Full Range Of Treatment Options Research Articles

Planning management for complex colorectal polyps: a qualitative assessment of factors influencing decision-making among colonoscopists

ObjectiveEndoscopic therapy is the recommended primary treatment for most complex colorectal polyps, but high colonic resection rates are reported. The aim of this qualitative study was to understand and compare...

Effect of Clinical Setting on Prevalence of Pregnancy of Unknown Location: A Retrospective Cohort Study [ID: 1377630

INTRODUCTION: Pregnancy of unknown location (PUL) is the diagnosis of a positive pregnancy test without ultrasonographic confirmation of pregnancy location. Using varying diagnostic criteria, studies from the 1980s to early 2000s estimated the prevalence of PUL diagnoses at 8–31%. With advances in ultrasound technology and increasing use of early ultrasound, we aimed to determine current prevalence of PUL and differences by clinical setting. METHODS: With IRB approval, we conducted a retrospective cohort study of all initial pregnancy ultrasounds less than 14 weeks performed at a single academic medical center from January 1, 2018, to December 31, 2019. Ultrasounds occurred in the outpatient perinatal ultrasound suite or inpatient radiology suite via the emergency department. We compared diagnoses by setting via chi-square tests and logistic regression using Stata SE. RESULTS: Of 1,775 ultrasounds, only 81 (4.6%) were PULs, while 308 (17.4%) were intrauterine pregnancies of uncertain viability (IPUV). Both types of uncertain pregnancy diagnosis were more common in the emergency department than the outpatient obstetrics and gynecology setting (PUL: 8.3% versus 2.0%, P<.001; IPUV: 23.8% versus 12.9%, P<.001). Patients with symptoms of cramping or vaginal bleeding were more likely to have uncertain diagnoses (33.1% versus 16.8%, P<.001); however, presence of symptoms was not independently associated with uncertain diagnosis after controlling for setting. CONCLUSION: Diagnoses of PUL have declined, largely replaced by diagnoses of IPUV. Differences in diagnosis prevalence unexplained by patient symptoms support existing evidence of disparate early pregnancy experiences between the outpatient and emergency settings. As over one-fifth of patients will have an uncertain pregnancy diagnosis on initial ultrasound, safe, efficient, and patient-centered follow-up protocols are crucial.

Indicators of frailty in newly diagnosed lung cancer patients: A retrospective review.

e24017 Background: Lung cancer is frequently diagnosed over the age of 70 years, in a population with increased risk factors for frailty. Frailty impacts cancer treatment selection, tolerance, and quality of life. We performed a retrospective study to determine whether there is a difference in the indicators of frailty in patients of different ages, and if this impacted treatment choice. Methods: Electronic records of patients who were discussed at the University Hospitals of Leicester Lung multidisciplinary team meeting (MDT) between January to December 2019 with a suspected diagnosis of lung cancer were reviewed. Populations below the age of 65 years and over the age of 65 years were compared. Results: 846 patient records were reviewed, and 80% were aged over 65 years. Baseline WHO performance status (PS) where recorded showed 35% were PS 0-1, and 28% were 3-4. Comparatively, in the under 65 population 46% were PS 0-1, and 10% were 3-4. The over 65s had a lower rate of independence with activities of daily living (ADLs) compared to the under 65s (54% vs 71%), assistance with basic ADLs was higher (10% vs 5%) and patients with unassisted mobility was also lower (48% vs 66%). The over 65s had an increased rate of multiple comorbidities compared to the younger group (no comorbidity 25% vs 30%, 3 or more comorbidities 27% vs 14% respectively.) Where curative intent was intended, in the under 65s, surgical review deemed 24% unsuitable and of these, 72% had a discussion regarding radiotherapy with 61% receiving treatment. Comparatively in the older population, 40% of patients were deemed unsuitable for surgery and 69% went for discussion regarding radiotherapy with 44% receiving treatment. Where systemic anti-cancer therapy (SACT) discussion was advised, more patients in the under 65 group saw a medical oncologist compared to the older group (73% vs 61%) and had a higher rate of subsequent SACT (80% vs 61%). There were similar rates of non-completion of SACT in the over 65s compared to the younger group (55% vs 54%) and number of dose reductions (18% vs 15%). 35% of the over 65s and 46% of the under 65s received immunotherapy. In the older population, 30% received monotherapy, compared to 17% in the younger population. 37% of the older patients having SACT were admitted with a median stay of 2 days (range 1-30) compared to 31% in the younger group, with a median stay of 1.5 days (range 1-2). Conclusions: Our review demonstrates that in the older population, PS is higher, with a lower independence rate for ADLs, a higher level of assisted mobility and increased comorbidity. These frailty indicators impacted treatment options; less older patients were suitable for treatment compared to the younger population. The older population displayed more indicators of frailty potentially impacting treatment options, and this highlights the need for active frailty assessment and rapid intervention in the lung cancer population to allow a full range of treatment options.

