Care In Early Stages Research Articles

Socioeconomic Factors' Impact on Survivorship in Patients with Cervical Cancer: A Study from the Tertiary Cancer Center in Muzaffarpur, North Bihar, India

ObjectiveTo ascertain the survivorship among cervical cancer patients and the factors responsible for early death. In India, cervical cancer ranks second among cancer-related deaths among women. Estimating the survivability rate of patients with cervical cancer who come to our tertiary cancer care center was imperative, as was figuring out.What was causing the greater death rate.MethodThe present study is a retrospective audit of cervical cancer registered at our hospital-based cancer registry from 2021 till date.ResultThe three-year survival rate among women with late-stage cervical cancer was 45%, while 100% of women with early-stage care were alive at the end of three years. The survival rate was also poor among women belonging to middle and low socioeconomic status and illiterate women.ConclusionAmong women who have cervical cancer, those with early-stage cancer, who are literate and those who belong to above middle socioeconomic status have higher survivorship than their counterparts.

Validation of the NULL-EASE Score for Predicting Survival in a Multiethnic Asian Cohort of Out-of-Hospital Cardiac Arrest.

NULL-PLEASE is a simple and accurate clinical scoring system developed in a Western cohort of patients with out-of-hospital cardiac arrest (OHCA). The need for blood test results limits its use in early stages of care. We adapted and validated the NULL-EASE score (without laboratory tests) in an independent, multiethnic Asian cohort of patients with out-of-hospital cardiac arrest. Using the Singapore OHCA registry, we included consecutive adult patients with out-of-hospital cardiac arrest who survived to hospital admission between April 2010 to December 2020. In-hospital mortality was the primary outcome. Logistic regression analyses were performed with STATA MP v18. Of 3274 patients (median age 64, interquartile range 54-75; 67.9% male) included in the study, 2476 (75.6%) had in-hospital mortality. NULL-EASE score was significantly lower in survivors compared with nonsurvivors (median [inter quartile range] 3 [1-4] versus 6 [4-7]; P<0.001) and strongly predictive of mortality (area under receiver operating characteristic, 0.81 [95% CI, 0.79-0.83]). Patients with a score of ≥3 had higher odds of mortality (adjusted odds ratio, 8.11 [95% CI, 6.57-10.00]) when compared with those with lower scores, after adjusting for sex, residential arrest, diabetes, respiratory disease, and stroke. A cutoff value of ≥3 predicted mortality with 92.2% sensitivity, 84.1% positive predictive value, 46.1% specificity, and 65.5% negative predictive value. NULL-EASE score performed better in younger compared with older patients (area under receiver operating characteristic, 0.82 versus 0.77, P=0.008). The NULL-EASE score has good discriminative performance (sensitivity and accuracy) in our multiethnic Asian cohort, but the cutoff of ≥3 falls short of the desired level of specificity for therapeutic decision-making.

The development of working alliance in early stages of care from the perspective of patients attending a chiropractic teaching clinic

BackgroundThe clinician-patient relationship has consistently been found to predict treatment success in both physical and mental health settings. This relationship has been operationalised in the literature as “Working Alliance,” which consists of three key components: patient-clinician agreement on the goals of care, agreement on the tasks required to achieve those goals, and the establishment of a strong bond. While research has demonstrated the impact of working alliance in physical health settings, it often measures working alliance early in patients’ care journeys. However, no primary research has investigated how early working alliance develops between patients and chiropractors. Evidence suggests that musculoskeletal practitioners may require further training to feel confident in establishing working alliance. Therefore, this study aims to explore the development of working alliance in the early stages of chiropractic care from the patients’ perspective to inform evidence-based practice.MethodsParticipants for this qualitative study were recruited from a teaching clinic at a specialised healthcare professions training university in the United Kingdom between September 2022 and April 2023. A total of 25 adult patients completed semi-structured interviews during the early stages of their care. The interview transcripts were analysed using Reflexive Thematic Analysis, from a critical realist stance.ResultsThe findings highlight that an early working alliance entails the gradual development of patients’ confidence in their decision to seek help from trainee chiropractors to alleviate their symptoms. The four themes describe the impact of the clinical context on patients’ expectations, the trainee chiropractors’ qualities that participants considered important for early working alliance, the role of explanations, and the interplay between pain and early working alliance.ConclusionsEstablishing an early trainee chiropractor-patient working alliance involves a process of building patients’ confidence in the trainee chiropractors’ expertise, identifying the correct goals of care, and recognising the value of the proposed treatment plan. Factors shaping this process include the context of the care journey, patients’ perceptions of trainee chiropractors’ qualities, their bodily sensations, their expectations, their past experiences, and their satisfaction with trainee chiropractors’ explanations.

