Review Of Management Strategies Research Articles

Prevention and Management of Calorectal Cancer in Women

To review prevention and management strategies for colorectal cancer, with an emphasis on studies pertaining to women. Articles published from January 1990 through February 2001 identified through a MEDLINE search using the term colorectal cancer and the additional terms screening, prevention, and treatment. Additional references were identified from the bibliographies of the retrieved articles. Colorectal cancer is the third most common non-skin cancer in women, after breast and lung cancers. Many women underestimate their risk of colorectal cancer, which may lead them to underuse screening measures that have been proven to reduce disease morbidity and mortality. For average-risk women and men > or = 50 years of age, pharmacists should recommend regular screening for early detection and prevention of colorectal cancer. In its earliest, most curable stages, colorectal cancer is often asymptomatic. However, patients who report signs and symptoms, such as blood in the stool, abdominal pain, changes in bowel habits, unexplained weight loss, or iron deficiency anemia, should be referred for medical evaluation. The use of chemopreventive agents for colorectal cancer, such as nonsteroidal anti-inflammatory drugs, hormone replacement therapy, and dietary calcium, holds significant promise, but further studies are needed before these agents can be recommended for cancer prevention in the general population. Surgical resection is the primary treatment modality for colorectal cancer, and adjuvant chemotherapy is recommended in patients with stage III disease and some high-risk patients with stage II disease. Pharmacists should be aware that women are more susceptible to dose-related toxicity effects of fluorouracil and leucovorin combination chemotherapy, the first-line regimen for adjuvant chemotherapy. Although often perceived as a disease that primarily affects men, colorectal cancer is an equally important health concern for women. By providing education and counseling, pharmacists can help raise women's awareness of this disease and encourage them to take steps to significantly reduce their risk.

Management and outcomes in a low-volume cerebral aneurysm practice.

To review management strategies, outcomes, and complications in cerebral aneurysm surgery in a low-volume aneurysm practice. Seventy-nine craniotomies to treat aneurysms were performed between June 1996 and November 1999. Patient management strategy is outlined, complications are assessed, and outcomes are described. Twenty-six patients underwent surgery to treat unruptured aneurysms. Forty-two patients presented with Hunt and Hess Grade 1 to 3 subarachnoid hemorrhage. Eleven patients presented with Grade 4 or 5 subarachnoid hemorrhage. Twenty-four patients (92.3%) with unruptured aneurysms experienced favorable outcomes. Of the patients with unruptured anterior circulation aneurysms, 96% achieved favorable recoveries. Thirty-eight patients (90.5%) with Grade 1 to 3 subarachnoid hemorrhage experienced favorable outcomes; four of these patients were moderately disabled. Among patients with Grade 1 to 3 subarachnoid hemorrhage, the mortality rate was 7.1%. Of patients with Grade 4 or 5 subarachnoid hemorrhage, five (45.5%) experienced favorable outcomes, but four of these patients were moderately disabled; two patients (18.2%) were severely disabled, and four patients (36.4%) died. Acceptable clinical outcomes can be achieved in lower-volume aneurysm practices. A multidisciplinary subspecialty approach with aggressive perioperative care, especially in the prevention and treatment of cerebral vasospasm, is important in obtaining these results. Close interaction with medical consultants and other subspecialists is necessary.

Anxiety in cancer patients.

Anxiety is common in cancer patient populations, and must often initially be recognized and managed by cancer care professionals. This article reviews the recent oncology and mental health literature on anxiety. The aim is to help those involved in cancer patient care who are not specialists in mental health to understand the nature of anxiety, and discriminate morbid from normal anxiety. We review recent research into the association of anxiety with events during diagnosis and management of cancer, highlighting the importance of the meaning of events to an individual as an important factor in making people anxious. Lastly we review management strategies which might be used by cancer care professionals, in particular the importance of an awareness of specific patterns of communication which may alleviate or maintain anxiety for some cancer patients. © 2000 Cancer Research Campaign

Management of uninvestigated and functional dyspepsia: a Working Party report for the World Congresses of Gastroenterology 1998.