Special Report: Ethical Decision-Making in Contemporary Psychiatric Practice—An Evolving Challenge

Special Report: Ethical Decision-Making in Contemporary Psychiatric Practice—An Evolving Challenge

Dental professionals\u2019 experiences of managing children with carious lesions in their primary teeth \u2013 a qualitative study within the FiCTION randomised controlled trial

BackgroundThe lack of evidence for the effective management of carious lesions in children’s primary teeth has caused uncertainty for the dental profession and patients. Possible approaches include conventional and biological management alongside best practice prevention, and best practice prevention alone. The FiCTION trial assessed the effectiveness of these options, and included a qualitative study exploring dental professionals’ (DPs) experiences of delivering the different treatment arms. This paper reports on how DPs managed children with carious lesions within FiCTION and how this related to their everyday experiences of doing dentistry.MethodsOverall, 31 DPs from FiCTION-trained dental surgeries in four regions of the UK participated in semi-structured interviews about their experiences of the three treatment arms (conventional management of carious lesions and prevention (C + P), biological management of carious lesions and prevention (B + P) or prevention alone (PA)). A theoretical framework, drawing on social practice theory (SPT), was developed for analysis.ResultsParticipants discussed perceived effectiveness of, and familiarity with, the three techniques. The C + P arm was familiar, but some participants questioned the effectiveness of conventional restorations. Attitudes towards the B + P arm varied in terms of familiarity, but once DPs were introduced to the techniques, this was seen as effective. While prevention was familiar, PA was described as ineffective. DPs manage children with carious lesions day-to-day, drawing on previous experience and knowledge of the child to provide what they view as the most appropriate treatment in the best interests of each child. Randomisation undermined these normal choices. Several DPs reported deviating from the trial arms in order to treat a patient in a particular way. Participants valued evidence-based dentistry, and expect to use the results of FiCTION to inform future practice. They anticipate continuing to use the full range of treatment options, and to personally select appropriate strategies for individual children.ConclusionsRCTs take place in the context of day-to-day practices of doing dentistry. DPs employ experiential and interpersonal knowledge to act in the best interests of their patients. Randomisation within a clinical trial can present a source of tension for DPs, which has implications for assuring individual equipoise in future trials.

Implications of differing attitudes and experiences between providers and persons with obesity: results of the national ACTION study

ABSTRACTObjective: Our aim was to explore how differing attitudes, expectations, and experiences among people with obesity (PwO) and healthcare providers (HCPs) might have an impact on effectively implementing current obesity treatment guidelines.Methods: Online surveys were conducted among 3,008 adult PwO (BMI≥30 by self-reported height and weight) and 606 HCPs.Results: PwO with weight loss ≥ 10% during the previous three years were more likely to have been diagnosed with obesity and to have discussed a weight loss plan with an HCP. However, only 21% believe HCPs have a responsibility to actively contribute to their obesity treatment. Further, HCPs tend not to effectively communicate the diagnosis of obesity, its nature as a serious and chronic disease, the full range of treatment options, and obesity’s implications for health and quality of life.Regarding treatment goals, HCPs more often focus on BMI reduction, while PwO’s goals focus on improved functioning, energy, and appearance. HCPs also tend to underestimate their patients’ motivation to address their obesity. Twenty-eight percent of HCPs ‘completely agreed’ that losing weight was a high priority for PwO, whereas more than half of PwO ‘completely agreed’ that losing weight was a high priority for them. When asked how their HCP could better support them, PwO most often expressed a desire for helpful resources, as well as assistance with specific and realistic goal-setting to improve health.Conclusions: HCPs can more effectively implement obesity treatment guidelines by more clearly and proactively communicating with PwO about their diagnosis, health implications of obesity, desired treatment goals, and the full range of treatment options. HCPs should understand that most PwO believe that managing their disease is solely their own responsibility. HCPs can also encourage more effective conversations by better appreciating their patients’ motivation and treatment goals.Trial registration: ClinicalTrials.gov identifier: NCT03223493.