Association between cooling temperature and outcomes of patients with heat stroke

This study explored the relationship between body temperature and adverse outcomes in patients with heat stroke to identify the optimal target body temperature within the first 24 h. This retrospective, multicentre study enrolled 143 patients admitted to the emergency department and diagnosed with heat stroke. The primary outcome was the in-hospital mortality rate, while secondary outcomes included the presence and number of damaged organs and neurological sequelae at discharge. A body temperature curve was built using a generalized additive mixed model, and the association between body temperatures and outcomes was established by logistic regression. The threshold and saturation effects were used to explore the targeted body temperature management. Cases were divided into the surviving and non-surviving groups. The cooling rate within the first 2 h was significantly higher in the survival group than the non-survival group (β: 0.47; 95% confidence interval [CI]: 0.09–0.84; P = 0.014), while the non-survival group exhibited a lower body temperature within 24 h (β: − 0.06; 95% CI: − 0.08 to − 0.03; P ≤ 0.001). Body temperature after 2 h (odds ratio [OR]: 2.27; 95% CI: 1.14–4.50; P = 0.019) and lowest temperature within 24 h (OR: 0.18; 95% CI: 0.06–0.55; P = 0.003) were significantly related to in-hospital mortality rate. When the body temperature at 0.5 h was 38.5–40.0 °C, the number of damaged organs was at its lowest. In patients with heat stroke, both hyperthermia and hypothermia were associated with adverse outcomes. Hence, an accurate body temperature management is required during the early stages of care.

B cell-dependent subtypes and treatment-based immune correlates to survival in stage 3 and 4 lung adenocarcinomas.

Lung cancer is the leading cause of cancer-related deaths worldwide. Surgery and chemoradiation are the standard of care in early stages of non-small cell lung cancer (NSCLC), while immunotherapy is the standard of care in late-stage NSCLC. The immune composition of the tumor microenvironment (TME) is recognized as an indicator for responsiveness to immunotherapy, although much remains unknown about its role in responsiveness to surgery or chemoradiation. In this pilot study, we characterized the NSCLC TME using mass cytometry (CyTOF) and bulk RNA sequencing (RNA-Seq) with deconvolution of RNA-Seq being performed by Kassandra, a recently published deconvolution tool. Stratification of patients based on the intratumoral abundance of B cells identified that the B-cell rich patient group had increased expression of CXCL13 and greater abundance of PD1+ CD8 T cells. The presence of B cells and PD1+ CD8 T cells correlated positively with the presence of intratumoral tertiary lymphoid structures (TLS). We then assessed the predictive and prognostic utility of these cell types and TLS within publicly available stage 3 and 4 lung adenocarcinoma (LUAD) RNA-Seq datasets. As previously described by others, pre-treatment expression of intratumoral 12-chemokine TLS gene signature is associated with progression free survival (PFS) in patients who receive treatment with immune checkpoint inhibitors (ICI). Notably and unexpectedly pre-treatment percentages of intratumoral B cells are associated with PFS in patients who receive surgery, chemotherapy, or radiation. Further studies to confirm these findings would allow for more effective patient selection for both ICI and non-ICI treatments.

Earlier initiation of palliative care in the disease trajectory of people living with dementia: a scoping review protocol

IntroductionWhile the need for palliative care for people living with dementia has widely been recognised, they continue to be a disadvantaged group when it comes to timely initiation, and controversies...

