Assuntos
Neoplasias da Mama/cirurgia , Tempo de Internação , Adulto , Idoso , Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Feminino , Humanos , Mastectomia/estatística & dados numéricos , Mastectomia Segmentar/estatística & dados numéricos , Auditoria Médica , Pessoa de Meia-IdadeRESUMO
Multiparameter analysis of core regulatory proteins involved in G1-S and G2-M cell-cycle transitions provides a powerful biomarker readout for assessment of the cell-cycle state. We have applied this algorithm to breast cancer to investigate how the cell cycle impacts on disease progression. Protein expression profiles of key constituents of the DNA replication licensing pathway (Mcm2, geminin) and mitotic machinery (Plk1, Aurora A and the Aurora substrate histone H3S10ph) were generated for a cohort of 182 patients and linked to clinicopathological parameters. Arrested differentiation and genomic instability were associated with an increased engagement of cells into the cell division cycle (P<0.0001). Three unique cell-cycle phenotypes were identified: (1) well-differentiated tumours composed predominantly of Mcm2-negative cells, indicative of an out-of-cycle state (18% of cases); (2) high Mcm2-expressing tumours but with low geminin, Aurora A, Plk1 and H3S10ph levels (S-G2-M progression markers), indicative of a G1-delayed/arrested state (24% cases); and (3) high Mcm2-expressing tumours and also expressing high levels of the S-G2-M progression markers, indicative of accelerated cell-cycle progression (58% of cases). The active cell-cycle progression phenotype had a higher risk of relapse when compared with out-of-cycle and G1-delayed/arrested phenotypes (HR=3.90 (1.81-8.40, P<0.001)), and was associated with Her-2 and triple negative subtypes (P<0.001). It is of note that high-grade tumours with the G1-delayed/arrested phenotype showed an identical low risk of relapse compared with well-differentiated out-of-cycle tumours (HR=1.00 (0.22-4.46), P=0.99). Our biomarker algorithm provides novel insights into the cell-cycle state of dynamic tumour cell populations in vivo. This information is of major prognostic significance and may impact on individualised therapeutic decisions. Patients with an accelerated phenotype are more likely to derive benefit from S- and M-phase-directed chemotherapeutic agents.
Assuntos
Neoplasias da Mama/mortalidade , Neoplasias da Mama/patologia , Ciclo Celular , Aurora Quinases , Neoplasias da Mama/genética , Diferenciação Celular , Linhagem Celular Tumoral , DNA de Neoplasias/análise , Feminino , Instabilidade Genômica , Humanos , Antígeno Ki-67/análise , Fenótipo , Ploidias , Prognóstico , Proteínas Serina-Treonina Quinases/análiseRESUMO
Back pain is common in the elderly. Spinal infection is a rare, but possibly increasing, cause. We describe a retrospective case note review of 41 patients aged 65 years and over with spontaneous spinal infections over a 6-year period. The incidence was 9.8/100,000/year. Staphylococcus aureus was the most common isolate. The mean time from symptom onset to diagnosis was 34 days. Most patients presented with back pain and elevated CRP. Differentiation between discitis and other spinal infections does not appear to be important, as clinical characteristics and outcomes are similar.
