Malignant bowel obstruction is common in colorectal cancer and may require high-risk emergency surgery. A structured four-stage obstruction protocol may improve outcomes through early decompression and optimisation, thereby preventing deterioration, reducing acute resections and stoma formation, and minimising morbidity and mortality. This study evaluated clinical outcomes of this protocol. The protocol categorises patients by symptom severity and colonic distension, with stage-specific management and routine reassessment for improvement or deterioration. Deterioration was defined as worsening of symptoms requiring escalation to a higher stage and more intensive care. This retrospective study included patients treated between 2018 and 2024. Of 319 patients, 236 received curative and 83 palliative treatment. Stage distribution (curative/palliative): stage 1 (184/59), stage 2 (19/11), stage 3 (20/6), stage 4 (13/7). (Semi-)acute resections occurred more frequently in higher stages: 1% (stage 1), 6% (stage 2), 25% (stage 3), 15% (stage 4) (p<0.001). Overall, 6% of curative patients deteriorated: 3% (stage 1), 5% (stage 2), 30% (stage 3), and 8% (stage 4). In curative stage 3, acute resection was avoided in 75% treated with stenting or nasogastric decompression. In the palliative group, all stage 3-4 patients received a stent or stoma without deterioration. The four-stage obstruction protocol effectively manages colorectal cancer-related obstruction. In 94% of curative patients, deterioration was prevented, avoiding emergency surgery and its risks. While emergency resection was previously considered standard in stage 3, the protocol avoided this in most patients. Accurate staging and close monitoring remain essential to prevent deterioration.

To evaluate the suitability of "positive predictive value-recall" (PPV-recall) diagrams for monitoring performance and providing recommendations for groups of radiologists (RUs or reading units) in breast cancer screening. This retrospective study used datasets from triennial quality assurance audits within the Dutch screening programme. The recall rate (RR), cancer detection rate (CDR), and PPV between 2010 and 2019 were plotted in PPV-recall diagrams separately for initial and subsequent screening. Using PPV-recall diagrams per year we compared variations in performance of the RUs within the screening programme. Each group's screening behaviour characteristics were evaluated over time with RU-specific PPV-recall diagrams and related audit recommendations. The dataset comprised the aggregated results of 779,887 initial and 6,021,598 subsequent screenings read by 12 RUs between 2010 and 2019. The PPV-recall diagrams showed substantial variations in the individual RU performance over time, with PPVs ranging between 4.9 and 23.7% for initial and 21.2-54.3% for subsequent screening. Target values were less often met for initial (2010: 0 RUs; 2019: 5 RUs) than for subsequent screening (2010: 8 RUs; 2019: 10 RUs), resulting in more recommendations regarding initial screening (24 versus 13). All recommendations focused on adjusting RR, which often (17 out of 24) changed in the recommended direction, though not always sufficient to meet target values. PPV-recall diagrams offer valuable insights into variations and interrelationships between screening outcomes, helping the audit team in providing recommendations for improvement. However, feedback based on these diagrams alone may not always be sufficient for individual radiologists to achieve these improvements. Question Can positive predictive value (PPV)-recall diagrams help audit teams provide recommendations to radiologists to enhance their reading performance in a breast cancer screening programme? Findings PPV-recall diagrams help audit teams identify screening outcome variation. Recall rates often changed in the desired direction after recommendations, but did not always meet targets. Clinical relevance Incorporating PPV-recall diagrams into quality assurance audits in breast cancer screening can support audit teams to provide recommendations to radiologists to maximise cancer detection and minimise false positives. Radiologists may need additional individual feedback to optimally achieve these improvements.

Purpose To develop a deep learning-based, computer-aided diagnosis (CADx) model for preoperative classification of ovarian tumors (OTs) on CT scans and to compare its performance with current US models and radiologist assessments. Materials and Methods This retrospective multicenter study (January 2021-November 2023) included patients with indeterminate OTs. The dataset comprised training, internal (n = 360), and external test (n = 27) sets. Final histopathology served as the reference standard. The CADx model was trained using self-supervised learning on public and institutional CT datasets. Performance of the CADx model was compared with that of two current US-based models (Risk of Malignancy [RMI] and Assessment of Different NEoplasias in the adneXa [ADNEX] models) and with radiologist reports. Metrics included the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and positive and negative predictive values, with comparisons assessed using 95% CI overlap. Results The dataset contained 387 OT images from 344 patients (226 benign and 118 malignant OTs). The model achieved a median AUC of 0.84 (95% CI: 0.65, 0.92) on the internal test set and 0.61 (95% CI: 0.59, 0.65) on the external test set. The CADx model performed comparably with the two US models and radiologists. On the internal test set, AUCs for RMI, ADNEX, and radiologists were 0.77 (95% CI: 0.72, 0.83), 0.68 (95% CI: 0.51, 0.84), and 0.76 (95% CI: 0.69, 0.83), respectively. On the external test set, corresponding AUCs were 0.66 (95% CI: 0.44, 0.88), 0.86 (95% CI: 0.60, >0.99), and 0.67 (95% CI: 0.26, >0.99), respectively. The CADx model yielded the highest sensitivity (94.7%). Conclusion Despite disease and data variability, this CT-based deep learning model for preoperative OT classification achieved comparable performances to US models and radiologists on internal and external test sets, but further refinement is needed before clinical implementation. Keywords: Ovarian Tumor Classification, Ovarian Cancer, Computer-aided Diagnostics, Multicenter Trial Clinical trial registration no. NTC05174377 Supplemental material is available for this article. © RSNA, 2026.