Abstract SS2-05: Emerging from COVID-19 pandemic: Provider perspective on use of neoadjuvant endocrine therapy (NET) in early stage hormone receptor positive breast cancer

Introduction During the coronavirus 2019 (COVID-19) pandemic in USA, NET use has been recommended to allowsafe deferral of surgical treatment in early stage, estrogen receptor positive breast cancer (ER+BC) In suchcircumstances, after NET use there is limited guidance on locoregional treatment, especially with management of the axilla We aimed to evaluate patterns of care in early stage ER+BC during the first several months of theCOVID-19 pandemic Method A cross-sectional, 30-item survey was developed using a standardized surveydevelopment framework The survey was administered May 8 - June 12, 2020 to a convenience sample of medicaloncologists (MO), radiation oncologists (RO), and surgeons (SO) - breast committee members of two nationalcooperative groups (Alliance and SWOG) with additional participation through chain referrals Providers were presented with general questions on NET use before and during the pandemic They were asked their propensity foromitting axillary lymph node dissection (ALND) after NET if 1 micrometastatic node is found on sentinel lymph nodebiopsy, based on duration of NET Results 114 providers from 29 US states completed the survey - 42 (37%) MO, 14(12%) RO, and 58 (51%) SO, the majority (N=73/96, 76%) with practices dedicated ≥ 75% to BC, at NCI designatedcomprehensive cancer centers 52% (N=48/94) and in large cities (N=49/94, 52%) Prior to COVID-19, most rarely(N=49/107, 46%) or sometimes (N=36, 33%) used NET for early stage ER+BC Nearly half were willing to delay surgery up to 2 months (46%) and 3 months (21%) without use of NET (Table 1, p<0 05) Most providers wouldperform a genomic assay on the biopsy specimen on all or select patients prior to NET initiation, more frequently byMO compared to RO and SO (90% vs 75% and 60%, p<0 05) The most preferred regimen was tamoxifen (withoutovarian suppression) for premenopausal patients and aromatase inhibitor for postmenopausal patients Mostplanned to use NET for as little time as possible until surgery could proceed When stratified by specialty, more MOstated they would vary the duration of therapy based on patient's risk of cancer progression Most providersrecommended omitting ALND after 1, 2, or 3 months of NET (1 month N=56/93, 60%;2 months N=54/92, 59%;3months N=48/90, 53%) With longer duration of therapy, the propensity for omitting ALND decreased (definitely omitafter 6 months N=25/91, 27%;probably omit after 6 months N=38/91, 42%;definitely omit after 1 year N=26/92,28%;probably omit after 1 year N=29/92, 32%) Omitting ALND was not associated with provider's years in practice,percent of practice dedicated to BC, practice type or setting, participation in multidisciplinary tumor board, or numberof COVID-19 cases in the provider's practicing state ConclusionMost providers changed their management of early stage ER+BC during the COVID-19 pandemic by utilizing NET until surgery could proceed As the duration of NET extended, more providers favored ALND in low volume axillary metastatic disease in early stage ER+BC Additional data to inform the care on post-NET locoregional management is needed

QIM19-124: Does Virtual Navigation Improve Care Continuity and Compliance in Patients With Early Stage Colon Cancer?

Background: Colon cancer is the 3rd most common cancer in men and women combined, with an occurrence rate of 4.49% for men and 4.15% for women. The 2018 expectation is 50,630 deaths related to colon cancer in the United States (American Cancer Society Facts and Figures 2018). Early detection is increasing with nearly 45% of colon cancers diagnosed as stage I/II (Sarah Cannon Cancer Registry 2015). Treatment for early stage I/II colon cancer patients usually involves surgery then surveillance. On-site navigators perform their duties by patient need and barriers to care. Late stage III/IV colon cancer patients require more assistance and face more barriers, which often leaves early stage I/II patients without an advocate. This disparity can lead to lower rates of follow-up care for early stage I/II patients. Sarah Cannon created a program for virtual colon navigation (VCN) to determine if early stage I/II patients benefit from a virtual navigator who offers support by phone throughout their disease process. Objectives: The goal was to increase early stage I/II patients’ knowledge of their cancer and convey the importance of compliance with follow-up care, such as repeat colonoscopy as recommended by their physician and NCCN Guidelines. Methods: By developing software that utilizes artificial intelligence, Sarah Cannon created an automated process to identify colon cancer patients at the time of diagnosis. This technology then routes positive pathology reports to a VCN who contacts the early stage I/II patients by telephone, ensuring patient connection to the suitable physician for treatment. The VCN helps patients understand their diagnosis, provides education, assesses barriers to care, connects to resources, provides emotional support, and offers assistance with follow-up for physician visits, imaging and procedures such as colonoscopies, based upon NCCN Guidelines and physician guidelines. The VCN also connects stage III/IV patients with an on-site navigator in their region for more hands-on navigation. Results: Through September 2018, Sarah Cannon navigated 734 colon cancers, 332 stage I/II and 402 stage III/IV. With our increased capacity, Sarah Cannon/HCA maintained a 98% rate of follow-up care with new diagnoses of all stages of colon cancer. Conclusions: The VCN program allowed Sarah Cannon/HCA to improve care continuity and compliance based upon NCCN Guidelines for early stage I/II colon cancer patients throughout 5 regions and 37 facilities.