Assuntos
Dor nas Costas/microbiologia , Discite/microbiologia , Infecções Estafilocócicas/microbiologia , Idoso , Dor nas Costas/epidemiologia , Discite/epidemiologia , Feminino , Humanos , Incidência , Masculino , Nova Zelândia/epidemiologia , Infecções Estafilocócicas/epidemiologiaRESUMO
OBJECTIVES: To evaluate strategies designed to improve nutrition in elderly hospitalised patients with dementia. DESIGN: Observation phase followed by sequential interventions. SETTING: A Short stay assessment unit. PARTICIPANTS: Hospital Inpatients with a variety of conditions causing dementia. INTERVENTIONS: Phase 1: Observation. Phase 2: Encouraging dietary, 'Grazing'. Phase 3: Using volunteers to feed patients. Phase 4: Improving dining room ambience by playing soothing music. MEASUREMENTS: Body Mass Index (BMI), mid arm circumference, mini nutrition index and caloric intake by plate waste measurement. RESULTS: BMI fell in the Observation phase 0.6 +/- 0.68 kg/m2 (p < 0.001), but increased in each of the Intervention phases. Phase2 0.3 +/- 0.86 kg/m2 (p < 0.04), Phase 3 0.37 +/- 0.4 kg/m2 (p < 0.04), Phase 4 0.39 +/- 0.7 kg/m2 (p < 0.007). Caloric intake increased in the intervention phases. CONCLUSIONS: Simple, inexpensive and easy to implement strategies can improve nutrition in hospital inpatients with dementia.
Assuntos
Demência/complicações , Ingestão de Energia/fisiologia , Desnutrição/dietoterapia , Avaliação Nutricional , Estado Nutricional , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Índice de Massa Corporal , Cognição/fisiologia , Feminino , Serviço Hospitalar de Nutrição/normas , Humanos , Masculino , Desnutrição/epidemiologia , Desnutrição/etiologia , Casas de Saúde , Resultado do TratamentoAssuntos
Reservatórios de Doenças , Mustelidae , Tuberculose Bovina/prevenção & controle , Tuberculose Bovina/transmissão , Animais , Bovinos , Fatores de Confusão Epidemiológicos , Eutanásia Animal , Política de Saúde , Irlanda/epidemiologia , Tuberculose Bovina/epidemiologia , Reino Unido/epidemiologiaRESUMO
BACKGROUND: Several trials have been done to assess treatment of premenopausal breast cancer with luteinising-hormone-releasing hormone (LHRH) agonists, but results have been inconclusive, especially for patients with hormone-receptor-positive cancer. METHODS: We collected individual patients' data from published trials and did analyses focused on women with tumours positive for oestrogen receptor, progesterone receptor, or both. The main endpoints were recurrence and death after recurrence. FINDINGS: We obtained data for 11 906 premenopausal women with early breast cancer randomised in 16 trials. When used as the only systemic adjuvant treatment, LHRH agonists did not significantly reduce recurrence (28.4% relative reduction, 95% CI consistent with 50.5% reduction to 3.5% increase, p=0.08) or death after recurrence (17.8%, 52.8% reduction to 42.9% increase, p=0.49) in hormone-receptor-positive cancers. Addition of LHRH agonists to tamoxifen, chemotherapy, or both reduced recurrence by 12.7% (2.4-21.9, p=0.02); and death after recurrence by 15.1% (1.8-26.7, p=0.03). LHRH agonists showed similar efficacy to chemotherapy (recurrence 3.9% increase, 7.7% reduction to 17.0% increase; death after recurrence 6.7% reduction, 20.7% reduction to 9.6% increase; both not significant). No trials had assessed an LHRH agonist versus chemotherapy with tamoxifen in both arms. LHRH agonists were ineffective in hormone-receptor-negative tumours. INTERPRETATION: LHRH agonists provide an additional class of agents for treatment of premenopausal women with hormone-receptor-positive breast cancer. Optimum duration of use is unknown.
