Does serous tubal intraepithelial carcinoma (STIC) metastasize? The clonal relationship between STIC and subsequent high-grade serous carcinoma in BRCA1/2 mutation carriers several years after risk-reducing salpingo-oophorectomy.

OBJECTIVE: The majority of high-grade serous carcinomas (HGSC) of the ovary, fallopian tube, and peritoneum arise from the precursor lesion called serous tubal intraepithelial carcinoma (STIC). It has been postulated that cells from STICs exfoliate into the peritoneal cavity and give rise to peritoneal HGSC several years later. While co-existent STICs and HGSCs have been reported to share similarities in their mutational profiles, clonal relationship between temporally distant STICs and HGSCs have been infrequently studied and the natural history of STICs remains poorly understood. METHODS: We performed focused searches in two national databases from the Netherlands and identified a series of BRCA1/2 germline pathogenic variant (GPV) carriers (n = 7) who had STIC, and no detectable invasive carcinoma, at the time of their risk-reducing salpingo-oophorectomy (RRSO), and later developed peritoneal HGSC. The clonal relationship between these STICs and HGSCs was investigated by comparing their genetic mutational profile by performing next-generation targeted sequencing. RESULTS: Identical pathogenic mutations and loss of heterozygosity of TP53 were identified in the STICs and HGSCs of five of the seven patients (71%), confirming the clonal relationship of the lesions. Median interval for developing HGSC after RRSO was 59 months (range: 24-118 months). CONCLUSION: Our results indicate that cells from STIC can shed into the peritoneal cavity and give rise to HGSC after long lag periods in BRCA1/2 GPV carriers, and argues in favor of the hypothesis that STIC lesions may metastasize.

Dutch dairy farmers' perspectives on culling reasons and strategies.

Since the abolishment of the milk quota system in Europe in 2014 and the introduction of environmental policies such as the phosphate rights system in the Netherlands, the reasons for culling dairy cows might have changed. The aim of this study was to determine the culling reasons for dairy cattle and to identify farmers' culling strategies and their intentions regarding the alteration of indicated culling strategies. To this end, an online questionnaire was distributed among dairy farmers nationally that resulted in 207 responses. Results showed that the most frequent culling reasons were related to problems with reproduction, udder, and hoof health. Primiparous cows were primarily culled for miscellaneous reasons such as injury, reproduction failure, and low milk yield. Multiparous cows were culled predominantly for reproduction failure, udder health and hoof health reasons. Most respondents indicated that they consider formulating a culling strategy, based on certain rules of thumb regarding the most common reasons for culling. Most farmers also reported that culling decisions on their farms were perceived to be unavoidable, though reproductive culling decisions are primarily voluntary. Most respondents stated that they intended to reduce the culling rate for better economic gain did not intend to alter the amount of replacement stock reared. The applied rules of thumb regarding culling strategies do not seem to have changed since the policy changes in dairy farming. The question remains whether farmers' rules of thumb might have made them unaware of the actual economic consequences of their culling strategies under the altered situation.

Factors underlying Dutch farmers' intentions to adapt their agronomic management to reduce Fusarium species infection in wheat.

Infection of wheat by Fusarium species can lead to Fusarium Head Blight (FHB) and mycotoxin contamination, thereby reducing food quality and food safety, and leading to economic losses. Agronomic management through the implementation of various pre-harvest measures can reduce the probability of Fusarium spp. infection in the wheat field. To design interventions that could stimulate wheat farmers to (further) improve their agronomic management to reduce FHB, it is key to understand farmers' behaviour towards adapting their management. The aim of this paper was to understand the intention, underlying behavioural constructs, and beliefs of Dutch wheat farmers to adapt their agronomic management to reduce FHB and mycotoxin contamination in wheat, applying the Theory of Planned Behaviour (TPB). Data were collected from 100 Dutch wheat farmers via a questionnaire. The standard TPB analysis was extended with an assessment of the robustness of the belief results to account for the statistical validity of the analysis on TPB beliefs (i.e. to address the so-called expectancy-value muddle). Forty-six percent of the farmers had a positive intention to change their management in the next 5 years. The two behavioural constructs significantly related to this intention were attitude and social norm, whereas association with the perceived behavioural control construct was insignificant indicating that farmers did not perceive any barriers to change their behaviour. Relevant attitudinal beliefs indicated specific attributes of wheat, namely yield, quality and safety (lower mycotoxin contamination). This indicates that strengthening these beliefs-by demonstrating that a change in management will result in a higher yield and quality and lower mycotoxin levels-will result in a stronger attitude and, subsequently, a higher intention to change management. Interventions to strengthen these beliefs should preferably go by the most important referents for social norms, which were the buyers and the farmer cooperatives in this study.