Comment améliorer l’adhésion aux soins des adolescents suicidants après une prise en charge aux urgences : une revue de la littérature

ObjectivesSuicidal adolescents admitted in an Emergency Department (ED) present a high risk of suicidal reattempts. Poor observance of follow-up in this particular group imped the efficacity of the treatment. We propose to summarize the international literature on ED interventions promoting suicidal adolescents’ adherence to care. MethodWe carried out a comprehensive review of papers listed in PubMed, PsycInfo, and CINHAL databases using keywords about adolescence, suicide, and ED. We also manually consulted the main journals specialized in suicidology (Crisis and Suicide and Life-Threatening Behavior) and adolescence (Journal of the American Academy of Child and Adolescent Psychiatry, Journal of Adolescent Health, Neuropsychiatrie de l’Enfance et de l’Adolescence). We selected the relevant articles describing or evaluating one or more interventions initiated in the ED and designed to promote adolescent adherence to post-emergency care. The results are presented in a narrative review form. ResultsInterventions are organized in three groups: interventions that take place solely at the ED (problem-solving interventions and educational interventions directed to families) and interventions that take place during and after emergency care (we included in this group the ED-Care program, the FISP program, and the SAFETY program), to which should be added interventions that take place prior to care, in particular specific trainings for medical and paramedical teams. Small samples and barriers in measuring adherence to care make statistical comparisons difficult, yet the interventions that seem most effective are those that target the time both during and after ED discharge, those which are implemented most rapidly after discharge, those which actively include parents, and those which involve an implication of the families about barriers to follow-up. ConclusionOur results show an effectiveness of complete programs on short-term compliance but no conclusion can be drawn on long-term effects. Most comprehensive care programs are based on the principle of adolescent compliance, which remains problematic. Until today, no ideal protocol exists to improve short-term as well as long-term compliance to care among adolescents after a suicide attempt. We have to improve our understanding of facilitators and barriers to follow-up using quantitative as well as qualitative research studies. Although it is well established that parents’ involvement in the early stages of care is essential, little is known about the underlying processes. In these situations, qualitative studies could help to better target interventions that lead more particularly to follow up compliance in adolescence.

Fear affects parental care, which predicts juvenile survival and exacerbates the total cost of fear on demography.

Fear itself (perceived predation risk) can affect wildlife demography, but the cumulative impact of fear on population dynamics is not well understood. Parental care is arguably what most distinguishes birds and mammals from other taxa, yet only one experiment on wildlife has tested fear effects on parental food provisioning and the repercussions this has for the survival of dependent offspring, and only during early-stage care. We tested the effect of fear on late-stage parental care of mobile dependent offspring, by locating radio-tagged Song Sparrow fledglings and broadcasting predator or non-predator playbacks in their vicinity, measuring their parent's behavior and their own, and tracking the offspring's survival to independence. Fear significantly reduced late-stage parental care, and parental fearfulness (as indexed by their reduction in provisioning when hearing predators) significantly predicted their offspring's condition and survival. Combining results from this experiment with that on early-stage care, we project that fear itself is powerful enough to reduce late-stage survival by 24%, and cumulatively reduce the number of young reaching independence by more than half, 53%. Experiments in invertebrate and aquatic systems demonstrate that fear is commonly as important as direct killing in affecting prey demography, and we suggest focusing more on fear effects and on offspring survival will reveal the same for wildlife.

The effects of patient and physician characteristics on early outpatient satisfaction with substance dependence care: results of the SUBUSQOL study.

