EPIC Group Research Articles

Can EPIC Be a Low-Cost Alternative to HIPEC in Advanced Epithelial Ovarian Cancer in Resource-Constraint Settings? Experience from Tertiary Care Oncology Center.

Management of advanced ovarian cancer underwent a paradigm shift with advent of cytoreductive surgery and intraperitoneal chemotherapy. Hyperthermic intraperitoneal chemotherapy requires complex machinery and costly disposables, and increased operative time. Early postoperative intraperitoneal chemotherapy is a relatively less resource-intensive alternative way of intraperitoneal drug delivery. We started our HIPEC programme in 2013. In select cases, we offer EPIC. This study is an audit of outcomes to look into the feasibility of EPIC as alternative to HIPEC. We performed analysis of prospectively maintained database in the Department of Surgical oncology from January 2019 to June 2022. We had 15 patients who underwent CRS + EPIC and 84 CRS+ HIPEC. We did a propensity-matched analysis for demographics, baseline data and PCI and compared 15 CRS + EPIC with 15 CRS + HIPEC patients. We compared the perioperative outcomes-morbidity, mortality, length of ICU and hospital stay. Procedure time was significantly higher in the HIPEC compared to EPIC as HIPEC is an intraoperative procedure. Patients were admitted to intensive care unit (ICU) after surgery for a longer mean duration in HIPEC arm (1.4 + 0.7 days) compared to EPIC arm (1.2 + 0.41 days). Patients in HIPEC arm had a significantly shorter hospital stay (mean 7.93 vs. 9.93 days. Four patients in EPIC arm had Clavien-Dindo grade 3 and 4 morbidity compared to 1 patient in HIPEC arm. Hematological toxicity was more common in EPIC group. CRS with EPIC can be explored as an alternative to HIPEC in centres lacking facilities and expertise for HIPEC.

Excess Reintervention With Mitroflow Prosthesis for Aortic Valve Replacement: Ten-Year Outcomes of a Randomized Trial

BackgroundCurrent bioprostheses are considered to have improved durability and better hemodynamic performance compared with previous designs, but there are limited comparative data on late outcomes. MethodsFrom 2009 through 2011, 300 adults with severe aortic valve stenosis undergoing aortic valve replacement (AVR) were randomly assigned to receive Edwards Magna, St Jude Epic, or Sorin Mitroflow bioprostheses (n = 100, n = 101, n = 99, respectively). Overall survival was analyzed using Kaplan-Meier and Cox proportional hazards methods, whereas competing risk analysis was used for all time-to-event outcomes. Serial echocardiographic data were fitted with longitudinal models stratified by implant valve size. ResultsDuring median follow-up of 9.8 years (interquartile range, 8.7-10.2), 10-year survival was 50% for the Magna group, 42% for the Epic group, and 41% for the Mitroflow group (P = .415). Cumulative risk of stroke was 9% at 10 years, and rates were comparable for the three groups. Indexed aortic valve area and mean gradients were similar among the three groups receiving 19 mm and 21 mm valves, but in larger (23 mm or more) prostheses, gradients were lower (P < .001) and indexed aortic valve areas were higher in the Magna group (P < .001). The 10-year risk of endocarditis differed by group (P = .033), with higher incidence in the Mitroflow vs the Magna group (7% vs 0%, P = .019). Late risk of reinterventions in the Mitroflow group was 22%, compared with 0% in the Magna group (P < .001) and 5% in the Epic group (P = .008). ConclusionsThe Magna valve had the lowest gradients and largest indexed aortic valve area with larger implant sizes. The Mitroflow bioprosthesis is associated with an increased rate of reintervention and possible increased risk of infection compared with Magna and Epic valves.

Modes of the bioprosthetic valve failure of the porcine and pericardial valves in the mitral position.

This study was conducted to examine the incidence and modes of the bioprosthetic valve failure of the porcine valve in the mitral position and compare them with those of the pericardial valve. This study included 240 patients (116 men [48.3%]; mean age, 74.87 ± 6.61 years) who underwent mitral valve replacement using the St. Jude Medical Epic bioprosthesis (Epic) (N = 125) or Carpentier-Edwards Perimount (CEP) pericardial valve (N = 115) from January 2000 to December 2020. The median clinical follow-up durations in the Epic and CEP groups were 54.5 months (range, 0-111 months) and 81.5 months (range, 0-194 months), respectively. Structural valve degeneration (SVD) was observed in 9 patients (7.2%) in the Epic group and 11 patients (9.6%) in the CEP group. The rates of freedom from SVD at 3, 5 and 7 years were 97.7%, 90.5% and 75.5% in the Epic group and 100.0%, 96.1% and 90.0% in the CEP group, respectively. SVD reoperation was performed for 7 patients (5.6%) in the Epic group and 6 patients (5.2%) in the CEP group. The rates of freedom from SVD reoperation at 3, 5 and 7 years were 97.7%, 90.5% and 75.5% in the Epic group and 100%, 96.1% and 90.0% in the CEP group, respectively. Epic SVD was predominantly due to leaflet tearing, whereas CEP SVD was predominantly due to leaflet calcification and adhesion to the subvalvular apparatus. SVD of the porcine valve was predominantly due to leaflet tearing. The rate of reoperation for SVD was slightly higher for the porcine valve in the mitral position than for the pericardial valve at adjusted survival analysis.