Genetic counseling of patients with ovarian carcinoma: acceptance, timing, and psychological wellbeing.

The new Dutch guidelines on hereditary and familial ovarian carcinoma recommend genetic testing of all patients with epithelial ovarian cancer (EOC). With this study, we aimed to obtain insight into (1) the acceptance and timing of the offer of genetic counseling in women with EOC, (2) reasons for accepting or declining genetic counseling, and (3) psychological differences between women who did and did not have genetic counseling. A multicenter questionnaire survey was performed in patients with EOC in four Dutch oncology centers. The questionnaire addressed whether, how, and when genetic counseling was offered, women's arguments to accept or decline genetic counseling, and included the Cancer Worry Scale (CWS) and the Hospital Anxiety and Depression Scale (HADS). A total of 67 women completed the questionnaire, of which 43 had genetic counseling. Despite a wide variability in the timing of the offer of genetic counseling, 89% of the women were satisfied with the timing. No significant differences were found between the CWS and HADS scores for the timing of the offer of genetic counseling and whether or not women had genetic counseling. Taking the small sample size into account, the results tentatively suggest that genetic counseling may have limited impact on the psychosocial wellbeing of women with EOC. Therefore, we assume that implementation of the new guidelines offering genetic counseling to all patients with EOC will not cause considerable additional burden to these patients.

Farm-specific failure costs of production disorders in European organic dairy herds.

On-farm decision support in animal health management requires a tailor-made failure costs (FCs) assessment of production disorders for the individual farm. In our study we defined a generic framework to estimate the FC of production disorders in dairy cows. We converted the framework to a practical tool in which the farm-specific FC of mastitis, ketosis, lameness and metritis were estimated for 162 organic dairy farms in four European countries. Along with the structure of the framework, the FC estimation required three distinct types of model input: performance input (related to herd performance parameters), consequential input (related to the consequences of the disorders) and economic input (related to price levels). Input was derived from official herd recordings (e.g. test-day records and animal health recordings) and farmers' responses (e.g. questionnaire replies). The average FC of mastitis, ketosis, lameness and metritis amounted to € 96, € 21, € 43 and € 10 per cow per year, respectively. The variation in FC outcomes was high among farmers and countries. Overall ranking of the disorders based on absolute values was the same for all countries, with mastitis being the costliest disorder followed in order by lameness, ketosis, and metritis. Farm specific estimates can be used to rank production related disorders in terms of their associated failure costs and thus provide valuable insights for herd health management. The practical calculation tool developed in this study should be considered by farmers or herd health advisors to support their animal health practices or advice.

Mindfulness-based stress reduction for menopausal symptoms after risk-reducing salpingo-oophorectomy (PURSUE study): a randomised controlled trial.

OBJECTIVE: To assess the short- and long-term effects of mindfulness-based stress reduction (MBSR) on the resulting quality of life, sexual functioning, and sexual distress after risk-reducing salpingo-oophorectomy (RRSO). DESIGN: Randomised controlled trial. SETTING: A specialised family cancer clinic of the university medical center Groningen. POPULATION: Sixty-six women carriers of the BRCA1/2 mutation who developed at least two moderate-to-severe menopausal symptoms after RRSO. METHODS: Women were randomised to an 8-week MBSR training programme or to care as usual (CAU). MAIN OUTCOME MEASURES: Change in the Menopause-Specific Quality of Life Questionnaire (MENQOL), the Female Sexual Function Index, and the Female Sexual Distress Scale, administered from baseline at 3, 6, and 12 months. Linear mixed modelling was applied to compare the effect of MBSR with CAU over time. RESULTS: At 3 and 12 months, there were statistically significant improvements in the MENQOL for the MBSR group compared with the CAU group (both P = 0.04). At 3 months, the mean MENQOL scores were 3.5 (95% confidence interval, 95% CI 3.0-3.9) and 3.8 (95% CI 3.3-4.2) for the MBSR and CAU groups, respectively; at 12 months, the corresponding values were 3.6 (95% CI 3.1-4.0) and 3.9 (95% CI 3.5-4.4). No significant differences were found between the MBSR and CAU groups in the other scores. CONCLUSION: Mindfulness-based stress reduction was effective at improving quality of life in the short- and long-term for patients with menopausal symptoms after RRSO; however, it was not associated with an improvement in sexual functioning or distress. TWEETABLE ABSTRACT: Mindfulness improves menopause-related quality of life in women after risk-reducing salpingo-oophorectomy.