Management of asymptomatic severe mitral regurgitation (MR) is challenging. Both early mitral valve repair surgery and active surveillance with facilitated surgery are possible strategies. The DutchAMR registry compares clinical outcomes between these two strategies. Patients were included between 2013-2019. Primary endpoints were cerebrovascular accidents (CVA), reoperations, and mortality. Facilitated surgery was defined as mitral valve repair surgery performed after developing asurgical indication during active surveillance. Ninety-nine patients were enrolled; 71in active surveillance and 28in early surgery. Over amedian follow-up time of 5.1years, 51% of active surveillance patients underwent facilitated surgery due to ESC guideline triggers. Both the early and facilitated surgery groups had one perioperative CVA. During follow-up, in the active surveillance group, 5 (7%) patients died (3without surgery and 2after facilitated surgery), and 3 (4%) underwent reoperations. In the early surgery group, 4 (14%) patients reached aprimary endpoint, including2 (7%) CVAs (without residual symptoms) and 2 (7%) deaths. No reoperations occurred in the early surgery group. Baseline additional testing parameters based on CPET, Holter monitoring, and CMR showed no differences between the groups. After 5.1years, half of the active surveillance patients required facilitated surgery, with comparable postoperative outcomes to early surgery. Clinical endpoints were comparable between the early and facilitated surgery strategies. There were no differences in baseline additional testing parameters, suggesting no clear targets for upfront stratificatio. Thus, shared decision making weighing the different risks can be used to determine the strategy per patient.

We thank Zhang et al. [1] for their comments on our study [2]. They raised concerns about residual confounding related to frailty and the omission of transfusion volume and timing from the analysis. Frailty is a challenging confounder as it encompasses a heterogeneous, multidimensional syndrome that cannot be captured by a single variable [3]. Guidelines have only recently recommended incorporating frailty assessment into the pre-operative evaluation of older adults. Consequently, most registry datasets do not capture this information [3]. The primary aim of our analysis was to approximate causal relationships as closely as possible within the constraints of registry data, using robust statistical methods and accounting for confounders in each pathway of the mediation framework. To quantify residual confounding, we calculated an E-value of 2.48 (lower 95%CI 2.10), indicating that an unmeasured confounder would need to be associated with both pre-operative anaemia and mortality with an odds ratio of at least 2.48 to fully explain the observed association. Given the confounders already adjusted for and the strength of association required, it is unlikely that frailty alone would explain the observed effect. Regarding transfusion quantity and timing, modelling transfusion as a binary variable may obscure clinically relevant dose-dependent effects, limiting our conclusions to red blood cell transfusion vs. no transfusion. Nevertheless, in elective cardiac surgery, high-volume transfusion is uncommon, with most patients receiving 1–2 units due to low baseline haemoglobin and surgical blood loss [4]. Our sensitivity analysis in patients without postoperative cardiac reinterventions ruled out the effect of high-volume transfusions. More importantly, the clinical implications remain clear. The key pillar of patient blood management guidelines is the identification and treatment of pre-operative anaemia to reduce red blood cell transfusion requirements [5]. Regardless of when transfusion occurs or whether this is low- or high-volume, by identifying and treating pre-operative anaemia, clinicians can reduce the need for peri-operative transfusion. We agree that future research should incorporate additional variables including the underlying causes of anaemia. This will help improve patient blood management further.

Discussing end-of-life care with people with dementia and their family soon after diagnosis is a crucial aspect of professional care. Research in the hospital setting is scarce. To investigate how often end-of-life issues and euthanasia are discussed during hospital consultations with people with dementia; identify who initiates these conversations; explore physicians' perceptions of their own role in these conversations compared to actual practice and physicians' views on the family's involvement. Convergent mixed-method study.Setting/participant:11 Dutch hospitals involving 31 physicians. End-of-life topics were discussed in 36% of consultations (in regional hospitals, 53%; in academic settings, 27%), and predominantly during diagnostic consultations (54%). Euthanasia was discussed in 21%, often initiated by the patient (60%) or the family (31%). Family members were present in 96% of consultations. We identified 3 themes. (1) Struggle to initiate end-of-life conversations. Physicians acknowledged the importance of timely end-of-life discussions, but struggled to initiate those discussions. Introducing euthanasia is considered undesirable. (2) Appreciation and concern about family input. Physicians' experiences of family involvement were positive in both end-of-life and euthanasia conversations, yet the latter also raised concerns. (3) Moral concerns regarding euthanasia for dementia. Physicians emphasized the importance of raising patient awareness about other end-of-life options. End-of-life conversations with patients with dementia are not standard practice in the hospital setting. The availability of euthanasia can narrow patients' perspective on other end-of-life options. This hinders physicians from initiating end-of-life conversations and possibly end-of-life decision making and care.

