Patterns of retreatment by radiotherapy.

AIMS: To describe patterns of treatment for those who receive more than one episode of megavoltage radiotherapy (retreatment) by cancer type for better service planning and benchmarking. MATERIALS AND METHODS: Institutional databases of all patients who received their first megavoltage radiotherapy for any type of cancer at the Liverpool and Macarthur Cancer Therapy Centres (LM), New South Wales, Australia, Royal Brisbane and Women's Hospital (RBWH), Queensland, Australia and Radiotherapeutic Institution Friesland (RIF), Leeuwarden, the Netherlands, over the period 1991-2009 were examined. Radiotherapy retreatment was defined as any radiotherapy episode, to any body site, after an initial episode of radiotherapy, for the same cancer diagnosis. The total retreatment rate was defined as the number of retreatment episodes of radiotherapy divided by the number of cases in the cohort. RESULTS: In total, 62,270 patients (RBWH 38581, LM 9654, RIF 14035) received 77,762 episodes of radiotherapy, giving a total retreatment rate of 0.25; 52,351 patients (84%) received only one episode of treatment and 9919 (16%) received two or more episodes of treatment. Overall retreatment rates for LM, RBWH and RIF were 0.24, 0.25 and 0.26, respectively. For the five most common cancer types treated, the median time between treatment episodes was longest for breast cancer (11.3 months), then head and neck cancer (9.7 months), colorectal cancer (7.2 months), prostate cancer (4.4 months) and lung cancer (4.1 months). Ninety-one per cent of all fractions were delivered in the first episode of treatment. CONCLUSIONS: The retreatment rate was very similar between the three facilities, suggesting agreement about the indications for retreatment.

Patterns of retreatment by radiotherapy.

AIM: To describe patterns of radiotherapy retreatment by cancer type in order to develop methods of modelling retreatment for better service planning and benchmarking. MATERIALS AND METHODS: We examined an institutional database of all patients who received their first megavoltage radiotherapy for any type of cancer at the Liverpool and Macarthur Cancer Therapy Centres over the period 1997-2006. The database contains patient demographic data, dates, treatment sites and doses of radiotherapy. The treatment sites were entered as free text and were recoded into a limited number of sites; primary site, bone, brain, soft tissue, other and multiple, so that retreatment sites could be grouped for stratification and analysis. Multiple treatment sites that were part of a single treatment to a primary (for example, primary site and nodes) were recoded as 'primary'. The total retreatment ratio was defined as the number of episodes of radiotherapy divided by the number of cases in the cohort. RESULTS: In the period 1997-2006, 7853 patients had received 9859 episodes of radiotherapy, giving a total retreatment ratio of 26 per 100 patients. In total, 6524 patients (83%) received only one episode of treatment and 1329 received two or more episodes of treatment. The average number of retreatments was 0.26. The tumour type with the highest mean number of retreatments was myeloma (1.05), followed by unknown primary (0.41), lung (0.34) and melanoma (0.32). The lowest mean number of retreatments was for the brain (0.06). The median time between treatment episodes was longest for breast cancer (12.5 months), then colorectal cancer (12.3 months), head and neck cancers (9.0 months), lung cancer (3.8 months) and prostate cancer (5.9 months). CONCLUSION: The retreatment ratio for the cohort was affected by the length of follow-up and by the tumour type. The mean number of retreatments varied from 0.06 for central nervous system malignancy to 1.05 for myeloma, with an average of 0.026.

Combining components of quality of life to increase precision and evaluate trade-offs.

Methods for combining measurements on multiple dimensions of quality of life can reduce the dimensionality of the data and increase the precision of estimation. When the dimensions are weighted according to their importance to patients, the resulting estimate is clinically useful and provides a step towards a true utility estimate. We derive two such weighting methods using linear regression on a measure of overall quality of life and demonstrate their usefulness in the analysis of quality of life data from two clinical trials of cancer therapies. Procedures for transforming the quality of life measures into utility measures are demonstrated.

Vesico-diverticular fistula: a rare complication of Meckel's diverticulum.

Enterovesical fistulas usually result from diverticulitis, Crohn's disease, or colorectal cancer. A perforated Meckel's diverticulum can also result in an vesico-diverticulum fistula, as noted in three previously reported cases. In all three cases, bladder or bowel disease was associated with the fistula. Herein, the authors describe a previously healthy, 23-year-old man who presented with an enterovesical fistula. Exploratory laparotomy revealed a vesico-diverticular fistula resulting from a perforated Meckel's diverticulum. Pathologic examination revealed that the diverticulum did not contain ectopic gastric or pancreatic tissue and that the perforation was secondary to an enterolith. The patient underwent a diverticulectomy and had an uneventful postoperative course. Unlike any of the three previously reported cases, the authors' patient had no coexisting bowel or bladder disease occurring with his vesico-diverticular fistula. To the authors' knowledge, this is only the third reported case of a vesico-diverticular fistula resulting from a perforated Meckel's diverticulum that did not contain ectopic tissue. It represents the first case where the perforation was secondary to an enterolith.