Assuntos
Antineoplásicos Hormonais/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias da Mama/tratamento farmacológico , Hormônio Liberador de Gonadotropina/agonistas , Gosserrelina/uso terapêutico , Tamoxifeno/uso terapêutico , Adulto , Neoplasias da Mama/mortalidade , Neoplasias da Mama/patologia , Quimioterapia Adjuvante , Interações Medicamentosas , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/prevenção & controle , Pré-Menopausa , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND AND AIM: The risks of recurrent intracerebral haemorrhage (ICH) vary widely (0-24%). Patients with ICH also have risk factors for ischaemic stroke (IS) and a proportion of ICH survivors re-present with an IS. This dilemma has implications for prophylactic treatment. This study aims to determine the risk of recurrent stroke events (both ICH and IS) following an index bleed and whether ICH recurrence risk varies according to location of index bleed. PATIENTS AND METHODS: All patients diagnosed with an acute ICH presenting over an 8.5 year period were identified. Each ICH was confirmed by reviewing all of the radiology results and, where necessary, the clinical case notes or post-mortem data. Recurrent stroke events (ICH and IS) were identified by reappearance of these patients in our stroke database. Coronal post-mortem results for the same period were also reviewed. Each recurrent event was reviewed to confirm the diagnosis and location of the stroke. RESULTS: Of the 7686 stroke events recorded, 768 (10%) were ICH. In the follow-up period, there were 19 recurrent ICH and 17 new IS in the 464 patients who survived beyond the index hospital stay. Recurrence rate for ICH was 2.1/100 in the first year but 1.2/100/year overall. This compares with 1.3/100/year overall for IS. Most recurrences were "lobar-lobar" type. CONCLUSION: The cumulative risk of recurrent ICH in this population is similar to that of IS after the first year.
Assuntos
Hemorragia Cerebral/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica , Hemorragia Cerebral/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologiaRESUMO
Wide local excision followed by external beam radiation therapy (EBRT) to the whole breast has become the standard of care for most patients with localised 'early' breast cancer in the UK, Europe, and the USA. Local relapse rates are low, and overall survival figures have improved during the past decade, with the advent of more effective systemic endocrine- and chemo-therapy. A policy of EBRT for every patient undergoing breast conserving surgery (BCS) is however associated with a number of practical difficulties, acute radiation side effects and longer term toxicity, all of which detract from the obvious benefits of EBRT. In addition, with a disease as common as early breast cancer and a treatment programme typically requiring sophisticated radiation planning and many fractions of treatment, the policy of BCS plus EBRT has enormous resource implications within departments of oncology, greatly contributing to lengthy pre-treatment delays. For all these reasons, we and others have developed an increasing interest in techniques of partial breast irradiation, with an emphasis in our own Department on the emerging technique of intra-operative radiotherapy (IORT), which we initially employed as a boost to the tumour bed for use in conjunction with EBRT to the whole breast. To test the possibility of replacing the whole of the EBRT 3-6 week programme by a single application of IORT at the time of surgery, we and others have commenced a large scale prospectively randomised clinical trail in selected patients. Nine international centres are currently participating, and 350 patients have now been randomised to receive either IORT as part of the initial surgical excision or conventional EBRT with a pragmatic dose policy according to the preference of the contributing centre. The majority of patients undergoing IORT receive this at the time of initial surgery but it is also permissible within the trial programme to randomise suitable patients after the excised specimen has been histologically examined, thus avoiding any unsuitable patients - for example, those with a lobular carcinoma. These patients will be stratified and assessed separately from the 'pre-pathology' group, whose surgery and IORT is completed within a single session; if the latter patients are found to have unfavourable histology we have the facility, within the trial, to add EBRT. The trial is ongoing and our early experience has been encouraging. We have also recently assessed the long term local failure rate in patients offered IORT as a tumour bed boost, in conjunction with conventional EBRT. This methodology will also be the subject of a future randomised clinical trial.