Impact of Be EPIC on Person-Centered Communication

This study assessed the impact of Be EPIC, a dementia-focused, person-centered communication intervention for personal support workers (PSWs). Video-recorded conversations between PSWs and simulated persons with dementia assessed whether Be EPIC participants (n=13) (versus a wait-list control group, n=8) reported a greater proportion of person-centered communication utterances (recognition, negotiation, facilitation, validation). We used linear mixed model analysis to investigate if Be EPIC influenced PSWs’ person-centered communication. Group (Be EPIC versus control group), time (pre-, post-, and 3-months) and their interaction were included in the model. There was a significant group by time interaction. Follow-up tests showed that participants who took Be EPIC showed significant increases in person-centered utterances from pre- to post-training and pre-training to 3 months later. Participants in the control group showed no changes in person-centered communication. These findings show that Be EPIC enhanced person-centered communication, which is essential for quality of care.

Comparison Between Steroid and 2 Different Sites of Botulinum Toxin Injection in the Treatment of Lateral Epicondylalgia: A Randomized, Double-Blind, Active Drug-Controlled Pilot Study

ObjectiveTo compare the effects of 2 different injection sites of low doses of botulinum toxin type A with steroid in treating lateral epicondylalgia. DesignDouble-blind, randomized, active drug-controlled trial. SettingTertiary medical center. ParticipantsPatients with lateral epicondylalgia for >6 months were recruited from a hospital-based outpatient population (N=26). A total of 66 patients were approached, and 40 were excluded. No participant withdrew because of adverse effects. InterventionsPatients were randomly assigned into 3 groups: (1) botulinum toxin epic group (n=8), who received 20U of botulinum toxin injection into the lateral epicondyle; (2) botulinum toxin tend group (n=7), who received 20U of botulinum toxin injected into tender points of muscles; and (3) steroid group (n=11), who received 40mg of triamcinolone acetonide injected into the lateral epicondyle. Main Outcome MeasuresA visual analog scale, a dynamometer, and the Patient-Rated Tennis Elbow Evaluation were used to evaluate the perception of pain, maximal grip strength, and functional status, respectively. Outcome measures were assessed before intervention and at 4, 8, 12, and 16 weeks after treatment. The primary outcome measure was a visual analog scale. ResultsAt 4 weeks after injection, the steroid group was superior to the botulinum toxin tend group in improvement on the visual analog scale (P=.006), grip strength (P=.03), and Patient-Rated Tennis Elbow Evaluation (P=.02). However, these differences were not observed at the 8-, 12-, and 16-week follow-up assessments. There was no significant difference between the steroid and botulinum toxin epic groups. ConclusionsInjections with botulinum toxin and steroid effectively reduced pain and improved upper limb function in patients with lateral epicondylalgia for at least 16 weeks. The onset of effect was earlier in the steroid and botulinum toxin epic groups than in the botulinum toxin tend group.

Effect of introduction of a new electronic anesthesia record (Epic) system on the safety and efficiency of patient care in a gastrointestinal endoscopy suite-comparison with historical cohort.

Background:Use of electronic medical record systems has increased in the recent years. Epic is one such system gaining popularity in the USA. Epic is a private company, which invented the electronic documentation system adopted in our hospital. In spite of many presumed advantages, its use is not critically analyzed. Some of the perceived advantages are increased efficiency and protection against litigation as a result of accurate documentation.Materials and Methods:In this study, retrospective data of 305 patients who underwent endoscopic retrograde cholangiopancreatography (wherein electronic charting was used - “Epic group”) were compared with 288 patients who underwent the same procedure with documentation saved on a paper chart (“paper group”). Time of various events involved in the procedure such as anesthesia start, endoscope insertion, endoscope removal, and transfer to the postanesthesia care unit were routinely documented. From this data, the various time durations were calculated.Results:Both “anesthesia start to scope insertion” times and “scope removal to transfer” times were significantly less in the Epic group compared to the paper group. Use of Epic system led to a saving of 4 min of procedure time per patient. However, the mean oxygen saturation was significantly less in the Epic group.Conclusion:In spite of perceived advantages of Epic documentation system, significant hurdles remain with its use. Although the system allows seamless flow of patients, failure to remove all artifacts can lead to errors and become a source of potential litigation hazard.

