer

Paediatric Blunt Liver Trauma in a Dutch Level 1 Trauma Center

Introduction: Paediatric blunt hepatic trauma treatment is changing from operative treatment (OT) to non-operative treatment (NOT). In 2000 the American Pediatric Surgical Association has published guidelines for NOT of these injuries. Little is known about the treatment of paediatric liver trauma in the Netherlands. Patients and methods: Data of all patients aged 18 years and younger admitted to our hospital for blunt hepatic trauma in the past 18 years were retrospectively analysed using a prospective trauma registry. The mechanism Of injury, treatment, ICU admission time, total admission time, morbidity and mortality were assessed. Subsequently the group was divided into patients treated before and after 2000. Results: Eighty patients were identified: 52M, 28F with a mean age of 12 years (range 2-18). Thirty patients sustained isolated liver injury. Concomitant injuries were fractures of long bones (28), abdominal (25), chest (24) and head injuries (18). Mean ISS score was 18 (range 4-57). Mortality was 8%. Mechanisms of injury consisted of bicycle (25%), car (20%), and motorcycle accidents (15%), pedestrian hit by vehicle (15%), fall from height (14%) and accidents associated with animals (11%). Haemodynamically stable patients underwent NOT (55). 25 patients (31%) underwent a laparotomy, which in 20 cases (80%) was related to hepatic injury. Although the groups treated before and after 2000 did not differ haemodynamically on admission to hospital, a shift to NOT is evident: 24/37 (63%) patients underwent NOT before 2000 versus 38/45 (84%) after 2000 (p=0.04). Complications following NOT were rare. Late onset bleeding did not occur. Two patients developed an infected biloma, requiring a laparotomy. Mean ICU stay before 2000 was 4.2 days (range 0-25 days) and 2.6 days (range 0-17 days) after 2000. Total hospital time did not decrease: 14 days (range 1-39 days) before 2000 and 14 days (range 1-60 days) after 2000. The overall mortality was 8%. All deaths occurred in the operative group and were spread evenly over both periods. Conclusion: In blunt paediatric liver trauma, the incidence and trauma mechanism seem age-related. A shift to NOT is found in the treatment of paediatric blunt hepatic trauma. NOT is the preferred treatment for the haemodynamically stable patient. Complications are rare and the success rate is 96%. The mean ICU stay has decreased but the total admission time could possibly be shortened

Only Moderate Intra- and Inter-observer Agreement between Radiologists and Surgeons when Grading Blunt Paediatric Hepatic Injury on CT Scan

Introduction: The American Pediatric Surgical Association developed guidelines for the management of haemodynamically stable children with hepatic or splenic injury, based on grade of injury on CF scan. This study investigated the intra- and inter-observer agreement of radiologists, paediatric surgeons, trauma surgeons and hepatobiliary surgeons when scoring liver injury based on CT scan findings. Patients and Methods: CT scans of patients with blunt abdominal trauma were independently assessed twice by a fellow and a consultant radiologist, paediatric surgeon, trauma surgeon and one consultant hepatobiliary surgeon. Reviewers were unaware of the clinical course. All scans were multislice CTs with a slice thickness of 3 mm, and both the arterial and venous phase were assessed. Injury was scored using the American Association for the Surgery of Trauma (AAST) liver injury scale. Intra-observer agreement was tested using Cohen's kappa coefficient. Inter-observer agreement was tested using Cohen's kappa for the second reading of individual observers and Spearman's rank correlation for the mean of both readings from each observer. Results: CT scans of 27 patients (11 girls and 16 boys, median age 11.7 +/- 5.2 years) were reviewed. Mean AAST grade of liver injury was 3.3 +/- 1.1 for radiologists, 2.9 +/- 1.0 for paediatric surgeons, 3.0 +/- 0.9 for trauma surgeons and 3.2 +/- 0.8 for the hepatobiliary surgeon (p=0.30) Intra-observer agreement was moderate, with kappa below 0.7 for all observers except for one of the radiologists. Inter-observer correlation using Cohen's kappa coefficient was also moderate, with kappa below 0.5. In contrast, inter-observer correlation using Spearman's test was good, suggesting that there is agreement on the general severity of injury but not on the exact grading of injury using the AAST scoring system. Conclusion: Intra-observer agreement is only moderate when assessing liver injury using the AAST grading system. Only the most experienced radiologist demonstrated good intra-observer agreement which might indicate the necessity of the presence of a senior trauma radiologist at all times. However, this is not possible in most centres. Although there was agreement concerning the general severity of injury, inter-observer agreement is also moderate. These data cast doubt on the use of the AAST liver injury score alone as a decision-making tool when assessing haemodynamically stable children with blunt hepatic injury