Mindfulness, cognitive behavioural and behaviour-based therapy for natural and treatment-induced menopausal symptoms: a systematic review and meta-analysis.

BACKGROUND: During menopause women experience vasomotor and psychosexual symptoms that cannot entirely be alleviated with hormone replacement therapy (HRT). Besides, HRT is contraindicated after breast cancer. OBJECTIVES: To review the evidence on the effectiveness of psychological interventions in reducing symptoms associated with menopause in natural or treatment-induced menopausal women. SEARCH STRATEGY: Medline/Pubmed, PsycINFO, EMBASE and AMED were searched until June 2017. SELECTION CRITERIA: Randomised controlled trials (RCTs) concerning natural or treatment-induced menopause, investigating mindfulness or (cognitive-)behaviour-based therapy were selected. Main outcomes were frequency of hot flushes, hot flush bother experienced, other menopausal symptoms and sexual functioning. DATA COLLECTION AND ANALYSIS: Study selection and data extraction were performed by two independent researchers. A meta-analysis was performed to calculate the standardised mean difference (SMD). MAIN RESULTS: Twelve RCTs were included. Short-term (<20 weeks) effects of psychological interventions in comparison to no treatment or control were observed for hot flush bother (SMD -0.54, 95% CI -0.74 to -0.35, P < 0.001, I2  = 18%) and menopausal symptoms (SMD -0.34, 95% CI -0.52 to -0.15, P < 0.001, I2  = 0%). Medium-term (≥20 weeks) effects were observed for hot flush bother (SMD -0.38, 95% CI -0.58 to -0.18, P < 0.001, I2  = 16%). [Correction added on 9 July 2018, after first online publication: there were miscalculations of the mean end point scores for hot flush bother and these have been corrected in the preceding two sentences.] In the subgroup treatment-induced menopause, consisting of exclusively breast cancer populations, as well as in the subgroup natural menopause, hot flush bother was reduced by psychological interventions. Too few studies reported on sexual functioning to perform a meta-analysis. CONCLUSIONS: Psychological interventions reduced hot flush bother in the short and medium-term and menopausal symptoms in the short-term. These results are especially relevant for breast cancer survivors in whom HRT is contraindicated. There was a lack of studies reporting on the influence on sexual functioning. TWEETABLE ABSTRACT: Systematic review: psychological interventions reduce bother by hot flushes in the short- and medium-term.

Characteristics of Lynch syndrome associated ovarian cancer.

OBJECTIVE: To describe clinical characteristics of Lynch syndrome associated ovarian cancer and the efficacy of surveillance in the early detection of these ovarian cancers. METHODS: All Lynch syndrome associated ovarian cancer cases identified in either the Dutch Lynch syndrome registry (DLSR) between 1987 and 2016, and/or the cohort at the University Medical Center Groningen (UMCG) between 1993 and 2016 were included. Clinical data on age at diagnosis, mutation type, histological type, FIGO stage, treatment, follow-up and gynecological surveillance were collected. RESULTS: A total of 46/798 (6%) women in the DLSR and 7/80 (9%) in the UMCG cohort were identified as LS associated ovarian cancer patients. The median age at ovarian cancer diagnosis was 46.0 years (range 20-75 years). The most frequently reported histological type was endometrioid adenocarcinoma (40%; n = 21) and serous carcinoma (36%; n = 19). Most tumors (87%; n = 46) were detected at an early stage (FIGO I/II). Forty-one of 53 (77%) patients were diagnosed with ovarian cancer before LS was diagnosed. In the other 12/53 (23%) women, ovarian cancer developed after starting annual gynecological surveillance for LS; three ovarian cancers were screen-detected in asymptomatic women. Overall survival was 83%. CONCLUSION: Ovarian cancer in women with LS has a wide age-range of onset, is usually diagnosed at an early stage with predominantly endometrioid type histology and a good overall survival. The early stage at diagnosis could not be attributed to annual gynecological surveillance.