Assuntos
Neoplasias da Mama/radioterapia , Neoplasias da Mama/cirurgia , Cuidados Intraoperatórios/tendências , Recidiva Local de Neoplasia/prevenção & controle , Neoplasias da Mama/patologia , Fracionamento da Dose de Radiação , Relação Dose-Resposta à Radiação , Feminino , Previsões , Humanos , Mastectomia Segmentar , Estadiamento de Neoplasias , Seleção de Pacientes , Radioterapia Adjuvante/instrumentação , Radioterapia Adjuvante/métodos , Radioterapia Adjuvante/tendências , Ensaios Clínicos Controlados Aleatórios como Assunto , Reino Unido , Saúde da MulherRESUMO
BACKGROUND: Intraoperative detection of sentinel lymph node (SLN) metastases enables the surgeon to take an immediate decision to proceed to completion axillary lymph node dissection (ALND). The aim of this study was to determine the accuracy of touch imprint cytology (TIC) for the diagnosis of SLN metastases in sentinel nodes from women with breast cancer. METHODS: Touch imprints from 235 sentinel nodes in 133 women with breast cancer were diagnosed by cytopathology and compared with definitive histopathology results. After a feasibility study, a real-time study was performed with the surgeon proceeding to ALND based on the TIC diagnosis. The clinical opinion of the operating surgeon as to whether the SLN appeared to contain metastases was recorded, as was the time taken for the result to be available. RESULTS: TIC detected metastases with a sensitivity of 81.1 per cent and a specificity of 100 per cent. False-negative TIC diagnoses were associated with micrometastases and lobular carcinoma. The majority of false-negative diagnoses were due to sampling rather than interpretation errors. Clinical assessment of sentinel nodes had a sensitivity of 64.3 per cent and a specificity of 87.6 per cent. CONCLUSION: TIC is feasible and enables the rapid diagnosis of SLN metastases with an acceptable accuracy for clinical use in ductal carcinoma of the breast.
Assuntos
Neoplasias da Mama/patologia , Carcinoma Ductal de Mama/patologia , Biópsia de Linfonodo Sentinela , Neoplasias da Mama/cirurgia , Carcinoma Ductal de Mama/cirurgia , Reações Falso-Negativas , Feminino , Humanos , Cuidados Intraoperatórios/métodos , Excisão de Linfonodo , Metástase Linfática/patologia , Projetos Piloto , Sensibilidade e Especificidade , Biópsia de Linfonodo Sentinela/normasRESUMO
The Zoladex In Pre-menopausal Patients (ZIPP) study was designed to determine whether addition of goserelin ('Zoladex') and/or tamoxifen to adjuvant therapy (radiotherapy and/or chemotherapy), provided benefit to pre- or peri-menopausal women with operable, early breast cancer. A combined analysis of four randomised trials using a core protocol was performed. Patients (n = 2710) were randomised into a 2 x 2 factorial trial based on goserelin and tamoxifen (n = 1800) or randomised to receive goserelin or not (n = 910; some received elective tamoxifen) for 2 years. The analysis presented here compares women who did (n = 1354) or did not (n = 1356) receive goserelin. After a median follow-up of 5.5 years, goserelin provided a significant benefit for event-free survival (hazard ratio [HR] 0.80; 95% confidence interval [CI] 0.69, 0.92; P = 0.002) and overall survival (HR 0.81; 95% CI 0.67, 0.99; P = 0.038). Goserelin was well tolerated. These data show that the addition of goserelin to standard adjuvant therapy is more effective than standard therapy alone in pre-menopausal women with early breast cancer.