Results, Retrospectively Analysed, of the Current Trauma Database in Curacao, Dutch Caribbean

Background: A trauma registry plays an important role in the process of health-service improvement. The organization of trauma care in the Caribbean is limited; there is a lack of registry and distribution of patients. Objective: The purpose was to compare incidence-trends of patients with trauma-related injuries in the Curacao trauma registry over 14 years, since Curacao is part of the Dutch Caribbean. Methods: The data of all injured patients admitted to the Emergency Department (ED) from January 1, 2000 to December 31, 2013, were retrospectively analysed using a prospective trauma registry. Subsequently, they were crosschecked with the registry of Central Bureau of Statistics, Curacao (CBSC). Results: In the ED, 14 886 patients with trauma-related injuries were selected: 9390 M and 5496 F. The incidence per 100 000 inhabitants per year of traffic-related trauma was 529.7 (95% confidence interval [CI]: 430.9, 628.5); firearm-related 29.2 (95% CI: 18.3, 40.2); stab wound-related 26.4 (95% CI: 18.4, 34.4) and molestation-related 173 (95% CI: 127.5, 218.5). There is an overall decline in the incidence through the years. In all the trauma-related groups, there were significantly more men and people aged between 15 and 34 years. The hospitalization of traffic-related injured patients was 22.7%, firearm-related 48.3%, stab wound-related 30.5% and molestation-related 18.9%. Conclusion: The hospitalizations percentages differ. The incidence and trauma mechanism seem to be age-and gender-related. There is a higher incidence of trauma-related injuries, in Curacao compared with the incidence in the other countries in the region. This study is a start to the set-up of a new trauma registry

Blunt Splenic Trauma in Children:Are We Too Careful?

Introduction: There has been a shift from operative treatment (OT) to non-operative treatment (NOT) of splenic injury. We evaluated the outcomes of treatment of pediatric patients with blunt splenic trauma in our hospital, with special focus on the outcomes after NOT. Patients and Methods: The data of all patients <18 years with radiologically proven blunt splenic injury admitted between 1988 and 2007 were retrospectively analyzed. Mechanism of injury, type of treatment, ICU stay, total hospital stay, morbidity and mortality were assessed. Patients suffering isolated splenic injuries were assessed separately from patients with multiple injuries. Patients were subsequently divided into those admitted before and after 2000. Results: There were 64 patients: 49 males and 15 females with a mean age of 13 years (range 0 18). 3 patients died shortly after admission due to severe neurological injury and were excluded. In the remaining 61 patients concomitant injuries, present in 62 %, included long bone fractures (36 %), chest injuries (16 %), abdominal injuries (33 %) and head injuries (30 %). Mechanisms of injury were: car accidents (26 %), motorcycle (20 %), bicycle (19 %), fall from height (17 %) and pedestrians struck by a moving vehicle (8 %). A change in treatment strategy was evident for the pre- and post-2000 periods. Significantly more patients had NOT after 2000 in both the isolated splenic injury group and the multitrauma group [4/11 (36 %) before vs. 10/11 (91 %) after (p = 0.009); 15/19 (79 %) before vs. 8/20 (40 %) after 2000 (p = 0.03)]. There was also a significant shift to spleen-preserving operations. All life-threatening complications occurred within <24 h after injury. Mortality for the entire cohort was 7 %; all of these patients were treated operatively. When comparing the median ICU and hospital stay before and after 2000 it was found to be significantly higher in the isolated injury group and remained statistically the same in the multi-trauma group. Conclusion: Splenic injury in children is associated with substantial mortality. This is due to concomitant injuries and not to the splenic injury. Non-operative treatment is increasingly preferred to operative procedures when treating splenic injuries in hemodynamically, stable children. ICU and hospital stay have, despite the change from OT to NOT, remained the same. Complications after NOT are rare. We are still observing children in hospital for a longer period than is necessary