Laparoscopic versus medical treatment of undisturbed ectopic pregnancy, Minia University Hospital

Introduction: The incidence of ectopic pregnancy (EP) increased almost up to a level of 2% in developed countries. Using of transvaginal ultrasonography and sensitive plasma-human chorionic gonadotropin (β-HCG) has enabled an early diagnosis before rupture. Early diagnosis allows the full range of treatment options. So, emergency surgery has been changed to a more benign condition. Administration of methotrexate (MTX) has an acceptance in selected patients and is considered costly effective with no need for waiting period before attempting another pregnancy. Although methotrexate is a teratogenic agent, its half-life is very short.Aim of work: To evaluate the safety and efficacy of laparoscope versus MTX of well-selected cases of undisturbed ectopic pregnancy.Materials and Methods: This is a prospective study in Minia University Hospitals during the period from March 2015 to March 2016. Forty patients of undisturbed EPs were divided randomly into two groups (20 for each group), the first group included women undergoing laparoscopic salpingostomy and the second group included women undergoing MTX. Every participant was subjected to full history taking, general, abdominal and vaginal examinations, as well as β-HCG, abdominal and vaginal ultrasound scan investigations. Only with MTX group and according to Lipscomb 2012, MTX was administrated and assessed. After full range of treatment, a close weekly follow-up of all groups was done by β-HCG level as well as abdominal and vaginal examination and ultrasonography.Results: The mean pre-therapeutic level of β-HCG was 1081.9±655.85 mIU/ml in MTX group and 2180.75±1693.51 mIU/ml in laparoscopy group. As regarding the success rate, MTX group was 70% and not significantly different from laparoscopic 85%.Conclusion: Undisturbed EP can be treated effectively by MTX, especially in selected cases depending mainly on β-HCG low levels pre-therapeutic and follow-up.

Delays in the breast cancer pathway from assessment to treatment: Potential treatment implications

Introduction: An efficient pathway from diagnostic biopsy to obtaining complete pathology results is essential to allow the full range of treatment options to be discussed with patients, including neo-adjuvant therapies. We audited our unit pathway from assessment, through diagnosis to post-operative results to identify delays which may impact treatment discussions.

Transoral laser surgery for supraglottic squamous cancers

Objective: The objective of the study was to evaluate the oncological and functional results of transoral CO 2 laser microsurgery (TLM). Study Design: This is a retrospective study of squamous cancers of the supraglottis treated with transoral CO 2 laser resection. Materials and Methods: Between May 1997 and April 2014, 131 cases of T 1 /T 2 /T 3 squamous cancer of the supraglottis/hypopharynx with freely mobile vocal cords and no gross invasion of the laryngeal spaces, were resected transorally with the CO 2 laser. Results: Oncologically, resections performed under the magnification of the operating microscope are safe and yield high local control rates ranging from 79% to 85% for supraglottic cancer. For salvage of local recurrences following TLM, a full range of treatment options remains available including re-use of TLM. Of the 29 recurrences, 9 were salvaged with repeat TLM, 4 with radiotherapy, and 6 with total laryngectomy. In supraglottic cancer, management of neck is very important. Twenty patients with the clinically “N+” neck at presentation, underwent neck dissection at the same time of TLM or after an interval of 4–5 days. For the 111 “N0” cases, the neck was treated only if and when metastasis manifested at followup. Thus, nine patients underwent neck dissection for regional recurrence at followup. The neck was also treated in the local/locoregional recurrences salvaged either with radiotherapy or total laryngectomy. There were two cases of advanced regional recurrences that could only be offered palliative care.