Severity and duration of menopausal symptoms after risk-reducing salpingo-oophorectomy.

OBJECTIVES: To reduce the risk of ovarian cancer, women with BRCA1/2 mutations are advised to undergo risk-reducing salpingo-oophorectomy (RRSO) at a premenopausal age. Premenopausal RRSO results in acute menopause and is associated with various menopausal symptoms. This study investigates the severity and duration of subjective menopausal symptoms after premenopausal RRSO and associated factors. METHODS: We included 199 women who had undergone RRSO before age 52 in this cross-sectional study. The Menopause Rating Scale (MRS) was used to measure the level of psychological, somato-vegetative and urogenital symptoms (no/little, mild, moderate, or severe). Uni- and multivariate logistic regressions were performed to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) for having moderate or severe symptoms as compared to having no or mild symptoms. Duration of symptoms was investigated by calculating the time since RRSO. RESULTS: Sixty-nine percent (137/199) of the included women reported moderate or severe symptoms on the MRS, a mean of 7.9 years after RRSO. Fifty-seven percent (94/137) of these women reported severe urogenital symptoms, and about one-quarter reported severe psychological and/or somato-vegetative symptoms. Only psychological symptoms tended to improve over time (>=10 years). A personal history of breast cancer was independently associated with having moderate or severe menopausal symptoms (OR = 3.4; 95%CI = 1.6-7.1). CONCLUSIONS: The majority of women report moderate or severe menopausal symptoms, even 10 years after surgical menopause, and breast cancer survivors especially. To improve quality of life, follow-up care after RRSO should focus on these symptoms and be accessible for many years after RRSO.

Determinants of health seeking behaviour following rabies exposure in Ethiopia.

The objective of this study was to identify factors that determine medical treatment seeking behaviour following potential rabies exposure after being bitten by a suspected dog and the likelihood of compliance to receive sufficient doses of post-exposure prophylaxis after the visit to a health centre visit. A detailed survey based on case investigation was conducted on suspected rabid dog bite cases in three areas of Ethiopia. Two multivariable logistic regression models were created with a set of putative variables to explain treatment seeking and compliance outcomes. Based on the registered bite cases at each health centre and the set of unregistered bite cases derived by contact tracing, 655 bite victim cases were identified to have occurred between September 2013 and August 2014. Of these evaluated bite incidences, 465 cases were considered to have been caused by a potentially rabid dog. About 77% of these suspected rabid dog bite victims visited a health centre, while 57% received sufficient doses of PEP. The overall likelihood of seeking medical services following rabies exposure was higher for people bitten by dogs of unknown ownership, where the bite was severe, being bitten on the leg, spend of more than 100 USD per month and where the victim lived close to the nearest health centre, while the likelihood of receiving sufficient doses of PEP was sensitive to monthly spending and distance to health centre. However, the evaluated factors did only explain a part of the variation among the three districts. The district in which victims lived appeared to have a relevant influence on the likelihood of seeking medical treatment but did not improve the prediction on the likelihood of treatment compliance. Given the insights obtained from this study, improvements in the rural districts with regard to accessibility of post-exposure prophylaxis delivering health centres in shorter distance could improve health seeking behaviour. In addition, in rural districts, majority of exposed persons who seek medical treatment tend to comply with treatment regimen, indicating that the promotion of medical treatment through awareness creation campaigns could be beneficial.

[The impact of fireworks: the context of facial trauma]. / De impact van vuurwerk: achtergronden van het aangezichtsletsel.

In the Netherlands the general public can legally use fireworks on New Year's Eve. Despite the fact that the public is well aware of the dangers of fireworks, fireworks accidents occur in which the victims suffer a variety of injuries. In addition to burns, injuries to fingers and/or hands are most common. However, injuries to the eye, which can also involve facial trauma, frequently occur as well. Trauma mainly occurs as a result of the destructive effects of the wave of pressure released by the explosion. The best preventive measure would be to prohibit the use of fireworks by amateurs. Until such time, people should be advised to wear protective fireworks glasses when outside so that damage to the eyes from legal fireworks at least can be prevented.

