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1.
Zhonghua Wei Chang Wai Ke Za Zhi ; 23(3): 225-229, 2020 Mar 25.
Artigo em Chinês | MEDLINE | ID: mdl-32192299

RESUMO

The comprehensive treatment of solid tumor has become a mature treatment model. Under this model, many tumors, such as breast cancer, anal squamous cell carcinoma, rectal gastrointestinal stromal tumor and rectal cancer, are undergoing the evolutionary process of reducing the extent of surgery and witnessing an increasing demand for organ preservation. Watch and wait (W&W) after neoadjuvant chemoradiation therapy (nCRT) for rectal cancer is a hot topic in recent years. Available data suggest that patients with clinical or expected pathologic complete remission who adopt a W&W strategy are more likely to achieve an outcome similar to surgery, but with a significant improvement in quality of life. From the perspective of the evolution of surgical oncology, it is necessary to conduct further researches on patient screening, strategy improvement, evaluation optimization, and risk control during implementation. Encouraging doctor-patient shared decision-making, adequate patient communication and informed consent, careful design and practice of clinical research, and accumulation of high-level evidence are crucial to this effort. The concept of "intentional W&W" will help to promote the researches, and we should also be alert to the challenges and risks in the implementation process.


Assuntos
Neoplasias Retais , Oncologia Cirúrgica , Humanos , Terapia Neoadjuvante , Recidiva Local de Neoplasia , Qualidade de Vida , Neoplasias Retais/terapia , Conduta Expectante
2.
Zhonghua Wei Chang Wai Ke Za Zhi ; 23(3): 258-265, 2020 Mar 25.
Artigo em Chinês | MEDLINE | ID: mdl-32192305

RESUMO

Objective: To explore the safety and efficacy of watch and wait strategy and organ preservation surgery after total neoadjuvant treatment for MRI stratified low-risk rectal cancer. Methods: A prospective single arm phase Ⅱ trial developed at Department of Gastrointestinal Cancer, Peking University Cancer Hospital & Institute was preliminarily analyzed. Subjects were enrolled from August 2016 to January 2019. Low-risk rectal cancer with following MRI features were recruited: mid-low tumor, mrT2-3b, MRF (-), EMVI (-), CRM (-), differentiation grade 1-3. Patients received intensity-modulated radiotherapy (IMRT) 50.6 Gy/22f with concurrent capecitabine and 4 cycles of consolidation CAPEOX. Patients with cCR/near-cCR confirmed by physical examination, rectal MRI, endoscopy, and serum CEA were recommended for watch & wait approach or local excision (LE). The main study outcomes were 2-year organ preservation rate (OPR) and sphincter preservation rate (SPR). Results: Thirty-eight patients were eligible for analysis, including 24 males and 14 females with median age of 56 years; 9 cases of mrT2 (23.7%), 14 cases of mrT3a (36.8%) and 15 cases of mrT3b (39.5%); 5 cases of well differentiated adenocarcinoma (13.2%), 32 cases of moderately differentiated adenocarcinoma (84.2%) and 1 case of mucinous adenocarcinoma (2.6%). Carcinoemobryonic antigen (CEA) was elevated before treatment in 1 case. One case (2.6%) of grade 3 radiation dermatitis occurred during IMRT; 18 cases (47.4%) occurred grade 3 to 4 adverse events during consolidation chemotherapy. After total neoadjuvant treatment, the cCR and near-cCR rates were 42.1% (16/38) and 23.7% (9/38), respectively, while non-cCR rate was 34.2% (13/38). Twenty patients (20/38, 52.6%) of cCR or near-cCR underwent watch & wait approach, with a local regrowth rate of 20% (4/20). Four patients received LE, including one salvage LE. Thirteen patients (4 were ypCR) received radical resection, including 10 cases of initial low anterior resections (LAR), 1 cases of initial abdominal perineal resection (APR) and 2 cases of salvage LAR, four patients refused operation. The median follow-up time was 23.5 (8.5-38.3) months. At the last interview of follow-up, the OPR and SPR were 52.6% (20/38) and 84.2% (32/38), respectively. Only one patient developed lung metastasis and no local recurrence occurred after radical resection or LE. Conclusion: Total neoadjuvant treatment for low-risk rectal cancer achieves high cCR/near-cCR rate, with increased probability of receiving watch and wait approach and organ preservation in this subgroup.