PA02.05 Access to Care: Australia

In June 2016, Lung Foundation Australia launched an evidence-based, clear and concise guide, the “Lung Cancer Patient Pathway,” for patients with a confirmed lung cancer diagnosis. The guide is available as a printed resource and online resource supported by a micro-site on Lung Foundation Australia’s website and the Lung Cancer Network Australia website and has been distributed to the majority of dedicated lung cancer treatment centers around Australia. The main aim of producing the Lung Cancer Patient Pathway (LCPP) was to provide newly diagnosed patients with a “one stop” resource that outlines the clinical referral pathways and details the full range of treatment options and supportive care services available to them throughout their lung cancer journey. The LCPP also aims to improve patient health literacy and empower patients with access to evidence based information to support informed decision making and treatment choices, self- management and ultimately, to improve patient outcomes. The LCPP was launched in conjunction with the launch of the Lung Foundation’s Australian Lung Cancer Multi-Disciplinary Team Directory http://lungfoundation.com.au/mdt/. This national directory lists the current (64) dedicated lung cancer multidisciplinary (MDT) services around Australia. It is intended to facilitate referrals of patients to hospitals delivering MDT-based lung cancer management. The creation of this national directory has forged closer relationships between the Lung Foundation and dedicated lung cancer multidisciplinary (MDT) services and provided a mechanism to be able to reach patients at time of diagnosis. Lung Foundation has previously struggled to reach patients early in their cancer journey. Strengthening these relationships with Lung MDT services has led to a systematic distribution of Lung Foundation patient kits including the LCPP info-graph. The Cancer Nurses Society of Australia Winter Congress in May 2016 and Australian Lung Cancer Conference in August 2016 presented opportunities to distribute the printed LCPP in conference delegate bags and at trade exhibitions to more than 550 cancer clinicians and nurses. The Lung Foundation will implement the following strategies to ensure the sustainability of this project: Info-graph will be trialed in Lung Cancer MDTs around Australia, Info-graph will form part of the Lung Cancer Consultative Groups activities, A minimum review period of two years for info-graph and website content, Annual budget allocation for ongoing promotion and dissemination. The Lung Cancer Patient Pathway project has produced a patient centered resource to empower newly diagnosed patients with current, evidence based information so that they can make informed decisions on treatment options and supportive care services and access the right treatment and care at the right time. This project was managed by Glenda Colburn, Director, Lung Cancer National Program, Lung Foundation Australia. The Lung Cancer patient pathway was made possible via unrestricted education grants. Principal sponsor: Bristol-Myers Squibb Supporting Sponsors: AstraZenea, Boehringer Ingelheim, Cancer Australia, Pfizer, Maurice Blackburn Lawyers, MSD.

Invited commentary

The authors are to be congratulated for the detailed examination of the Vascular Quality Initiative (VQI) database to obtain a glimpse of the real-world outcomes of patients with critical limb ischemia (CLI) treated with endovascular peripheral vascular intervention (PVI) vs lower extremity bypass (LEB). Not surprisingly, PVI patients were found to have significantly more comorbidities, lower adjusted perioperative mortalities, and shorter lengths of stay. The perioperative mortality advantage disappeared in the cohorts that focused on patients with better operative risk and simpler anatomy. LEB patients, similar to previous studies, had improved 3-year survivals and improved survival free of major adverse limb events in the overall cohort. This study raises important questions, but similar to previous evaluations of endovascular therapy CLI and Vascular Quality Initiative reports, has significant limitations. Follow-up at 1 year was <50%, and no hemodynamic or detailed anatomic information was available. The most reliable 3-year data (based on Social Security data) confirm the survival advantage to patients undergoing LEB. So how are we to use these data in our own selection of PVI vs LEB for CLI patients? Perhaps this study supports most vascular surgeons' bias that PVI (or even serial PVIs) is the best way to bring our most severely ill CLI patients to the finish line with their legs intact; hopefully, in relative comfort with wounds healed or healing. Unfortunately, this study does little to inform our treatment of the great majority of our patients who live ≥2 years beyond the first intervention for CLI. Vascular surgeons are the most well-equipped clinicians to manage patients with CLI because only we can offer these patients the full range of treatment options, including PVI and LEB. The best application of these complementary techniques depends on accurate comparative effectiveness data based on precise anatomic criteria, hemodynamic results, patency rates, limb salvage rates, wound healing rates, quality of life, and cost effectiveness. As the authors rightly point out, such data awaits completion of randomized prospective trials such as the ongoing Best Endovascular Versus Best Surgical Therapy in Patients With CLI (BEST) trial. I would ask you to consider for one moment the effect previous randomized prospective vascular surgery trials, such as Asymptomatic Carotid Artery Stenosis Study (ACAS), North American Symptomatic Carotid Endarterectomy Trial (NASCET), Carotid Revascularization Endarterectomy vs Stent Trial (CREST), Comparison of Endovascular Aneurysm Repair with Open Repair in Patients with Abdominal Aortic Aneurysm (EVAR), Dutch Randomised Endovascular Aneurysm Management (DREAM), Aneurysm Detection and Management (ADAM), Bypass Versus Angioplasty in Severe Ischaemia of the Leg (BASIL) and Edifoligide for the Prevention of Infrainguinal Vein Graft Fail (PREVENT) among others, have had on our education of patients and trainees as well as our daily practice of vascular and endovascular surgery. We must actively support and enroll in the BEST trial to bring it to successful completion to generate similar data to help guide us in the treatment of our most challenging CLI patients. Only then will vascular surgeons know how to best use our complementary tools of PVI and LEB. Comparison of open and endovascular treatment of patients with critical limb ischemia in the Vascular Quality InitiativeJournal of Vascular SurgeryVol. 63Issue 4PreviewThere is significant controversy in the management of critical limb ischemia (CLI) arising from infrainguinal peripheral arterial disease. We sought to compare practice patterns and perioperative and long-term outcomes for patients undergoing lower extremity bypass (LEB) and percutaneous vascular interventions (PVIs) for CLI in the Vascular Quality Initiative (VQI). Full-Text PDF Open Archive