Cognitive decline after major oncological surgery in the elderly.

BACKGROUND: Elderly patients undergoing oncological surgery experience postoperative cognitive decline. The aims of this study were to examine the incidence of cognitive decline 3 months after surgery and identify potential patient-, disease- and surgery-related risk factors for postoperative cognitive decline in onco-geriatric patients. METHODS: A consecutive series of elderly patients (≥65 years) undergoing surgery for the removal of a solid tumour were included (n = 307). Cognitive performance was assessed pre-operatively and 3 months postoperatively. Postoperative decline was defined as a decline in scores of cognitive tests of ≥25% on ≥2 of 5 tests. RESULTS: Of the patients who had completed the assessments, 117 (53%, 95% confidence interval [CI]: 47-60) had improved cognitive test scores, whereas 26 (12%, 95% CI: 7.6-16) showed cognitive decline at 3 months postoperatively. In patients aged >75 years, the incidence of overall cognitive decline 3 months postoperatively was 18% (95% CI: 9.3-27). In patients with lower pre-operative Mini-Mental State Examination (MMSE) score (≤26) the incidence was 37% (95% CI: 18-57), and in patients undergoing major surgery it was 18% (95% CI: 10.6-26). Of the cognitive domains, executive function was the most vulnerable to decline. CONCLUSION: About half of the elderly patients show improvement in postoperative cognitive performance after oncological surgery, whereas 12% show cognitive decline. Advanced age, lower pre-operative MMSE score and major surgery are risk factors for cognitive decline at 3 months postoperatively and should be taken into account in the clinical decision-making progress. Research to develop interventions to preserve quality of life should focus on this high-risk subpopulation.

[Diagnosis and treatment of orbital cellulitis]. / Diagnostiek en behandeling van orbitale cellulitis.

Orbital cellulitis is a rare disease usually caused by sinusitis. Generally, the prognosis of both preseptal cellulitis and orbital cellulitis is favourable. Radiological distinction should be made between an orbital abscess and subperiosteal empyema. Theoretically, empyema is more accessible to antibiotics and, as it arises in a pre-existing anatomical space, it needs less aggressive treatment than an abscess. In contrast, the wall of an abscess created by the bacteria is scarcely permeable to antibiotics. Indications for surgical drainage should be based on clinical findings and not on Chandler's classification. Loss of vision, an unresponsive pupil or a densely packed orbit are indications for immediate surgical drainage. Drainage of an orbital abscess may speed up recovery.

Improved cancer detection in automated breast ultrasound by radiologists using Computer Aided Detection.

OBJECTIVE: To investigate the effect of dedicated Computer Aided Detection (CAD) software for automated breast ultrasound (ABUS) on the performance of radiologists screening for breast cancer. METHODS: 90 ABUS views of 90 patients were randomly selected from a multi-institutional archive of cases collected between 2010 and 2013. This dataset included normal cases (n=40) with >1year of follow up, benign (n=30) lesions that were either biopsied or remained stable, and malignant lesions (n=20). Six readers evaluated all cases with and without CAD in two sessions. CAD-software included conventional CAD-marks and an intelligent minimum intensity projection of the breast tissue. Readers reported using a likelihood-of-malignancy scale from 0 to 100. Alternative free-response ROC analysis was used to measure the performance. RESULTS: Without CAD, the average area-under-the-curve (AUC) of the readers was 0.77 and significantly improved with CAD to 0.84 (p=0.001). Sensitivity of all readers improved (range 5.2-10.6%) by using CAD but specificity decreased in four out of six readers (range 1.4-5.7%). No significant difference was observed in the AUC between experienced radiologists and residents both with and without CAD. CONCLUSIONS: Dedicated CAD-software for ABUS has the potential to improve the cancer detection rates of radiologists screening for breast cancer.

Does early response to intravenous glucocorticoids predict the final outcome in patients with moderate-to-severe and active Graves' orbitopathy?

