Context The improved remission and complication rates of current transsphenoidal surgery warrant reappraisal of the position of surgery as a viable alternative to dopamine agonists in the treatment algorithm of prolactinomas. Objective To compare clinical outcomes after dopamine agonist withdrawal and transsphenoidal surgery in prolactinoma patients. Methods Eight databases were searched up to July 13, 2018. Primary outcome was disease remission after drug withdrawal or surgery. Secondary outcomes were biochemical control and side effects during dopamine agonist treatment and postoperative complications. Fixed- or random-effects meta-analysis was performed to estimate pooled proportions. Robustness of results was assessed by sensitivity analyses. Results A total of 1469 articles were screened: 55 (10 low risk of bias) on medical treatment (n = 3564 patients) and 25 (12 low risk of bias) on transsphenoidal surgery (n = 1836 patients). Long-term disease remission after dopamine agonist withdrawal was 34% (95% confidence interval [CI], 26-46) and 67% (95% CI, 60-74) after surgery. Subgroup analysis of microprolactinomas showed 36% (95% CI, 21-52) disease remission after dopamine agonist withdrawal, and 83% (95% CI, 76-90) after surgery. Biochemical control was achieved in 81% (95% CI, 75-87) of patients during dopamine agonists with side effects in 26% (95% CI, 13-41). Transsphenoidal surgery resulted in 0% mortality, 2% (95% CI, 0-5) permanent diabetes insipidus, and 3% (95% CI, 2-5) cerebrospinal fluid leakage. Multiple sensitivity analyses yielded similar results. Conclusions In the majority of prolactinoma patients, disease remission can be achieved through surgery, with low risks of long-term surgical complications, and disease remission is less often achieved with dopamine agonists.

The basis for the diversity in the screening policies among high-income countries does not appear to relate to the screening policies' cost-effectiveness ratios, which are highly sensitive to the number of Pap smears offered during a lifetime.

Key Points Question Is cardiac telerehabilitation with relapse prevention cost-effective compared with center-based cardiac rehabilitation for the treatment of patients with coronary artery disease? Findings In this economic evaluation of data from 300 participants with coronary artery disease enrolled in the SmartCare-CAD randomized clinical trial, patients who received cardiac telerehabilitation with relapse prevention vs traditional center-based cardiac rehabilitation experienced comparable quality of life and nonsignificantly lower cardiac-associated health care costs and non–health care costs. Meaning This study found that cardiac telerehabilitation with relapse prevention was likely to be cost-effective compared with center-based cardiac rehabilitation and may be used as an alternative to center-based cardiac rehabilitation among patients with coronary artery disease.

Summary Human papillomavirus (HPV) is the main risk factor for invasive cervical cancer. High risk ratios are found in cross-sectional data on HPV prevalence. The question raised is whether this present evidence is sufficient for making firm recommendations on HPV screening. A validated cervical cancer screening model was extended by adding HPV infection as a possible precursor of cervical intraepithelial neoplasia (CIN). Two widely different model quantifications were constructed so that both were compatible with the observed HPV risk ratios. One model assumed a much longer duration of HPV infection before progressing to CIN and a higher sensitivity of the HPV test than the other. In one version of the model, the calculated mortality reduction from HPV screening was higher and the (cost-)effectiveness was much better than for Pap smear screening. In the other version, outcomes were the opposite, although the cost-effectiveness of the combined HPV + cytology test was close to that of Pap smear screening. Although small follow-up studies and studies with limited strength of design suggest that HPV testing may well improve cervical cancer screening, only large longitudinal screening studies on the association between HPV infection and the development of neoplasias can give outcomes that would enable a firm conclusion to be made on the (cost-)effectiveness of HPV screening. Prospective studies should address women aged 30-60 years.Keywords: cervical cancer; human papilloma virus; mass screening; Pap smear; cost-effectiveness Molecular and epidemiological studies have clearly demonstrated that HPV is the main risk factor for cervical cancer (IARC working group, 1995;Zur Hausen, 1994). These epidemiological studies are case-control studies that consistently show a very highrisk ratio for HPV in women with (precursors of) cervical cancer compared with controls with negative cytology (Morrison et al, 1991; Munoz et al, 1992; Elut-Neto et al, 1994;De SanJose et al, 1994). The association between CIN and high-risk HPV infection is stronger in high-grade than in low-grade abnormalities (van den Brule et al, 1991;Bergeron et al, 1992;Lorincz et al, 1992;Gaarenstroom, 1994; Kjear et al, 1996) and is well over 90% in invasive cancers (van den Brule et al, 1991;Bosch et al, 1995). A few small follow-up studies also corroborate the crucial role of HPV infections: progression is found almost only in women with (persistent) high-risk HPV genotypes both in normal (Rozendaal et al, 1996) and in dysplastic cases Remmink et al, 1995). In a small retrospective study on archived false-negative smears from women with subsequent invasive cervical cancer, the high-risk HPV types found in the cancers were detected in nearly 100% of the preceding smears (Munoz et al, 1992;Bauer et al, 1993;Cuzick et al, 1995;Rozendaal et al, 1996). This is much higher than can be explained by the life-time risk of developing cervical cancer in these countries. For example, in the Netherlands, the rate for high-risk HPV types in woman aged 30+ with norm...

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