Assuntos
Antineoplásicos Hormonais/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias da Mama/tratamento farmacológico , Gosserrelina/uso terapêutico , Adulto , Neoplasias da Mama/radioterapia , Neoplasias da Mama/cirurgia , Quimioterapia Adjuvante , Intervalo Livre de Doença , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Pré-Menopausa , Ensaios Clínicos Controlados Aleatórios como Assunto , Tamoxifeno/administração & dosagem , Resultado do TratamentoRESUMO
BACKGROUND: Most women with oestrogen receptor (ER) positive primary breast cancer receive adjuvant tamoxifen after surgery. The measurement of tumour biomarkers should allow better selection of patients for such treatment or for therapies such as aromatase inhibitors. PATIENTS AND METHODS: Histopathological blocks of primary breast cancer patients who had been randomized to receive 2-years tamoxifen or no adjuvant therapy in two mature randomised clinical trials were retrieved. Immunohistochemical staining for ER, progesterone receptor (PgR), HER2 and epidermal growth factor receptor (EGFR) was undertaken. The primary endpoint was relapse free survival. RESULTS: 813 patients were included in the study. Benefit from tamoxifen was seen in ER-positive patients [Relative risk (rr) 0.77, ci 0.63-0.93]. ER-negative patients also showed a strong trend to benefit from tamoxifen (rr 0.73, ci 0.52-1.02) which was largely confined to the PgR-positive group. Amongst the ER-positive group, PgR-positive and PgR-negative patients showed similar benefit (rr 0.81; ci 0.65-1.02 and 0.70; ci 0.49-0.99, respectively). Patients positive for HER2 did not benefit significantly (rr 1.14; ci 0.75-1.73) but this group was small. CONCLUSIONS: Measurement of PgR status in ER-negative patients defines a group of patients that benefit from tamoxifen but would be excluded from tamoxifen therapy on the basis of ER status alone. The data are consistent with HER2 positive tumours being resistant to tamoxifen.
Assuntos
Antineoplásicos Hormonais/uso terapêutico , Neoplasias da Mama/tratamento farmacológico , Receptores ErbB/metabolismo , Receptor ErbB-2/metabolismo , Receptores de Estrogênio/metabolismo , Receptores de Progesterona/metabolismo , Tamoxifeno/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/metabolismo , Neoplasias da Mama/patologia , Quimioterapia Adjuvante , Progressão da Doença , Resistencia a Medicamentos Antineoplásicos , Feminino , Humanos , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/diagnóstico , Valor Preditivo dos Testes , Prognóstico , Fatores de Tempo , Resultado do TratamentoRESUMO
PURPOSE: The majority of breast cancers are diagnosed at an early stage, and treatment is focused on cure and prolonging disease-free survival. Local therapy (surgery and/or radiation treatment) is standard, along with systemic adjuvant therapy that may effectively prevent or delay relapse and death in early-stage disease. In premenopausal women, adjuvant therapeutic approaches include combination cytotoxic chemotherapy and endocrine therapy. Cyclophosphamide, methotrexate and 5-fluorouracil (CMF) was the established chemotherapy regimen; however, newer regimens have more recently been introduced that may offer some benefit over CMF including anthracycline-containing regimens [e.g. cyclophosphamide, epirubicin and 5-fluorouracil (CEF)], and taxane-containing regimens. For women with oestrogen receptor (ER)-positive disease, a second option is endocrine therapy that aims to suppress mitogenic oestrogen signalling. Until recently, 5 years of tamoxifen was regarded as the standard adjuvant endocrine treatment in ER-positive disease. Ovarian ablation is also effective in premenopausal women, and can be achieved by surgery, radiotherapy, or via the use of a luteinising hormone-releasing hormone analogue such as goserelin. Combining tamoxifen and goserelin treatment provides more effective oestrogen blockade than either drug alone. However, as the third-generation aromatase inhibitors (AIs) have demonstrated improved efficacy over tamoxifen in postmenopausal women with early and advanced disease, combination treatment with goserelin plus an AI may provide optimal oestrogen blockade in premenopausal patients. CONCLUSIONS: This review assesses the relative merits of chemotherapeutic and endocrine approaches for the treatment of early breast cancer, and summarises relevant ongoing clinical trials, with an emphasis on the premenopausal setting.