PURPOSE: Intravenous glucocorticoids (ivGCs) given as 12-weekly infusions are the first-line treatment for moderate-to-severe and active Graves' orbitopathy (GO), but they are not always effective. In this study, we evaluated whether response at 6 weeks correlated with outcomes at 12 (end of intervention) and 24 (follow-up) weeks, particularly in patients initially unresponsive. METHODS: Our database (Bartalena et al. J Clin Endocrinol Metab 97:4454-4463, 10), comprising 159 patients given three different cumulative doses of methylprednisolone (2.25, 4.98, 7.47 g) was analyzed, pooling data for analyses. Responses at 6 weeks were compared with those at 12 and 24 weeks using three outcomes: overall ophthalmic involvement [composite index (CI)]; quality of life (QoL); Clinical Activity Score (CAS). Responses were classified as "Improved", "Unchanged", "Deteriorated", compared to baseline. RESULTS: Deteriorated patients at 6 weeks for CI (n = 8) remained in the same category at 12 weeks and 7/8 at 24 weeks. Improved patients at 6 weeks for CI (n = 51) remained in the same category in 63% and 53% of cases at 12 and 24 weeks, respectively. Unchanged patients at 6 weeks (n = 100) eventually improved in 28% of cases (CI), 58% (CAS), 32% (QoL). There was no glucocorticoid dose-dependent difference in the influence of early response on later outcomes. CONCLUSIONS: Patients who deteriorate at 6 weeks after ivGCs are unlikely to benefit from continuing ivGCs. Patients unresponsive at 6 weeks still have a significant possibility of improvement later. Accordingly, they may continue ivGC treatment, or, alternatively, possibly stop ivGCs and be switched to a second-line treatment.

Cost-Effectiveness of Mass Dog Vaccination Campaigns against Rabies in Flores Island, Indonesia.

A dynamic deterministic simulation model was developed to determine the cost-effectiveness of different mass dog vaccination strategies against rabies in a dog population representative of a typical village on Flores Island. Cost-effectiveness was measured as public cost per averted dog-rabies case. Simulations started with the introduction of one infectious dog into a susceptible dog population of 399 dogs and subsequently ran for a period of 10 years. The base scenario represented a situation without any control intervention. Evaluated vaccination strategies were as follows: annual vaccination campaigns with short-acting vaccine (immunity duration of 52 weeks) (AV_52), annual campaigns with long-acting vaccine (immunity duration of 156 weeks) (AV_156), biannual campaigns with short-acting vaccine (BV_52) and once-in-2-years campaigns with long-acting vaccine (O2V_156). The effectiveness of the vaccination strategies was simulated for vaccination coverages of 50% and 70%. Cumulative results were reported for the 10-year simulation period. The base scenario resulted in three epidemic waves, with a total of 1274 dog-rabies cases. The public cost of applying AV_52 at a coverage of 50% was US$5342 for a village. This strategy was unfavourable compared to other strategies, as it was costly and ineffective in controlling the epidemic. The costs of AV_52 at a coverage of 70% and AV_156 at a coverage of 70% were, respectively, US$3646 and US$3716, equivalent to US$3.00 and US$3.17 per averted dog-rabies case. Increasing the coverage of AV_156 from 50% to 70% reduced the number of cases by 7% and reduced the cost by US$1452, resulting in a cost-effectiveness ratio of US$1.81 per averted dog-rabies case. This simulation model provides an effective tool to explore the public cost-effectiveness of mass dog vaccination strategies in Flores Island. Insights obtained from the simulation results are useful for animal health authorities to support decision-making in rabies-endemic areas, such as Flores Island.

Seven-year follow-up of unilateral multifocal pseudophakia in a child.

The purpose of the study was to report the long-term outcome of unilateral implantation of a multifocal intraocular lens (IOL) in a pediatric cataract. This study was carried out at Tertiary Academic Ophthalmology Department, AMC, Amsterdam. This is a case report study of a 7-year-old child with a unilateral irradiation cataract, in whom an apodized diffractive multifocal IOL (SN6D3, Alcon) was implanted at the time of cataract surgery. During the follow-up period, visual acuity was preserved at logMAR -0.1; the child did not develop amblyopia. Binocular single vision was established. Few glistenings were seen on the IOL. The non-operated eye developed more myopia during the follow-up period than the multifocally implanted eye. Straylight was increased to log(s) 1.83. Patient and parents satisfaction were high. In selected cases, unilateral implantation of apodized diffractive multifocal IOLs leads to good long-term results in terms of visual acuity and patient satisfaction. No untoward effects were seen, including few glistenings on the IOL. Straylight is increased, but subjectively not disturbing.

Psychological factors associated with the intention to choose for risk-reducing mastectomy in family cancer clinic attendees.