BackgroundAlthough patient perceptions of health care have increasingly been explored in the literature, little is known about care satisfaction among individuals with substance dependence. This exploratory study assessed the relationships between patient and physician characteristics and early outpatient satisfaction with care for alcohol and opioid dependence.MethodsSatisfaction was assessed using a multidimensional, self-administered and validated questionnaire during the early care process among a prospective outpatient cohort. In addition to measuring satisfaction and obtaining sociodemographic and clinical data, this study collected data on the self-reported health status and physician characteristics at inclusion. Cross-sectional analysis with multiple linear regression was performed to identify the variables associated with satisfaction level.ResultsA total of 249 outpatients were included, and 63.8% completed the satisfaction questionnaire. Patients without a history of previous care for substance dependence were more satisfied with the appointment-making process (β=7.2; P=0.029) and with the doctor consultation (β=10.3; P=0.003) than those who had received care previously. Neither sociodemographic characteristics nor self-reported health status was associated with outpatient satisfaction.ConclusionThe factors that affect patients’ ratings of early satisfaction with the care that they receive should be studied further because increased understanding of the factors that negatively affect these ratings might enable caregivers and outpatient management facilities to improve the patient experience during the early stages of care, which might in turn improve treatment adherence, continuity of care, and other health-related outcomes.

Motivations and Barriers in Promoting Preschool Education

AbstractThis study is designed to explore the reasons for sending and not sending preschool age children to preschools at an early age by exploring the motivations for and barriers towards promoting preschool education in Turkey. It aimed to determine various stakeholders' perceptions, attitudes, and knowledge related to preschool education in order to promote high-quality and comprehensive preschool education. The research was conducted with 224 participants in five cities in Turkey. Qualitative data was collected through individual and focus group interviews and interpreted by content analysis and descriptive analysis. The findings indicated that families put forward the following reasons for sending their children to preschool: preschool education prepares children for school and helps form the habit of attending school, teachers' efforts in convincing parents to send their children to preschool, providing the care for the children of working mothers with preschool teachers , and preschool helps children develop social behavior. The following factors were reasons families did not send their children to preschool: economic conditions, perceiving the child as too young, concerns over practices at school, perceptions about the mother's role, and distrust of the transportation system. The results will help decision makers develop policies and strategies to heighten the general public's awareness of the need for early education, as well as better provide early education opportunities.KeywordsPreschool education · Motivation · Barrier · Pre-schooling · Dissemination of preschool educationResearch is well established in showing that access to a high-quality early childhood education has a direct and permanent effect at every stage of human development (Avila & Baldwin, 2007; Barnett, 2008; Blau & Currie, 2005; Heckman & Masterov, 2007; Reynolds, 1992; Reynolds, Mehana, & Temple, 1995). For this reason, in order to provide early education policies, countries determine their equality in opportunity policies and form new strategies. Many countries regulate their early childhood education practices through the state legislature and as part of the education system according to the socio-political developments of the country. These legislative regulations determine basic core values in areas like curriculum, institutional process, teacher education, personnel requirement, monitoring and finance, and parent-teacher cooperation (Bankovic, 2014; Karila, 2008; Kuisma & Sandberg, 2008; Sheridan, Williams, Sandberg, & Vuorinen, 2011).Likewise, preschool education and the preschool teacher training system have been changed and developed in Turkey. Even though kindergartens opened before 1908, they became organized and widespread following the Temporary Preschool Law dated 23 September 1913. After two years, the Law Primary school bylaws were issued in 1915.Accordingly, kindergartens were opened, whether attached or unattached to primary schools, in order to provide education for children aged four to seven (Akyuz, 1989; Cicioglu, 1989). With the opening of kindergartens, the need for trained teachers in these schools arose. In the same year as the issuance of the bylaws, a kindergarten teacher education school providing one year of education was opened in Istanbul, but it was closed after four years of operation in 1919. In this period, 370 preschool teachers were educated (Oguzkan & Oral, 1987) and preschool education took its institutional place in the education process in real terms.However, for many years, the insufficient quality and quantity of early education, the changing position of women within the family and their active roles in real life due to rapid socio-cultural and economical changes, and, most importantly, the positive impact of early education on a child's development as proven by educational studies and brain surveys demonstrate the necessity to take certain measures in the early stages of care and education of children. …

El proceso de transición de servicios pediátricos a adultos: visión de adolescentes hospitalizados portadores de enfermedades crónicas