Assuntos
Antineoplásicos Hormonais/uso terapêutico , Neoplasias da Mama/tratamento farmacológico , Carcinoma/tratamento farmacológico , Tratamento Farmacológico/tendências , Pré-Menopausa , Neoplasias da Mama/patologia , Carcinoma/patologia , Quimioterapia Adjuvante , Feminino , Humanos , Neoplasias Hormônio-Dependentes/tratamento farmacológico , Neoplasias Hormônio-Dependentes/patologia , Ovário/efeitos dos fármacos , Satisfação do Paciente , Pré-Menopausa/efeitos dos fármacos , Qualidade de VidaRESUMO
Mcm2-7 (MCM) proteins are part of the origin licensing machinery that regulates initiation of DNA replication. Geminin is a licensing repressor and prevents reinitiation of DNA replication during S-G2-M phase by blocking reloading of Mcm2-7 at replication origins. Here, we have analysed these replication licensing factors (RLFs) to determine whether the pathway becomes deregulated during mammary carcinogenesis, and have assessed their potential value as prognostic markers. Protein expression profiles were generated for Ki67, Mcm2, geminin, HER-2, ER and PR in a series of reduction mammoplasty (n=18) and breast cancer specimens (n=120), and compared to clinicopathological parameters. A large proportion of epithelial cells of the terminal duct lobular unit reside in a primed 'replication licensed' but not proliferating state. This state is characterised by Mcm2 expression and absence of Ki67 and the S/G2/M marker geminin. In breast cancers, increasing tumour grade is associated with increased Ki67, Mcm2 and geminin expression. The Mcm2/Ki67 ratio decreases through the grades, indicating a shift from a predominantly licensed state to an actively proliferating state. This shift is associated with an increase in the geminin/Ki67 ratio, signifying a shortening of G1 phase in breast cancer cells. Ki67, Mcm2 and the Mcm2/Ki67 ratio are statistically significantly associated with the Nottingham Prognostic Index (NPI), but geminin and the geminin/Ki67 ratio are not. Ki67, Mcm2 and Mcm2/Ki67 are highly correlated with one another, with Mcm2 being the single most important predictor of NPI score (P<0.001). However, only 12% of variation in NPI is explained by Mcm2, as the labelling index for this marker is approaching 100% for many of the high-grade tumours. The origin licensing phenotypes of normal breast and breast cancers therefore relate to their cellular differentiation status, and high-level MCM expression in more poorly differentiated tumours severely constrains their use as prognostic markers in breast cancer.
Assuntos
Neoplasias da Mama/genética , Neoplasias da Mama/patologia , Proteínas de Ciclo Celular/biossíntese , Ciclo Celular/fisiologia , Replicação do DNA , Antígeno Ki-67/biossíntese , Proteínas Nucleares/biossíntese , Adulto , Biomarcadores Tumorais/análise , Estudos de Casos e Controles , Proteínas de Ciclo Celular/análise , Diferenciação Celular , Feminino , Geminina , Perfilação da Expressão Gênica , Humanos , Imuno-Histoquímica , Antígeno Ki-67/análise , Cinética , Mamoplastia , Pessoa de Meia-Idade , Componente 2 do Complexo de Manutenção de Minicromossomo , Proteínas Nucleares/análise , Fenótipo , PrognósticoRESUMO
Two-thirds of breast tumours are oestrogen-receptor positive and 60-70% of these tumours respond to interventions that reduce the effects of oestrogen. Until recently, tamoxifen was the drug of choice for the treatment of hormone-responsive early and advanced breast cancer. However, tamoxifen is associated with increased incidences of endometrial cancer and thromboembolic disease, and many tumours eventually become resistant to treatment with tamoxifen. Thus, there is a need for alternative therapies with different mechanisms of action. In postmenopausal women, aromatase inhibitors (AIs) suppress oestrogen levels by inhibiting oestrogen synthesis via the aromatase enzyme pathway. The third-generation AIs (anastrozole, letrozole and exemestane) are more potent than the earlier AIs (aminoglutethimide, formestane and fadrozole) with respect to both aromatase inhibition and oestrogen suppression. While the earlier AIs were unable to show any benefit over megestrol acetate or tamoxifen as second- and first-line therapy, respectively, in postmenopausal women with advanced breast cancer, third-generation AIs have shown significant benefits in both settings. Comparison of aromatase inhibition and oestrogen suppression between the third-generation AIs anastrozole and letrozole showed a small but significantly greater difference in the degree of suppression of oestrone and oestrone sulphate (but not oestradiol), with letrozole. In an open-label trial, there were no significant differences between letrozole and anastrozole for the clinical end points of time to progression (primary end point), time to treatment failure, overall survival, clinical benefit, duration of clinical benefit, time to response, duration of response or objective response rate in patients with confirmed hormone receptor-positive tumours. Together these data suggest that once a certain threshold of aromatase inhibition is reached, small differences in oestrogen suppression between the third-generation AIs do not lead to clinically significant differences in overall efficacy.