Abstract 4830: Dietary intake of dairy foods, calcium, fat, protein and risk of hepatocellular carcinoma in the European Prospective Investigation into Cancer and Nutrition (EPIC) study.

Abstract Background: Dairy foods are an important food group whose intake may be associated with cancer. On the one hand, dairy foods are high in saturated fats and high dairy food consumption may increase circulating levels of IGF-1, a growth factor. Conversely, dairy foods contain calcium and vitamin D, which have been shown to be cancer protective at some sites. However, information on association of intake of dairy foods is limited or inconsistent for many cancer sites, such as hepatocellular carcinoma (HCC), the sixth most common malignancy and the third most common cause of cancer death worldwide. Objective: To investigate the association between dairy foods and their components (calcium, fat and protein intakes), with incident HCC (Ncases=191) in the EPIC cohort, including a nested case-control sub-set with assessment of hepatitis B/C virus infections status. Methods: A total of 477,206 participants were followed up for an average of 11 years. Diet was assessed by country-specific validated questionnaires. For cohort analyses, the Cox proportional hazard model was used to estimate hazard ratios (HRs) and 95% confidence intervals (95%CI). For case-control analyses, conditional logistic regression was used to calculate odds ratios (ORs) and 95%CI. All models were adjusted for relevant confounders. Results: In the cohort study, a significant positive association for total dairy foods (highest vs. lowest tertile, HR=1.58, 95% CI:1.08-2.33; Ptrend=0.022), total dietary calcium (HR=1.74, 95%CI:1.14-2.68; Ptrend=0.009), and dairy calcium (HR per 200 g/day 1.11, 95% CI:1.02-1.20) were observed with HCC risk after multivariable adjustment. Non-significant associations were observed for milk (HR per 200g/day 1.06, 95% CI:0.95-1.17), cheese (HR per 50 g/day 1.21, 95% CI: 0.96-1.53), yoghurt (HR per 100 g/day 1.03, 95% CI:0.89-1.19), dairy fat (highest vs. lowest tertile, HR=1.36, 95% CI:0.90-2.04; Ptrend=0.290) and dairy protein intakes (HR=1.29, 95%CI:0.86-1.92; Ptrend=0.214). The results were similar after excluding individuals diagnosed with HCC within 2 years after recruitment or with self-reported diabetes at baseline. In the nested case-control study, similar results were observed among hepatitis-free individuals. Conclusions: Results from this large prospective cohort study suggest that higher consumption of total dairy foods, total dietary calcium, and calcium from dairy sources are associated with increased HCC risk, emphasizing the role of diet in liver cancer etiology. Potential biologic mechanisms that could explain the positive associations may include circulating IGF-I or vitamin D concentrations, and require further exploration in prospective settings. Citation Format: Talita Duarte-Salles, Veronika Fedirko, Antonia Trichopoulou, Christina Bamia, Isabelle Romieu, Mazda Jenab, on behalf of the EPIC Group. Dietary intake of dairy foods, calcium, fat, protein and risk of hepatocellular carcinoma in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 4830. doi:10.1158/1538-7445.AM2013-4830

Perioperative intraperitoneal chemotherapy for advanced gastric cancer

Background-Aims: Perioperative intraperitoneal chemotherapy either under normothermia during the early postoperative period (EPIC) or intraoperatively combined with heat (HIPEC) has been shown to improve survival after radical resection of advanced gastric cancer. The purpose of the study is to compare the effect of EPIC and HIPEC in patients undergoing D 2 gastrectomy for advanced gastric cancer. Patients-Methods: Patients that received EPIC after D 2 gastrectomy were retrospectively compared to those that received HIPEC after D 2 gastrectomy. The end point of the study was the assessment of survival, and recurrences. Results: The groups were comparable for age, gender, performance status, tumor anatomic distribution, stage, degree of differentiation, Lauren classification, hospital mortality, morbidity, and type of surgery. 5-year survival rate for HIPEC group was 68% and for EPIC group was 14% ( p =0.0054).The recurrence rate in EPIC group was 57.9% and in HIPEC group 17.4% ( p =0.001). Conclusions: Patients with advanced gastric cancer undergoing D 2 gastrectomy in combination with HIPEC have improved survival and lower recurrence rate as compared to those undergoing D 2 gastrectomy in combination with EPIC.