Assuntos
Terapia Neoadjuvante , Neoplasias Retais , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Preservação de Órgãos , Estudos Prospectivos , Neoplasias Retais/terapia , Resultado do Tratamento , Conduta Expectante
3.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(11): 1051-1057, 2019 Nov 25.
Artigo em Chinês | MEDLINE | ID: mdl-31770836

RESUMO

Objective: To explore the short-term efficacy and prognosis of palliative surgical treatment for malignant bowel obstruction (MBO) caused by peritoneal metastasis of colorectal cancer (mCRC). Methods: A retrospective cohort study was conducted. The inclusion criteria for patients were as follows: (1) primary colorectal cancer; (2) massive peritoneal metastasis; (3)obstructive site located below Treitz ligament by imaging; (4) obstruction refractory to conservative treatment; (5) estimated rese survival time more than 2 months; (6) patients and their families had strong willingness for operation; (7) surgical treatment included stoma/bypass and debulking surgery. In accordance with the above criteria, clinicopathological data of 46 patients undergoing palliative surgery at Peking University Gastrointestinal Cancer Center, Unit III from January 2016 to October 2018 were retrospectively collected. Postoperative symptomatic relief rate, morbidity of complication within 30 days, complication classification (Clavien-Dindo classification), mortality and survival after operation were analyzed. Kaplan-Meier method was used to evaluate survival and Cox regression analysis was used to identify prognostic factors. Results: Among 46 patients, 30 were male and 16 were female with median age of 63 (19-87) years; 23 patients received stoma/bypass surgery (stoma/bypass group), and 23 cases received tumor debulking surgery (debulking group). The overall symptom relief rate was 76.1% (35/46), while symptom relief rate in the debulking group was 91.3% (21/23), which was significantly higher than 60.9% (14/23) in the stoma/bypass group (χ(2)=4.301, P=0.038). Postoperative complications occurred in 25 patients. The complication rate was 52.2% (12/23) in the debulking group and 56.5% (13/23) in the stoma/bypass group, without statistically significant difference (χ(2)=0.088, P=0.767). Morbidity of complication beyond grade III was 8.7% (2/23) and 13.0% (3/23) in the debulking group and stoma/bypass group respectively, without statistically significant difference (χ(2)=0.224, P=0.636). Four patients died within 30 days after operation, 2 (8.7%) in each group. Twenty-four patients underwent 1-8 cycles of chemotherapy ± targeting therapy (regimens: CapeOX ± Bevacizumab, FOLFOX/FOLFIRI ± Bevacizumab/Cetuximab), including 10 cases in the stoma/bypass group and 14 cases in the debulking group. Two patients of debulking group received postoperative radiotherapy and chemotherapy (50.6 Gy/22 f, with concurrent oral capecitabine). Till the last follow up of April 2019, 34 patients died (34/46, 73.9%) with a median overall survival time of 6.4 months, and the 6-month and 1-year survival rate was 54.5% and 29.2% respectively. The median survival time in the debulking group was significantly longer than that in the stoma/bypass group (11.5 months vs. 5.2 months, χ(2)=5.117, P=0.024). The median survival time of the 35 patients with symptomatic relief after operation was significant longer than that of 11 patients without relief (7.1 months vs 5.1 months, χ(2)=3.844, P=0.050). Multivariate analysis showed stoma/bypass surgery (HR=2.917, 95%CI:1.357-6.269, P=0.006) and greater omental metastasis (HR=4.060, 95%CI:1.419-11.617, P=0.009) were independent risk factors associated with prognosis of patients with MBO caused by peritoneal mCRC. Conclusions: For patients of MBO caused by peritoneal mCRC, tumor debulking surgery may achieve higher symptom relief rate and prolong survival. Greater omental metastasis indicates poor prognosis.