Assuntos
Antineoplásicos Hormonais/uso terapêutico , Inibidores da Aromatase , Neoplasias da Mama/tratamento farmacológico , Anastrozol , Androstadienos/uso terapêutico , Aromatase/efeitos dos fármacos , Neoplasias da Mama/mortalidade , Feminino , Humanos , Letrozol , Pessoa de Meia-Idade , Nitrilas/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Tamoxifeno/uso terapêutico , Triazóis/uso terapêuticoRESUMO
A protocol for initiation of warfarin therapy, targeted specifically for older people and based on individual responses to initial warfarin doses, was evaluated in a case-control study. People within the protocol group: (i) received higher initial doses of warfarin, (ii) reached an international normalized ratio (INR) of 2 more quickly, (iii) spent more time with INR of 2-3 in the first week and (iv) were less likely to be over-anticoagulated. However, the proportion of people who reached an INR of 2 too quickly (in <4 days) was no greater. The protocol correctly predicted the maintenance dose range of warfarin in over 70% of cases.
Assuntos
Anticoagulantes/administração & dosagem , Protocolos Clínicos , Varfarina/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Coeficiente Internacional Normatizado , Masculino , Pessoa de Meia-IdadeRESUMO
National guidance and clinical guidelines recommended multidisciplinary teams (MDTs) for cancer services in order to bring specialists in relevant disciplines together, ensure clinical decisions are fully informed, and to coordinate care effectively. However, the effectiveness of cancer teams was not previously evaluated systematically. A random sample of 72 breast cancer teams in England was studied (548 members in six core disciplines), stratified by region and caseload. Information about team constitution, processes, effectiveness, clinical performance, and members' mental well-being was gathered using appropriate instruments. Two input variables, team workload (P=0.009) and the proportion of breast care nurses (P=0.003), positively predicted overall clinical performance in multivariate analysis using a two-stage regression model. There were significant correlations between individual team inputs, team composition variables, and clinical performance. Some disciplines consistently perceived their team's effectiveness differently from the mean. Teams with shared leadership of their clinical decision-making were most effective. The mental well-being of team members appeared significantly better than in previous studies of cancer clinicians, the NHS, and the general population. This study established that team composition, working methods, and workloads are related to measures of effectiveness, including the quality of clinical care.
Assuntos
Neoplasias da Mama/terapia , Equipe de Assistência ao Paciente , Encaminhamento e Consulta , Carga de Trabalho , Adulto , Atitude do Pessoal de Saúde , Tomada de Decisões , Feminino , Humanos , Relações Interprofissionais , Liderança , Masculino , Pessoa de Meia-Idade , Enfermeiros Clínicos , Avaliação de Processos e Resultados em Cuidados de Saúde , Qualidade da Assistência à Saúde , Análise de RegressãoRESUMO
The formation of multidisciplinary breast teams across the UK is intended to concentrate the assessment and treatment of breast cancer into the hands of high volume specialists. We undertook a retrospective population-based study in order to determine the trends in surgeon breast cancer workload in Yorkshire, UK, and to investigate whether patients treated by low-workload surgeons had poorer survival. Of 11 329 female breast cancer patients diagnosed in 1989-1994 in Yorkshire, 6% were managed by surgeons with a mean annual workload of less than 10 new patients, while surgeons with workloads of 10-29, 30-49 and >50 treated 21, 21 and 52%, respectively. Over the study period, increasing number of patients were managed by surgeons with higher workloads. Patients treated by low-workload surgeons had poorer survival. Five-year survival was 60% in the lowest workload category compared to 68% in the highest category. The relative risk of death was increased by 15% (RR=1.15, 95% CI 1.03-1.28) and by 10% (RR=1.10, 95% CI 1.02-1.18) for patients managed by surgeons with workloads <10 and 10-29 cases per annum in comparison to patients managed by surgeons with workloads of >50. The results of this study suggest increasing site specialisation in breast cancer among general surgeons. It also provides further evidence that the management of patients by surgeons with low workloads decreases overall survival.