Consensus on current management of endometriosis

Is there a global consensus on the management of endometriosis that considers the views of women with endometriosis? It was possible to produce an international consensus statement on the current management of endometriosis through engagement of representatives of national and international, medical and non-medical societies with an interest in endometriosis. Management of endometriosis anywhere in the world has been based partially on evidence-based practices and partially on unsubstantiated therapies and approaches. Several guidelines have been developed by a number of national and international bodies, yet areas of controversy and uncertainty remain, not least due to a paucity of firm evidence. A consensus meeting, in conjunction with a pre- and post-meeting process, was undertaken. A consensus meeting was held on 8 September 2011, in conjunction with the 11th World Congress on Endometriosis in Montpellier, France. A rigorous pre- and post-meeting process, involving 56 representatives of 34 national and international, medical and non-medical organizations from a range of disciplines, led to this consensus statement. A total of 69 consensus statements were developed. Seven statements had unanimous consensus; however, none of the statements were made without expression of a caveat about the strength of the statement or the statement itself. Only two statements failed to achieve majority consensus. The statements covered global considerations, the role of endometriosis organizations, support groups, centres or networks of expertise, the impact of endometriosis throughout a woman's life course, and a full range of treatment options for pain, infertility and other symptoms related to endometriosis. This consensus process differed from that of formal guideline development. A different group of international experts from those participating in this process would likely have yielded subtly different consensus statements. This is the first time that a large, global, consortium, representing 34 major stake-holding organizations from five continents, has convened to systematically evaluate the best available current evidence on the management of endometriosis, and to reach consensus. In addition to 18 international medical organizations, representatives from 16 national endometriosis organizations were involved, including lay support groups, thus generating input from women who suffer from endometriosis.