Assuntos
Neoplasias Colorretais/patologia , Obstrução Intestinal/cirurgia , Cuidados Paliativos , Neoplasias Peritoneais/secundário , Neoplasias Peritoneais/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos de Citorredução , Feminino , Humanos , Obstrução Intestinal/etiologia , Masculino , Pessoa de Meia-Idade , Omento , Neoplasias Peritoneais/complicações , Neoplasias Peritoneais/tratamento farmacológico , Prognóstico , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
4.
Zhonghua Wai Ke Za Zhi ; 57(9): 666-672, 2019 Sep 01.
Artigo em Chinês | MEDLINE | ID: mdl-31474058

RESUMO

Objective: To analyze the status of domestic surgical treatment of synchronous peritoneal carcinomatosis from colorectal cancer in China. Methods: Clinicopathological data of patients who underwent surgery from October 2003 to October 2018 in 16 domestic medical centers was retrospectively analyzed. Excel database was created which covered 77 fields of 7 parts: baseline information of patients, laboratory tests, imaging tests, chemoradiotherapy information, intra-operative findings, postoperative pathology and follow-up data. The Wilcoxon rank-sum test was used for comparison of the measurement data between groups. The χ(2) test was used for comparison of the categorical data between groups. The survival curve was calculated by the Kaplan-Meier method. Results: Of the 1 003 patients, there were 575 male and 428 female patients with the age of (58.5±14.1) years (range: 18 to 92 years). In a total of 920 patients, the carcinoma of sigmoid colon was performed in 292 cases (31.8%) with the highest ratio. The proportion of patients with liver metastasis and lung metastasis were 27.9% (219/784) and 8.3% (64/769). Preoperative detection of carcino-embryonic antigen level was the most common method in China (87.74%, 880/1 003), and the positive rate was 64.5% (568/880). The correct rate of preoperative imaging tests was 40.7% (280/688). The ratio of peritoneal carcinomatosis index (PCI) scores between 0 and 10 was the highest (59.6%, 170/285). Two hundred and sixty-two (27.0%) patients were performed by totally laparoscopic operation in 971 patients. The resection of primary tumor was performed in 588 of the 817 patients (72.0%). In a total of 457 cases, 253 (55.4%) patients were performed cytoreduction which group scored completeness of cytoreduction (CCR) 0. The postoperative hyperthermic intraperitoneal chemotherapy was implemented in 70 of the 334 cases (21.0%). Among 1 003 cases, 562 cases (56.03%) had complete follow-up data and the median overall survival was 15 months. The primary tumor resection and the CCR scores were affected by the PCI scores. The patients underwent primary tumor resection (187/205 vs. 26/80, χ(2)=105.085, P=0.000) and the patients were performed cytoreduction which scored CCR 0 or CCR 1 (162/204 vs. 8/78, Z=-10.465, P=0.000) had significant difference between the groups of PCI<20 and ≥20. There was a close correlation between the surgical method and the CCR scores (Z=-3.246,P=0.001).When the maximum degree of tumor reduction was planned, most surgeons would choose laparotomy. The overall survival time was longer in patients with primary tumor resection (P=0.000). The median survival time was 18.6 months in the group of primary tumor resection. Conclusions: It is difficult to diagnose the synchronous peritoneal carcinomatosis from colorectal cancer before the operation. Primary tumor resection has an obvious effect to prolong the survival time. It is necessary to standardize the treatment of peritoneal metastasis.


Assuntos
Neoplasias Colorretais/patologia , Neoplasias Primárias Múltiplas/diagnóstico , Neoplasias Primárias Múltiplas/terapia , Neoplasias Peritoneais/diagnóstico , Neoplasias Peritoneais/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , China , Neoplasias Colorretais/terapia , Terapia Combinada , Procedimentos Cirúrgicos de Citorredução , Feminino , Humanos , Hipertermia Induzida , Laparoscopia , Masculino , Pessoa de Meia-Idade , Neoplasias Peritoneais/mortalidade , Neoplasias Peritoneais/secundário , Estudos Retrospectivos , Taxa de Sobrevida , Adulto Jovem
5.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(7): 648-655, 2019 Jul 25.
Artigo em Chinês | MEDLINE | ID: mdl-31302963