Adjuvant Perioperative Intraperitoneal Chemotherapy in Locally Advanced Colorectal Carcinoma: Preliminary Results

Background and Aims. Intraperitoneal chemotherapy is a basic tool in the treatment of peritoneal malignancy. The purpose of the study is to investigate the effect of adjuvant perioperative intraperitoneal chemotherapy in the treatment of locally advanced colorectal cancer. Patients and Methods. Patients with T3 and T4 colorectal carcinomas that underwent R0 resection received either hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC group = 40 patients) or early postoperative intraperitoneal chemotherapy (EPIC group = 67 patients). The survival, the recurrences and the sites of recurrence were assessed. Results. The 3-year survival rate for HIPEC group was 100% and for EPIC group 69% (P = .011). Nodal infiltration was found to be the single prognostic indicator of survival. The incidence of recurrence in EPIC group was higher than in HIPEC group (P = .009). The independent indicators of recurrence were the use of HIPEC and the degree of differentiation (P < .05). Conclusions. Intraperitoneal chemotherapy, particularly HIPEC, as an adjuvant in locally advanced colorectal carcinomas appears to improve survival and decrease the incidence of recurrence.

Relative validity and reproducibility of a diet history questionnaire in Spain. II. Nutrients. EPIC Group of Spain. European Prospective Investigation into Cancer and Nutrition

A pilot study was carried out to evaluate the relative validity and reproducibility of a dietary history questionnaire (DH) administered by interview and designed to be used in a prospective study on diet and cancer.The DH was administered twice, with a year's interval, to 91 volunteers of various occupational categories, aged 35-60 years, of both sexes. Twelve 24-hour recalls applied monthly during the year between the two administrations of the DH were used as a reference method.Mean values of daily intake between the two methods were very similar for most nutrients. The DH tended to underestimate intake, compared to the 24-hour recall, for some nutrients like saturated fat and dietary fibre in males and saturated and polyunsaturated fat, cholesterol and retinol in females. It tended to overestimate intake of vitamin C, retinol and beta-carotene in males and dietary fibre, vitamin C and beta-carotene in females. Pearson correlation coefficients between the daily intake of nutrients based on the mean of the 12 24-hour recalls and the second use of the DH showed most values to be > 0.80 in males (ranging from 0.28 for retinol to 0.89 for energy, lipids, mono and polyunsaturated fat) and 0.60 in females (ranging from 0.33 for cholesterol to 0.83 for alcohol). For the great majority of nutrients studied, more than 80% of the subjects classified in the two highest quintiles and in the two lowest quintiles according to the DH2 which coincided with the highest and lowest quintiles of the classification according to the average of 24-hour recalls.The DH method provides quite good information on the habitual nutrient intake of the individual in a recent 1-year reference period.

Relative validity and reproducibility of a diet history questionnaire in Spain. I. Foods. EPIC Group of Spain. European Prospective Investigation into Cancer and Nutrition.

A pilot study was carried out to evaluate the relative validity and reproducibility of a dietary history questionnaire (DH) designed to be used in Spain as part of a prospective European research project on diet and cancer. A total of 91 volunteers (46 men and 45 women) aged 35-60 years, and of various occupational categories, participated in the study. The DH was structured according to occasions of intake and was administered twice by interview, with a year's interval. Twelve 24-hour diet recalls, administered monthly between the two administrations of the DH, were used as a reference method. Natural units, geometric figures and a set of photographs were used to quantity portion size. Of a total of 17 food groups, the Pearson correlation coefficients between the daily intake of food groups, based on the mean of 12 24-hour diet recalls, and the second DH showed values between 0.65 and 0.90 in 14 groups (potatoes, vegetables, fruits, cheese, other dairy products, bread, other cereals, meat and poultry, fish and shellfish, butter, margarine and oils, sugar and sweets, other desserts, alcohol and coffee and tea) in males and in 11 groups (potatoes, other vegetables, fruits, cheese, other dairy products, bread, meat and poultry, fish and shellfish, sugar and sweets, alcohol and coffee and tea) in females. In comparison with the mean of 12 24-hour diet recalls the DH questionnaire over-estimated (in both sexes) the intake of vegetables, cereals, butter, margarine and oils and underestimated the intake of sugar and sweets, and other desserts. The DH method is more expensive and more difficult to apply than other instruments but it provides good information on the habitual food intake of the individual.