Prostate cancer pain management: EAU guidelines on pain management

The first publication of the European Association of Urology (EAU) guidelines on Pain Management in Urology dates back to 2003. Since then, these guidelines have been revised several times with the most recent update achieved in 2010. Given the scope of the full text guidelines, condensing the entire document was no option in this context. This paper presents a summary of the section of pain management in prostate cancer, a topic considered of direct relevance for the practicing urologist. A multidisciplinary expert panel (urologists, anaesthesiologists, radio-oncologists) compiled this document based on a comprehensive consultation of the literature. Data were identified through a structured search, covering the time frame 2000 through 2010, using Medline and Embase as well as the Cochrane Library of systematic reviews. The scientific papers were weighed by the expert panel and a level of evidence (LE) assigned. Recommendations have been graded as a means to provide transparency between the underlying evidence and the guidance provided. Pain can occur in each stage of prostate cancer. It could be caused by the cancer itself (77%), be related to the cancer treatment (19%) or be unrelated to either (3%). The incidence of pain rises to 90% as patients enter the terminal phase of their illness. The physician's task is to discover and treat the cause of pain and the pain itself, to determine whether or not the underlying cause is treatable, to provide pain relief and palliative care. These tasks more often than not require a multidisciplinary team. Pain management involves mainly pharmacotherapy, including direct anticancer therapy such as androgen deprivation and chemotherapy, as well as analgetics, for instance non-steroidal anti-inflammatory drugs (NSAIDs) or opioids. In case of local impairment due to the cancer or its metastases, primary treatments like surgery, radiotherapy or radionuclides can provide adequate pain relief. In addition, in palliative care, functional, psychosocial and spiritual support are essential components. The EAU guidelines on Pain Management in Urology are available in a number of different formats through the EAU Central Office and the EAU website ( http://www.uroweb.org/guidelines/online-guidelines/ ). The mainstay of pain management in prostate cancer is involvement of and collaboration between experts from a number of disciplines to be able to achieve a complete pain evaluation and to offer the full range of treatment options. Prostate cancer-related pain can, in most cases, be managed effectively, but it requires careful monitoring where a balance should be found between pain relief and potential side effects of treatment and quality of life (QoL).

Geographic Variations in Percutaneous Coronary Interventions and Coronary Artery Bypass Graft Surgery Among Tennessee Elders

Coronary heart disease often presents with ST segment elevation acute myocardial infarction (STEMI). The American College of Cardiology/American Heart Association guidelines stress prompt reperfusion for STEMI. Examining geographic variations in treatment with PPCI (percutaneous primary coronary intervention) and CABG (coronary artery bypass graft) among metropolitan, micropolitan and non-micropolitan rural residents provides a descriptive basis for generating hypotheses concerning place and receipt of guidelines-based treatment. Using ICD-9 codes for STEMI and excluding beneficiaries with pre-existing MI in claims data, yielded a subset of 18,775 Tennessee Medicare beneficiaries experiencing STEMI from 1996 to 2002. The outcome variable is type of treatment, i.e., in accord (PPCI or CABG present) or not in accord (PPCI or CABG absent) with guidelines. Independent variables include type county residence, hospital volume, race, gender, and age. Analyses include cross-tabulation and logistic regression, estimating separate models by age and type of MI. Micropolitan residents with STEMI have the lowest rates for PPCI (18.8%) versus 28.1% percent for metropolitan and 24.2% for non-micropolitan rural residents. CABG follows similar patterns at lower overall rates. Treatment at a heart center with high volume PPCI mediated the relationship between the likelihood of PPCI and place. The correspondence between metropolitan and rural utilization suggests that access to a full range of treatment options and likelihood of "best practice" care is not dependent on metropolitan residence. This presents the possibility that with some policy changes, e.g., centralization of emergency heart care, the same may ultimately be true for micropolitan residents.

Do Religious Restrictions Influence Ectopic Pregnancy Management? A National Qualitative Study

Introduction In the United States, ectopic pregnancies are relatively common and associated with significant maternal morbidity and mortality. The Ethical and Religious Directives for Catholic Health Care Services (the Directives) govern the provision of care in Catholic-affiliated hospitals and prohibit the provision of abortion in almost all circumstances. Although ectopic pregnancies are not viable, some Catholic ethicists have argued that the Directives preclude physicians at Catholic hospitals from managing tubal pregnancies with methods and procedures that involve “direct” action against the embryo. Methods We undertook this qualitative study to explore the relationship between the Directives, hospital policies regarding ectopic pregnancy management, and clinical practices. We recruited participants at non-Catholic, longstanding Catholic, and recently merged facilities and conducted focused interviews with 24 physicians at 16 hospitals in 10 states. Findings Participants from three Catholic facilities reported that medical therapy with methotrexate was not offered because of their hospitals’ religious affiliation. The lack of methotrexate resulted in changes in counseling and practice patterns, including managing ectopic pregnancies expectantly, providing the medication surreptitiously, and transferring patients to other facilities. Further, several physicians reported that, before initiating treatment, they were required to document nonviability through what they perceived as unnecessary paperwork, tests, and imaging studies. Conclusion Our findings suggest that some interpretations of the Directives are precluding physicians from providing women with ectopic pregnancies with information about and access to a full range of treatment options and are resulting in practices that delay care and may expose women to unnecessary risks.