RESUMO

Objective: To investigate the value of colonoscopic assessment in "watch and wait" strategy for mid-lower rectal cancer after neoadjuvant chemoradiotherapy (nCRT). Methods: A single-center retrospective case series study was performed. Database of mid-lower rectal cancer patients at Department of Gastrointestinal Oncology, Peking University Cancer Hospital & Institute from March 2011 to June 2017 was retrieved. Inclusion criteria: (1) nCRT was completed (50.6 Gy/22 f, plus oral capecitabine); (2) radical surgery was performed within 12 weeks after nCRT treatment; (3) clinical response to nCRT was determined as clinical complete response (cCR) or near-cCR. Patients who did not undergo colonoscopy and MRI in our center during initial assessment and follow-up, or whose colonoscopy data were unable to re-evaluated, were excluded. Initial evaluation of nCRT response was carried out between 6 and 16 weeks after nCRT. The results of endoscopy (eCR, near-eCR and non-eCR) and MRI (mCR, near-mCR and non-mCR) were compared to local lesion relapse during follow-up. The consistency of the results of colonoscopy and MRI was evaluated by Kappa test (Kappa value of 0.21 to 0.40 indicates general consistency, 0.41 to 0.60 moderate consistency, and 0.61 to 0.80 high consistency). The non-regrowth disease-free survival (NR-DFS) curves of the eCR group and the near-eCR group were plotted by Kaplan-Meier method and compared by log-rank test. Clinical significance of colonoscopy examination in the following "watch and wait" strategy during follow-up period was analyzed. Results: A total of 32 patients were enrolled in the study, including 21 (65.6%) males and 11 (34.4%) females with a median age of 57 years old. The differentiated type of rectal cancer included 1 (3.1%) case of well-differentiated, 26 (81.2%) of moderately differentiated and 5 (15.6%) of poorly differentiated. Clinical stage of the patients included 9 (28.1%) cases of T2-3N0 and 23 (71.9%) of T2-3N+. Median follow-up period was 48 (18 to 80) months. The local regrowth rate was 34.4% (11/32) and median interval of local regrowth was 10.0 (4 to 37) months. Initial colonoscopy evaluation was carried out at a median time of 9 (5 to 19) weeks after nCRT was completed. According to endoscopic findings, patients were divided into 3 groups, including 15 cases in eCR group, 15 cases in near-eCR group and 2 cases in non-eCR group. According to the appearance of MRI, patients were divided into 3 groups, including 8 cases in mCR group, 21 cases in near-mCR group and 3 cases in non-mCR group. The regrowth rate of eCR group was lower than that of mCR group (1/15 vs. 1/8) without significant difference (P=1.000). The regrowth rate of near-eCR group was higher than that of near-mCR group [9/15 vs. 42.9% (9/21)] without significant difference as well (P=0.500). The consistency between colonoscopy and MRI in response evaluation of cCR or near-cCR after nCRT was unsatisfactory (Kappa=0.341, P=0.011). After initial evaluation, 31 patients underwent watch and wait strategy, and 1 underwent local resection. The 1- and 3-year NR-DFS in the eCR group was both 100%, which was higher than that in the near-eCR group (53.3% and 38.9%, respectively), and the difference was statistically significant (P=0.001). During watch and wait period, 11 cases developed local regrowth by colonoscopy examination and the biopsy result included 4 case of high-grade intraepithelial neoplasia (HIN), 6 cases of adenocarcinoma and 1 case of chronic mucosal inflammation. Meanwhile lateral developmental tumor of ascending colon in 1 case and of sigmoid in a case was found by colonoscopy and confirmed as HIN by postoperative pathology. Besides, 4 cases developed colonic multiple adenoma and all underwent endoscopic resection. Conclusion: Colonoscopy examination plays an important role in both initial assessment and regrowth monitoring during watch and wait strategy after nCRT treatment.


Assuntos
Adenocarcinoma/diagnóstico , Quimiorradioterapia/métodos , Colonoscopia , Recidiva Local de Neoplasia/diagnóstico , Neoplasias Retais/diagnóstico , Conduta Expectante , Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/radioterapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Neoplasias Retais/tratamento farmacológico , Neoplasias Retais/radioterapia , Estudos Retrospectivos
6.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(6): 521-526, 2019 Jun 25.
Artigo em Chinês | MEDLINE | ID: mdl-31238632