Assuntos
Neoplasias da Mama/mortalidade , Neoplasias da Mama/cirurgia , Cirurgia Geral , Equipe de Assistência ao Paciente , Qualidade da Assistência à Saúde , Carga de Trabalho , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Encaminhamento e Consulta , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento , Reino Unido , Recursos HumanosRESUMO
BACKGROUND: Ovarian ablation has been employed in the treatment of breast cancer for many decades and, more recently, its value as an adjuvant treatment for premenopausal women with early-stage disease has been clearly demonstrated. This review examines the different methods of achieving ovarian ablation and assesses the relevance of ovarian suppression as a treatment aim. METHODS: Medline searches were used to identify recent key articles relating to the adenoma-carcinoma sequence. Further relevant articles were obtained by manual scanning of the reference lists of selected papers. RESULTS AND CONCLUSION: Ovarian ablation has historically been achieved by surgical or radiological intervention. Although beneficial in premenopausal disease, these methods produce permanent ablation that results in a premature menopause, which may be associated with long-term adverse events. A series of trials have recently demonstrated the benefits of luteinizing hormone releasing hormone (LHRH) agonists, such as goserelin and leuprorelin, as adjuvant treatment for premenopausal hormone-sensitive disease. LHRH agonists produce a reliable suppression of ovarian oestrogen production of equivalent efficacy to adjuvant chemotherapy in hormone-sensitive disease. Effective ovarian suppression is marked by amenorrhoea, but studies have suggested that permanent amenorrhoea is not necessary to confer benefit in the treatment of early breast cancer. LHRH agonists therefore represent a beneficial therapeutic option for premenopausal patients with hormone-sensitive early disease.
Assuntos
Neoplasias da Mama/terapia , Hormônio Liberador de Gonadotropina/uso terapêutico , Ovariectomia , Ovário/efeitos dos fármacos , Adulto , Amenorreia/etiologia , Intervalo Livre de Doença , Feminino , Hormônio Liberador de Gonadotropina/antagonistas & inibidores , Humanos , Menopausa , Pessoa de Meia-Idade , Terapia Neoadjuvante/métodos , Ovário/efeitos da radiaçãoRESUMO
AIM: To investigate the financial circumstances of families whose child had died after a long-term illness and the factors contributing to financial difficulties. RESEARCH METHODS: Qualitative exploration involved semi-structured interviews with a purposive sample of 16 families whose child had died in the last 2 years and who were in touch with a children's hospice. RESULTS: All parents were affected by loss of or reduction in social security benefits. This could result in an immediate drop in income of as much as 72%. Paying for funerals and headstones could be hard. Financial problems after the child's death often had origins in the period of care, when parents had reduced incomes but faced extra costs of care. Some families had got into debt. Re-engaging with employment could be a slow process, and it was not clear where professional responsibility lay in providing financial advice and support. Insensitive treatment by administrative agencies increased problems for parents. DISCUSSION: Findings provide further evidence of the financial impact for families of caring for severely disabled children. This study shows how this impact can extend far into the period after death. Findings indicate the need for financial advice and support to families both during the period of care and after bereavement.