Can weight loss treat urinary incontinence in obese women?

New research confirms that weight loss is an effective first-line intervention for overweight or obese women with urinary incontinence. Such patients should be encouraged to lose weight, but must also be given access to a full range of treatment options.

Management of Mucinous Urachal Neoplasm Presenting as Pseudomyxoma Peritonei

Mucinous neoplasms of the urachus are rare malignancies so that the physicians' index of suspicion for a timely and accurate diagnosis is low. Also, this disease may present with a wide variety of symptoms and signs. Two patients with pseudomyxoma peritonei as the initial presentation of urachal mucinous adenocarcinoma were treated successfully. The medical literature regarding treatment options for this manifestation of the disease was searched. Two patients with large volume of pseudomyxoma peritonei originating in a mucinous urachal neoplasm were treated with cytoreductive surgery and perioperative intraperitoneal chemotherapy. Our first patient required two reoperations to palliate the accumulation of gross mucinous ascites. She died 11 years after diagnosis with progression of mucinous adenocarcinoma resulting in starvation. The second patient had ostomy closure with second look surgery at one year after definitive treatment; four small tumor nodules were seen and easily resected. The patient is currently without evidence of disease and has a normal quality of life. Seven prior manuscripts that report a single case of pseudomyxoma peritonei were reviewed to explore the full range of treatment options and survival for this rare condition. Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy may be a new treatment option for mucinous urachal neoplasms presenting with pseudomyxoma peritonei. Other management strategies such as systemic chemotherapy seemed to hold little promise for this group of patients.

Formal Treatment, Self-Help, or No Treatment for Alcohol-Use Disorders? Evidence from the National Household Survey on Drug Abuse

The purpose of this study was to examine further alcohol treatment choice by using data from a nationally representative sample of adults with alcohol-use disorders to test which of three models-sequential, multinomial, or nested best fit the data. The goals were to provide evidence about how this choice was made and to provide improved coefficient estimates, as well as to inform future analyses of treatment choice. Data from the 2000 National Household Survey of Drug Abuse include respondents ages 18-64 reporting symptoms consistent with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses of alcohol abuse or dependence. A nested multinomial framework is used to determine the preferred model and to estimate the effect of respondents' characteristics on the decisions to receive help and what kind of help to receive. A sequential model, in which the choice of whether to receive help is unaffected by the level of satisfaction afforded by the alternatives, best fit the data. Older respondents had higher odds of both receiving help and choosing self-help, and those with a DSM-IV diagnosis of abuse had lower odds of receiving help but higher odds of entering self-help. The decision to receive help for alcohol problems appears unaffected by the perceived differences between these two broad categories of alternatives: self-help or formal treatment. This result may indicate the need to provide more information on the full range of treatment options to those for whom self-help may not be sufficient.

Matching control options to a pest complex: the integrated pest management of aphids in sequentially-planted crops of outdoor lettuce

Sequentially planted short-season vegetable crops grown in temperate climates offer the opportunity to use known variations in pest phenology through the season to develop a strategic way of matching control options on different plantings to predicted levels of pest risk. To test this approach in the UK, five field experiments were done over two years to test integrated pest management (IPM) programmes for four aphid pest species ( Nasonovia ribisnigri, Macrosiphum euphorbiae, Pemphigus bursarius and Myzus persicae) on outdoor lettuce crops. Crops were planted to coincide with different periods of forecast aphid risk. The results suggested that acceptable levels of aphid control could be achieved, provided a full range of treatment options (resistant cultivars, selective insecticides, biocontrol agents and validated pest forecasts) could be utilised. Commercial and technical constraints to the commercial adoption of this approach are discussed.

The development and management of an in vitro fertilisation unit.

In this brief presentation on the development, management and results of treatment in the first year of operation of the Fertility Unit at the Humana Hospital Wellington, we have tried to give an overview of how we believe a large regional reproductive medicine centre could be managed and developed within the National Health Service. Such a centre should provide a comprehensive range of fertility treatment, preferably every day of the week. It would include the full range of treatment options including induction of ovulation, artificial insemination, tubal microsurgery, as well as IVF and the T-SET methods. The advantage to the patients would be considerable and it may even be possible to make financial savings compared with those expenses incurred by the unstructured infertility services offered at present.