RESUMO

Neoadjuvant chemoradiation has been accepted as a standard of care for local advanced middle to low rectal cancer. Patients with clinical complete response (cCR) or near cCR following neoadjuvant chemoradiation may benefit from watch and wait strategy or organ-preserving surgery with good short- and long-term outcome and quality of life (QOL). Yet the criteria of cCR varies and cCR is not consistent with pCR. Therefore, the obstacle to the strategy lies on whether its failure can be salvaged and the complexity of follow-up. Available studies demonstrated that local recurrence or regrowth can be salvaged by surgery without compromising the survival. So, the key is appropriate follow-up schedule and timely salvage. The strategy has not drawn much attention until recently, and relevant studies go slowly because of low data availability, patient awareness, and peer acceptance. We still believe that more and more patients might benefit from this strategy, along with the increasing attention of QOL from the patients. That may be obtained through screening of the right patients and optimizing treatment modality, evaluation methods, and protocol of follow-up.


Assuntos
Quimiorradioterapia Adjuvante/métodos , Terapia Neoadjuvante , Recidiva Local de Neoplasia/prevenção & controle , Neoplasias Retais/terapia , Conduta Expectante/métodos , Humanos , Qualidade de Vida , Neoplasias Retais/patologia , Conduta Expectante/normas
7.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(6): 550-559, 2019 Jun 25.
Artigo em Chinês | MEDLINE | ID: mdl-31238634

RESUMO

Objective: To understand the perceptions, attitudes and treatment selection of Chinese surgeons on the "watch and wait" strategy for rectal cancer patients after achieving a clinical complete response (cCR) following neoadjuvant chemoradiotherapy (nCRT). Methods: A cross-sectional survey was used in this study. Selection of subjects: (1) Domestic public grade III A (provincial and prefecture-level) oncology hospitals or general hospitals possessing the radiotherapy department and the diagnosis and treatment qualifications for colorectal cancer. (2) Surgeons of deputy chief physician or above. Using the "Questionnaire Star" online survey platform to create a questionnaire about cognition, attitude and treatment choice of the "watch and wait" strategy after cCR following nCRT for rectal cancer. The questionnaire contained 32 questions, such as the basic information of doctor, the current status of rectal cancer surgery, the management of pathological complete remission (ypCR) after nCRT for rectal cancer, the selection of examination items for diagnosis of cCR, the selection of suitable people undergoing "watch and wait" approach, the nCRT mode for promotion of cCR, the choice of evaluation time point, the willingness to perform "watch and wait" approach and the treatment choice, and the risk and monitoring of "watch and wait" approach. A total of 116 questionnaires were sent to the respondents via WeChat between January 31 and February 19, 2019. Statistical analysis was performed using Fisher's exact test for categorical variables. Results: Forty-eight hospitals including 116 surgeons meeting criteria were enrolled, of whom 77 surgeons filled the questionnaire with a response rate of 66.4%. "Watch and wait" strategy was carried out in 76.6% (59/77) of surgeons. Seventy surgeons (90.9%) were aware of the ypCR rate of rectal cancer after preoperative nCRT and 49 surgeons (63.6%) knew the 3-year disease-free survival of patients with ypCR in their own hospitals. Fifty-five surgeons (71.4%) believed that patients with ypCR undergoing radical surgery met the treatment criteria and were not over-treated. Three most necessary examinations in diagnosing cCR were colonoscopy (96.1%, 74/77), digital rectal examination (DRE) (90.9%,70/77) and DWI-MRI (83.1%, 64/77). Responders preferred to consider a "watch and wait" strategy for patients with baseline characteristics as mrN0 (77.9%, 60/77), mrT2 (68.8%, 53/77) and well-differentiated adenocarcinoma (68.8%, 53/77). Sixty-six surgeons (85.7%) believed that long-term chemoradiotherapy (LCRT) with combination or without combination of induction and/or consolidation of the CapeOX regimen (capecitabine + oxaliplatin) should be the first choice as a neoadjuvant therapy to achieve cCR. Forty-one surgeons (53.2%) believed that a reasonable interval of judging cCR after nCRT should be ≥ 8 weeks. Forty-four surgeons (57.1%) routinely, or in most cases, informed patient the possibility of cCR and proposed to "watch and wait" strategy in the initial diagnosis of patients with non-metastatic rectal cancer. Thirteen surgeons (16.9%) would take the "watch and wait" strategy as the first choice after the patient having cCR. Fifty-two surgeons (67.5%) would be affected by the surgical method, that was to say, "watch and wait" approach would only be recommended to those patients who would achieve cCR and could not preserve the anus or underwent difficult anus-preservation surgery. Sixteen surgeons (20.8%) demonstrated that "watch and wait" strategy would not be recommended to patients with cCR regardless of whether the surgical procedure involved anal sphincter. Eleven surgeons (14.3%) believed that the main risk of "watch and wait" approach came from distant metastasis rather than local recurrence or regrowth. Twenty-nine of surgeons (37.7%) did not understand the difference between "local recurrence" and "local regrowth" during the period of "watch and wait". Twenty-six surgeons (33.8%) thought that the monitoring interval for the first 3 years of "watch and wait" strategy was 3 months, and the follow-up monitoring interval could be 6 months to 5 years. Surgeons from cancer specialist hospitals had higher approval rate, notification rate, and referral rate of "watch and wait" strategy than those from general hospitals. Thirty-one surgeons (42.5%) considered that the difficulty and concern of carrying out "watch and wait" approach in the future was the disease progress leading to medical disputes. Twenty-six surgeons (35.6%) demonstrated that their concern was lack of uniform evaluation standard for cCR. Conclusions: Chinese surgeons seem to have inadequate knowledge of non-operative management for rectal cancer patients achieving cCR after nCRT and show relatively conservative attitudes toward the strategy. Chinese consensus needs to be formed to guide the non-operative management in selected patients. Chinese Watch & Wait Database (CWWD) is also needed to establish and provide more evidence for the use of alternative procedure after a cCR following nCRT.