IntroductionChronic illnesses during adolescence are a big challenge for the patient, his or her family, and health care providers. The transition from paediatric health services to adult health services involves a programmed and planned transfer process of adolescent sufferers of chronic illnesses, in order to maintain a high quality of life and bio-psycho-social development. There is currently no transition model. The objective of the study is to understand the transition process from the perspective of hospitalised adolescents to collaborate towards the design of a model that meets the needs studied. Patients and methodSemi-structured interviews with 13 adolescent sufferers of chronic illnesses, hospitalised in two healthcare centres in Santiago, Chile, in one analytical-relational study, supported by qualitative methodology. ResultsIn the analysis, 5 major themes stand out: experience of living with the illness, the importance of the doctor-patient relationship, the concept of limited autonomy to the pharmacology, the absence of the transition process as such, and the identification of barriers and needs for an adequate transition. ConclusionsThis study is new in Chile in that it explores the phenomenom of the transition of adolescents with chronic illnesses. It emphasises the need to reinforce the concept of self-care and autonomy from early stages of care, and the importance of early planning of a healthy transition process, in accordance to the detected needs of the adolescents themselves.

Early Secondary Neurologic Deterioration After Blunt Spinal Trauma: A Review of the Literature.

The objectives were to review published reports of secondary neurologic deterioration in the early stages of care after blunt spinal trauma and describe its nature, context, and associated risk factors. The authors searched the MEDLINE, EMBASE, and CINAHL databases for English-language studies. Cases were included meeting the criteria age 16 years or older, nonpenetrating trauma, and experiencing neurologic deterioration during prehospital or emergency department (ED) care prior to definitive management (e.g., discharge, spinal clearance by computed tomography, admission to an inpatient service, or surgical intervention). Results were qualitatively analyzed for characteristics and themes. Forty-one qualifying cases were identified from 12 papers. In 30 cases, the new deficits were apparently spontaneous and were not detected until routine reassessment. In 12 cases the authors did attribute deterioration to temporally associated precipitants, seven of which were possibly iatrogenic; these included removal of a cervical collar, placement of a halo device, patient agitation, performance of flexion/extension films, "unintentional manipulation," falling in or near the ED, and forced collar application in patients with ankylosing spondylitis. Thirteen cases occurred during prehospital care, none of them sudden and movement-provoked, and all reported by a single study. Published reports of early secondary neurologic deterioration after blunt spinal trauma are exceptionally rare and generally poorly documented. High-risk features may include altered mental status and ankylosing spondylitis. It is unclear how often events are linked with spontaneous patient movement and whether such events are preventable.

Zero ischemia robotic-assisted partial nephrectomy in Alberta: Initial results of a novel approach.

Partial nephrectomy remains the standard of care in early stage, organ-confined renal tumours. Recent evidence suggests that minimally invasive surgery can proceed without segmental vessel clamping. In this study, we review our experience at a Canadian centre with zero ischemia robotic-assisted partial nephrectomy (RAPN). A retrospective chart review of zero ischemia RAPN was performed. All surgeries were consecutive partial nephrectomies performed by the same surgeon at a tertiary care centre in Northern Alberta. The mean follow-up period was 28 months. These outcomes were compared against the current standards for zero ischemia (as outlined by the University of Southern California Institute of Urology [USC]). We included 21 patients who underwent zero ischemia RAPN between January 2012 and June 2013. Baseline data were similar to contemporary studies. Twelve (57.1%) required no vascular clamping, 7 (33.3%) required clamping of a single segmental artery, and 2 (9.5%) required clamping of two segmental arteries. We achieved an average estimated blood loss of 158 cc, with a 9.2% average increase in creatinine postoperatively. Operating time and duration of hospital stay were short at 153 minutes and 2.2 days, respectively. Zero ischemia partial nephrectomy was a viable option at our institution with favourable results in terms of intra-operative blood loss and postoperative creatinine change compared to results from contemporary standard zero ischemia studies (USC). To our knowledge, this is the first study to review an initial experience with the zero ischemia protocol in robotic-assisted partial nephrectomies at a Canadian hospital.

Randomised trial of the fascia iliaca block versus the ‘3-in-1’ block for femoral neck fractures in the emergency department

IntroductionFemoral neck fractures are a common and painful injury. Femoral nerve blocks, and a variant of this technique termed the ‘3-in-1’ block, are often used in this patient group, but...

Retrospective analysis of neoadjuvant chemoradiotherapy for esophageal cancer: The Knight Cancer Institute experience.