Laparoscopic cholecystectomy in a renal transplant recipient.

Laparoscopic cholecystectomy is a viable and safe alternative for the treatment of symptomatic gallstones and biliary colic. As surgeons gain more experience with this procedure, contraindications become fewer and indications increase. Well-documented advantages of this approach include less patient discomfort, less surgical scarring, and earlier return to employment. Not previously discussed in the literature, however, are the additional advantages that this procedure holds for a specific subset of patients--namely, those patients that have undergone successful organ transplantation and are receiving immunosuppressive drugs. We report a case of a laparoscopic cholecystectomy in such a patient.

The management of traumatic aortic tear in the multiply-injured patient.

Patients with traumatic aortic tears and severe life-threatening associated injuries require early and expeditious evaluation and treatment in order to improve survival. Diagnostic and treatment priorities, however, are not clearly established in this subset of patients. The purpose of this retrospective analysis was to help identify successful diagnostic and treatment priorities in this group of patients. Between 1979-1989 the medical records of all patients sustaining blunt chest trauma resulting in a traumatic aortic tear were reviewed. There were 11 patients with multiple injuries and this diagnosis was treated at Boston University Medical Center. Five patients had diagnostic peritoneal lavage or an exploratory laparotomy prior to a thoracotomy. Four patients had only a thoracotomy. Two patients in this series had a thoracotomy prior to treatment of suspected intraabdominal injuries. One of these two patients died. Our overall survival rate was 82%. This series suggests that the management sequence in patients with coexistent injuries should include treatment of severe associated injuries prior to treatment of the aortic injury and that initial treatment of traumatic aortic tears is appropriate if there is no evidence of severe life-threatening trauma.

Intraaortic balloon pump entrapment.

Catheter entrapment is a rare complication of intraaortic balloon counterpulsation caused by the formation of hard blood clot within the balloon itself. We present two cases of intraaortic balloon pump entrapment seen at the University Hospital, Boston. This phenomenon usually presents as a limb threatening vascular emergency. The entrapped catheter becomes stuck fast within the iliac system during withdrawal of the device, occluding arterial flow at that level. The etiology of this phenomenon, and a proposed management scheme is discussed. Preoperative radiographic determination of the level of entrapment may be necessary. We feel it is necessary to control the abdominal aorta prior to removal of an entrapped intraaortic balloon.

Do symptoms of gastric ulcer become less frequent with time?

It has been claimed that gastric and duodenal ulcer (GU and DU) symptoms decrease in frequency with time, indicating 'burn out' of ulcer. The present study was undertaken to investigate further this phenomenon in GU. The prevalence of symptom experience during 1 year was examined in 447 medically treated patients with GU diagnosed 2-20 or more years previously. When ulcer history length was measured from either first symptom onset or first ulcer diagnosis, reporting of symptoms did not become less frequent as history length increased. This remained true after adjustment for GU location, sex, age, smoking, and analgesic and non-steroidal anti-inflammatory drug ingestion. It is concluded that GU symptoms do not decrease in frequency with time.

Mortality among Vietnam veterans compared with non-veterans and the Australian population.

A retrospective cohort study of mortality was conducted to assess whether the military service of young Australian men in Vietnam has influenced their overall death rates, or those from specific causes. The study was of all national servicemen who were conscripted during the conflict and served in the Army for at least 12 months. Of these, 19 205 served in Vietnam (veterans) while 25 677 served only in Australia (non-veterans). These men were traced from the end of their national service (between 1966 and 1973) until the beginning of 1982. For most causes of death, the observed number of deaths of veterans and of non-veterans was less than expected from Australian population death rates, and for no cause was there a statistically significant excess of deaths compared with that of the Australian population. Similarly, when veterans were compared with non-veterans, there was no statistically significant difference in deaths for all causes combined, for diseases of the circulatory system, for deaths in motor vehicle accidents, for suicide and for all external causes after adjustment for the different subsequent death rates of men who had served in different Army corps. All seven deaths from diseases of the digestive system were of veterans. There was no excess of deaths among veterans from cancer or from atypical causes of death in this group of young men. Three-quarters of deaths of both veterans and non-veterans were from external causes, often involving motor vehicle accidents.

Factors relevant to the prognosis of chronic duodenal ulcer.

The aim of the study was to define the effects of sex, age, smoking, alcohol, analgesic ingestion, and treatment method whereby healing was initially induced on the prognosis of patients with a chronic duodenal ulcer (DU). 122 patients were assessed 1 year after the endoscopic demonstration of a DU. Two outcome variables for this 1-year period were studied - freedom from symptoms, and proven recurrence of the DU. Additionally, the outcome groups were compared to a community control population as regards the exposure variables. The results of the study indicate that each increase in smoking by 10 cigarettes daily increased the risk of DU recurrence within 1 year by 40%. Comparisons between patients and community controls revealed that smoking was significantly associated with DU and this association was present whether the ulcer was in exacerbation or in remission.