The management of dyspepsia is controversial. An international Working Party was convened in 1998 to review management strategies for dyspepsia and functional dyspepsia, based on a review of the literature and best clinical practice. Dyspepsia, defined as pain or discomfort centred in the upper abdomen, can be managed with reassurance and over-the-counter therapy if its duration is less than 4 weeks on initial presentation. For patients with chronic symptoms, clinical evaluation depends on alarm features including patient age. The age cut off selected should depend on the age specific incidence when gastric cancer begins to increase, but in Western nations 50 years is generally an acceptable age threshold. In younger patients without alarm features, Helicobacter pylori test and treatment is the approach recommended because of its value in eliminating the peptic ulcer disease diathesis. If, after eradication of H. pylori, symptoms either are not relieved or rapidly recur, then an empirical trial of therapy is recommended. Similarly, in H. pylori-negative patients without alarm features, an empirical trial (with antisecretory or prokinetic therapy depending on the predominant symptom) for up to 8 weeks is recommended. If drugs fail, endoscopy should be considered because of its reassurance value although the yield will be low. In older patients or those with alarm features, prompt endoscopy is recommended. If endoscopy is non-diagnostic, gastric biopsies are recommended to document H. pylori status unless already known. While treatment of H. pylori is unlikely to relieve the symptoms of functional dyspepsia, the long-term benefits probably outweigh the risks and treatment can be considered on a case-by-case basis. In H. pylori-negative patients with documented functional dyspepsia, antisecretory or prokinetic therapy, depending on the predominant symptom, is reasonable, assuming reassurance and explanation are insufficient, unless patients have already failed this approach. Other treatment options include antidepressants, antispasmodics, visceral analgesics such as serotonin type 3 receptor antagonists, and behavioural or psychotherapy although these are all of uncertain efficacy. Long-term drug treatment in functional dyspepsia should be avoided; intermittent short courses of treatment as needed is preferred. The management of dyspepsia recommended is based on current best evidence but must be tailored to local factors such as practice setting, the background prevalence of H. pylori and structural disease, and costs.

Management of pancreatic injury in pediatric blunt abdominal trauma

Background/Purpose: Nonoperative management of lowgrade pancreatic injury is widely accepted. Management of major pancreatic parenchymal or ductal injury in children remains controversial. This study will review management strategies as they relate to site and type of pancreatic injury and their outcomes.Methods: A total of 11,794 consecutive admissions to a regional pediatric trauma center from 1984 to 1997 were reviewed to identify children with pancreatic injury as documented by serum amylase; imaging by computed tomographic (CT) scan, ultrasonography (US), and endoscopic retrograde cholangiopancreatography (ERCP); and surgical or postmortem reports.Results: Pancreatic injury was documented in 56 children, age 2 months to 14 years, with blunt mechanisms of injury. Serum amylase level was elevated on admission in 40 (71%), and no correlation was found between admission amylase values and severity of pancreas injury. An admission CT scan was obtained in 44 (79%) patients and was positive for pancreatic injury in 25 (57%). Twelve children, who had diagnoses of other intraabdominal injury by CT scan, had pancreatic injuries discovered on exploratory laparotomy. Seven children with normal admission CT scans, and the 12 children who did not undergo imaging on admission, had pancreatic injuries that were later documented by imaging, exploration, or autopsy. Thirty children were treated with immediate exploration, 17 for nonpancreatic indications and 13 with pancreatic injuries on admission CT scan. Of 19 minor injuries noted in the operating room, only three were treated with external drainage. Seven patients with distal duct injuries underwent distal pancreatectomy with splenic preservation. Twenty-six children were treated nonoperatively, including 19 with minor pancreas injuries, three with proximal pancreatic duct injuries, and four with duct injuries that were missed at admission. There were no advantages or complications of external drainage versus nondrainage of minor pancreatic injuries. There were seven deaths (overall mortality rate, 12.5%), none related to pancreatic injury. Of the seven patients in whom pseudocysts developed (two not imaged at admission, two from known proximal duct injuries treated nonoperatively, and three from injuries missed by initial studies), five were treated by delayed internal drainage and recovered promptly, and two resolved spontaneously. Pancreas-related complications included one persistent fistula and one prolonged hyperamylasemia, both of which resolved.Conclusions: Pancreatic injuries are uncommon in children. Initial serum amylase level does not correlate with the severity of pancreatic injury. The majority of pancreatic injuries can be managed nonoperatively. Initial nonoperative management of injuries of the proximal pancreatic duct allows for the formation and uneventful delayed drainage of a pseudocyst, rather than the risks of early radical interventions. Distal duct injuries are best managed by prompt spleen-sparing distal pancreatectomy. There is no benefit of closed drainage for management of minor pancreatic injuries discovered at laparotomy.

Streptococcus pneumoniae Transmission in Chronic-Care Facilities: Description of an Outbreak and Review of Management Strategies

Streptococcus pneumoniae Transmission in Chronic-Care Facilities: Description of an Outbreak and Review of Management Strategies

Streptococcus pneumoniae transmission in chronic-care facilities: description of an outbreak and review of management strategies.