OBJECTIVES: Women seeking counseling because of familial breast cancer occurrence face difficult decisions, such as whether and when to opt for risk-reducing mastectomy (RRM) in case of BRCA1/2 mutation. Only limited research has been done to identify the psychological factors associated with the decision for RRM. This study investigated which psychological factors are related to the intention to choose for RRM. MATERIALS & METHODS: A cohort of 486 cancer-unaffected women with a family history of breast cancer completed the following questionnaires prior to genetic counseling: the Cancer Worry Scale, Positive And Negative Affect Scale, Perceived Personal Control Scale, Hospital Anxiety and Depression Scale and State Anxiety Scale and questions regarding socio-demographic characteristics, family history, risk perception and RRM intention. Multivariate logistic regression was used to analyze the relation between psychological factors and women's intention to choose for RRM. RESULTS: Factors associated with RRM intention were high positive affect (OR = 1.86, 95%CI = 1.12-3.08), high negative affect (OR = 2.52, 95%CI = 1.44-4.43), high cancer worry (OR = 1.65, 95%CI = 1.00-2.72), high perceived personal control (OR = 3.58, 95%CI = 2.18-5.89), high risk-perception (OR = 1.85, 95%CI = 1.15-2.95) and having children (OR = 2.06, 95%CI = 1.21-3.50). CONCLUSION: Negative and positive affects play an important role in the intention for RRM. Furthermore, perceived personal control over the situation is associated with an intention for RRM. In addition to focusing on accurate risk communication, counseling should pay attention to the influence of perceived control and emotions to facilitate decision-making.

[CanMEDS 2015: better doctors?]. / CanMEDS 2015: nog betere dokters?

Recently, the CanMEDS model, which forms the basis for competency-based learning in both undergraduate and postgraduate training, has been renewed by the introduction of CanMEDS 2015. The most prominent change is the emphasis on leadership skills, which is also reflected by the name change for the role of 'manager' to 'leader'. The addition of milestones provides clearly defined targets for learning and assessment, which facilitates the monitoring of the progression in competence. Furthermore, CanMEDS 2015 strongly focusses on the overall coherence of the separate competencies. CanMEDS, designed as a model that helps to train young doctors to become good doctors, also helps us - the trainers - to become better doctors ourselves.

Reducing contrast medium volume and tube voltage in CT angiography of the pulmonary artery.

AIM: To evaluate image quality after contrast medium (CM) and tube voltage reduction in computed tomography angiography (CTA) of the pulmonary artery. MATERIALS AND METHODS: Thirty-three patients referred for CTA of the pulmonary artery for suspected pulmonary embolism were included. Patients were randomly assigned to Protocol I (100 ml of 350 mg iodine/ml iodinated CM; n=16) or Protocol II (50 ml of 350 mg iodine/ml iodinated CM; n=17). Dual-energy CT (80 kV and 140 kV) was performed in all patients. An averaged weighted series equivalent to a 120 kV image acquisition was reconstructed. The mean attenuation value of CM was measured at eight positions in the pulmonary trunk and pulmonary arteries. Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated. Qualitative assessment of the vascular enhancement was performed independently by two experienced radiologists using a three-point scale. Mean attenuation values, image noise, CNR, and SNR of images with 50 ml CM and images with 100 ml CM were compared and mean attenuation values, image noise, CNR, and SNR in 80 kV images and 120 kV images were compared. For qualitative analysis, interobserver variability was analysed using Cohen's kappa statistics. RESULTS: The mean attenuation values in Protocol I and Protocol II were not significantly different at 80 kV (634.6±168.3 versus 537.9±146.7 HU; p=0.088) and 120 kV (482.8±127.7 versus 410.4±106.0 HU; p=0.085). The mean attenuation value at 80 kV was significantly higher than the mean attenuation value at 120 kV in Protocols I and II (p<0.001). The CNR and SNR were higher at 120 kV than at 80 kV in both protocols (p=0.000-0.019); however, there were no significant differences in the CNR and SNR between both protocols (p=0.600-0.952). Qualitative (subjective) analysis showed no statistical significant difference between Protocols I and II (p=0.524-1.000). CONCLUSION: Low tube voltage (80 kV) CTA using 50 ml CM is not inferior to CTA at 120 kV using 100 ml CM.