Currently, there are no available fast-acting agents to control the ventricular rate (VR) during atrial fibrillation (AF) episodes that can be self-administered by patients on an as-needed basis without medical supervision. Here, we aim to evaluate the effect of intranasal etripamil on VR in patients treating presumed paroxysmal supraventricular tachycardia (PSVT) episodes later identified as AF. NODE-303 is a phase 3, multicenter, open-label study to evaluate the safety and efficacy of self-administered intranasal etripamil. The study enrolled adult (≥ 18 years) patients with prior documented PSVT. Patients self-administered 70 mg of intranasal etripamil after applying an ECG monitor and performing a vagal maneuver. An optional second 70 mg dose was permitted if symptoms persisted after 10 min. This post hoc analysis specifically focused on AF patients (those with presumed PSVT episodes subsequently identified as AF) and evaluated the change from baseline VR (beats per minute, bpm), calculated using patient ECG data that was recorded through 60 min after drug administration, during an etripamil-treated AF episode. Of 1116 total enrolled patients, 503 self-administered ≥ 1 dose of etripamil for presumed PSVT, and 18 had ≥ 1 episode(s) later identified as AF with adequate ECG data. AF episode baseline median VR (range) was 127 bpm (79, 164), and the average maximum reduction in VR was 27.4 bpm ± 6.1 at 22 min. VR reduction was sustained for at least 30 to 60 min (median VR reduction -22 and -18 bpm, respectively). No serious adverse events or adverse events of special interest were observed, including bradyarrhythmias, AV block, or sinus pauses ≥ 3 s, and treatment-emergent adverse events were mild to moderate, transient, and related to the nasal administration route. In this post hoc subgroup analysis of the open-label NODE-303 trial, self-administered etripamil nasal spray led to a clinically significant and sustained VR reduction in patients with symptomatic AF. Further studies are needed to confirm efficacy in a broader AF population. Self-administered etripamil may help to acutely control symptomatic AF-RVR episodes outside of the healthcare setting. NCT04072835.

BackgroundGonorrhoea is an infection caused by Neisseria gonorrhoeae. It is considered a significant public health problem. Asymptomatic infections are common, especially in women, and can lead to systemic dissemination.Case presentationWe discuss a unique case of a 48-year old woman presenting with disseminated gonococcal infection (DGI) complicated by pleural and pericardial effusions. Microbiological confirmation was obtained by N. gonorrhoeae polymerase chain reaction on pleural fluid. The patient was successfully treated with intravenous ceftriaxone and pleural drainage. We provide a comprehensive review of the literature on gonococcal pleuritis and pericarditis. Both are rare complications of (DGI), but the combination has never been described in literature.ConclusionThis case highlights the importance of early recognition and treatment of gonorrhoea and DGI to prevent severe complications.Clinical trialNot applicable.

Several factors, including device design, annulus size, and sizing strategies, influence transcatheter heart valve (THV) haemodynamic outcomes in patients with aortic stenosis (AS). This sub-study evaluates early (30-day) echocardiographic outcomes of the Myval, Sapien, and Evolut THV series, focusing on haemodynamic performance and valve durability. The LANDMARK trial is a prospective, randomised, multicentre, open-label, non-inferiority trial comparing 384 patients implanted with Myval THV series to 384 receiving Sapien and Evolut THV series. Haemodynamic assessments followed Valve Academic Research Consortium-3 recommendations. At 30-day, haemodynamic device success rates were 85.9%, 77.8, and 85.4% for Myval, Sapien, and Evolut THV series, respectively (PMyval-Sapien = 0.03 and PMyval-Evolut = 0.98). Significant improvements in peak aortic flow velocity, pressure gradients, effective orifice area (EOA), Doppler velocity index (DVI), and cardiac indices were observed across all groups, except for unchanged left ventricular ejection fraction. Moderate prosthesis-patient mismatch (PPM) was less frequent with Myval THV series(11.3%) vs. Sapien THV series(21.8%), but higher than Evolut THV series (5.3%) (PMyval-Sapien = 0.0024, PMyval-Evolut = 0.0396), while severe PPM showed no significant differences (4.2% vs. 6.3% vs. 1.8%; PMyval-Sapien = 0.394, PMyval-Evolut = 0.2438). Rates of ≥ moderate paravalvular leak (PVL) were lower in Myval (3.5%), and Sapien (1.7%) compared with Evolut THV series (8.3%) (PMyval-Sapien = 0.3769, PMyval-Evolut = 0.0336). Myval THV series required minimal oversizing compared with Evolut THV series (P < 0.0001). The Myval THV series demonstrates short-term haemodynamic performance comparable to Evolut THV series and superior to Sapien THV series. Including intermediate sizes minimizes oversizing, underscoring its potential as an alternative for TAVI patients. Long-term follow-up is necessary to confirm these findings. ClinicalTrials.gov: NCT04275726, EudraCT number 2020-000,137-40.