We report an outbreak of invasive Streptococcus pneumoniae disease in a chronic-care facility with a documented immunization rate of only 2.5%. We describe and discuss the infection control strategies used in prevention and management of such outbreaks, highlighting the role of immunization and presumptive chemotherapy.

Long-term outcome in patients with four or more positive lymph nodes treated with conservative surgery and radiation therapy

The purpose of this study was to review management strategies with respect to systemic therapy, radiation therapy treatment techniques, and patient outcome (local regional control, distant metastases, and overall survival) in patients undergoing conservative surgery and radiation therapy (CS + RT) who had four or more lymph nodes involved at the time of original diagnosis. Of 1040 patients undergoing CS + RT at our institution prior to December 1989, 579 patients underwent axillary lymph node dissection. Of those patients undergoing axillary lymph node dissection, 167 had positive nodes and 51 of these patients had four or more positive lymph nodes involved and serve as the patient population base for this study. All patients received radiation therapy to the intact breast using tangential fields with subsequent electron beam boost to the tumor bed to a total median dose of 64 Gy. The majority of patients received regional nodal irradiation as follows: 40 patients received RT to the supraclavicular region without axilla to a median dose of 46 Gy, 10 patients received radiation to the supraclavicular region and axilla to a median dose of 46 Gy. Thirty of the 51 patients received a separate internal mammary port with a mixed beam of photons and electrons. One patient received radiation to the tangents alone without regional nodal irradiation. Adjuvant systemic therapy was used in 49 of the 51 patients (96%) with 27 patients receiving chemotherapy alone, 14 patients receiving cytotoxic chemotherapy and tamoxifen, and 8 patients receiving tamoxifen alone. As of December 1994, with a minimum evaluable follow-up of 5 years and a median follow-up of 9.29 years, there have been 18 distant relapses, 2 nodal relapses, and 5 breast relapses. Actuarial statistics reveal a 10-year distant metastases-free rate of 65%, 10-year nodal recurrence-free rate of 96%, and a 10-year breast recurrence-free rate of 82%. All five patients who sustained a breast relapse were successfully salvaged with mastectomy. Both patients with nodal relapses (one supraclavicular and one axillary/supraclavicular) failed within the irradiated volume. Of the 40 patients treated to the supraclavicular fossa (omitting complete axillary radiation), none failed in the dissected axilla. With a median follow-up of nearly 10 years, 29 of the 51 patients (57%) remain alive without evidence of disease, 15 (29%) have died with disease, 2 (4%) remain alive with disease, and 5 (10%) have died without evidence of disease. Overall actuarial 10-year survival for these 51 patients is 58%. We conclude that in patients found to have four or more positive lymph nodes at the time of axillary lymph node dissection, conservative surgery followed by radiation therapy to the intact breast with appropriate adjuvant systemic therapy results in a reasonable long-term survival with a high rate of local regional control. Omission of axillary radiation in this subset of patients appears appropriate because there were no axillary failures among the 41 dissected but unirradiated axillae.

Should medicare provide reimbursement for prostate-specific antigen testing for early detection of prostate cancer? Part II: Early detection strategies

This article represents Part II of a four-part policy analysis that will be published over 4 consecutive months. The articles are based on a background article originally prepared for the Office of Technology Assessment of the United States Congress, which has released its own report on the costs and effectiveness of prostate cancer screening among Medicare-aged men. The four parts will frame the debate, review early detection strategies for prostate cancer, review management strategies, and estimate the risks, benefits, and costs of an early detection program among older men. This article represents Part II of a four-part policy analysis that will be published over 4 consecutive months. The articles are based on a background article originally prepared for the Office of Technology Assessment of the United States Congress, which has released its own report on the costs and effectiveness of prostate cancer screening among Medicare-aged men. The four parts will frame the debate, review early detection strategies for prostate cancer, review management strategies, and estimate the risks, benefits, and costs of an early detection program among older men.

Radiological evidence of progression of bronchiectasis

Radiological evidence of progression of bronchiectasis was sought in a group of 84 consecutive adult patients admitted to a tertiary unit with a particular interest in the disease. Methodical comparison for each patient of the earliest and most recent chest X-rays (n = 84), bronchograms (n = 1) and thoracic computed tomography (CT) scans (n = 32) was performed. Fifteen patients (18%) were considered to show radiological evidence of progression of bronchiectasis, 14 on chest X-ray, two of whom also showed progression on CT scans, and in one patient on bronchography alone. The likelihood of finding evidence of radiological progression increased the longer the interval between examinations. Serial radiology allows identification of patients with progression of disease and indicates the need to review management strategy.