126 Background: Neoadjuvant chemoradiotherapy (NAT) followed by esophagectomy has been established as standard of care for early stage (II – III), resectable esophageal cancer (EC). Patients (pts) treated with NAT are more likely to be downstaged and have a complete (R0) resection. Additionally, pts with aggressive disease are more likely to progress during NAT and, consequently, avoid unnecessary surgery. The aim of the current report was to analyze the outcomes of trimodality therapy at the Knight Cancer Institute. Methods: A retrospective study of 124 pts who underwent NAT followed by esophagectomy for EC from 1999-2010 at our institution was performed. All pts were initially staged by imaging (EUS, CT and/or PET imaging) prior to commencing treatment. After esophagectomy, pathological staging was compared to initial staging to determine the effect of NAT. Results: There were 25 women and 99 men. Initial staging is shown in the table below. Patients received cisplatin, oxaliplatin or carboplatin with 5-FU plus concurrent radiotherapy (RT). RT total dose of 45 Gy to the tumor and regional nodes was given in 1.8 Gy daily fractions, followed by a boost to the tumor for final dose 50.4-54 Gy. 27 (21.8%) of the pts had a pathologic complete response. Additionally, 54 (43.6%) pts were downstaged by chemoradiation. Of the pts that had complete remission or were downstaged, pre-treatment clinical stage was Stage II (22 pts), Stage III (55 pts), and Stage IVa (4 pts). Conclusions: NAT was effective in complete remission or downstaging of two-thirds (81) pts, including 4 pts that were initially unresectable (Stage IVa) and successfully underwent subsequent esophagectomy. As has been shown previously, NAT is effective for downstaging prior to esophagectomy making it more likely that pts will undergo R0 resection. This study also demonstrated that some pts with clinically unresectable tumors could undergo successful esophagectomy after NAT. [Table: see text]

Formal and informal care for people with dementia: variations in costs over time

The services used by people with dementia and their carers were measured at three time points over 17 months. This analysis is unusual in that both informal care and formal inputs were costed. The costs estimates for informal inputs developed here may be applied to other data sets. Two hypotheses to explain the inter-relationship between informal and formal care inputs, substitution and supplementation, were compared in analysing the data. This paper explores the variations in costs according to the living arrangements of the people with dementia, by level of dependency and over time, and finds systematic differences. The costs of the inputs from co-resident carers consistently exceeded the costs of formal services, with informal care constituting up to 40 per cent of the total costs burden for dementia care. When informal inputs were included, non-domestic residential care emerged as less, not more, costly than care in the community. There was a shift in costs burden from health services to social services over time as more people moved into non-domestic settings. Multivariate analyses identified several predictors of informal and formal care costs: physical disability, level of cognitive impairment, living in non-domestic settings, and formal care provided. Non-domestic care predicted lower inputs of both formal and informal services. Dementia level was positively associated with informal inputs. Physical frailty was associated with more formal care, but less informal care. More formal service inputs predicted higher informal care inputs. There is evidence of supplementation of informal care by formal services in the early stages of care, followed by substitution as the person with dementia enters residential care.

Traumatic Brain Injury

Traumatic Brain Injury

Cancer in Crohn's disease: dispelling the myths.

<h3>Introduction</h3> Femoral neck fractures are a common and painful injury. Femoral nerve blocks, and a variant of this technique termed the ‘3-in-1’ block, are often used in this patient group, but their effect is variable. The fascia iliaca compartment block (FIB) has been proposed as an alternative, but the relative effectiveness of the two techniques in the early stages of care is unknown. We therefore compared the FIB versus the 3-in-1 block in a randomised trial conducted in two UK emergency departments. <h3>Methods</h3> Parallel, two-group randomised equivalence trial. Consenting patients &gt;18 years with a femoral neck fracture were randomly allocated to receive either a FIB or a 3-in-1 block. The primary outcome was pain measured on a 100 mm visual analogue scale at 60 min. The between-group difference was adjusted for centre, age, sex, fracture type, pre-block analgesia and pre-block pain score. <h3>Results</h3> 178 patients were randomised and 162 included in the primary analysis. The mean 100 mm visual analogue pain scale score at 60 min was 38 mm in the FIB arm and 35 mm in the 3-in-1 arm. The adjusted difference between the arms was 3 mm, with a 95% CI (−4.7 to 10.8) that excluded a clinically important difference between the two interventions. <h3>Conclusions</h3> FIB is equivalent to the 3-in-1 block for immediate pain relief in adult neck of femur fractures. <h3>Trial registration number</h3> ISRCTN16152419.