Assuntos
Quimiorradioterapia Adjuvante/métodos , Terapia Neoadjuvante , Neoplasias Retais/terapia , Conduta Expectante/métodos , Atitude do Pessoal de Saúde , Estudos Transversais , Pesquisas sobre Serviços de Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Recidiva Local de Neoplasia , Inquéritos e Questionários
8.
Zhonghua Wai Ke Za Zhi ; 55(7): 481-485, 2017 Jul 01.
Artigo em Chinês | MEDLINE | ID: mdl-28655073

RESUMO

Laparoscopic surgery has been increasingly used in rectal cancer surgery. Though there are still some controversies, most of the research results support that the outcome is similar for rectal cancer patients with either laparoscopic or open surgery, in term of short-term such as safety and efficacy and long-term such as oncologic outcome. Standardization of laparoscopic training together with the comprehensive management concept are the prerequisites of laparoscopic rectal cancer surgery. Those doctors who do minimally invasive surgery should follow the rationale that smaller incision and sphincter preservation are secondary to safety and oncological result of the patients. It is the comprehensive management and personalized treatment that bring opportunities for the continuous development and innovation of innovative technologies and concepts, for example, non-operative treatment, endoscopic therapy, natural orifice transluminal endoscopic surgery, single incision laparoscopic surgery, and robotic surgery. And they may finally lead to better outcome and quality of life for the patients.


Assuntos
Neoplasias Colorretais/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos , Neoplasias Retais/cirurgia , Procedimentos Cirúrgicos Robóticos , Humanos , Laparoscopia , Cirurgia Endoscópica por Orifício Natural , Qualidade de Vida , Resultado do Tratamento
9.
Clin Microbiol Infect ; 21(12): 1047-51, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26417851

RESUMO

Hand hygiene is considered to be the most effective way of preventing microbial transmission and healthcare-associated infections. The use of alcohol-based hand rubs (AHRs) is the reference standard for effective hand hygiene. AHR consumption is a valuable surrogate parameter for hand hygiene performance, and it can be easily tracked in the healthcare setting. AHR availability at the point of care ensures access to optimal agents, and makes hand hygiene easier by overcoming barriers such as lack of AHRs or inconvenient dispenser locations. Data on AHR consumption and availability at the point of care in European hospitals were obtained as part of the Prevention of Hospital Infections by Intervention and Training (PROHIBIT) study, a framework 7 project funded by the European Commission. Data on AHR consumption were provided by 232 hospitals, and showed median usage of 21 mL (interquartile range (IQR) 9-37 mL) per patient-day (PD) at the hospital level, 66 mL/PD (IQR 33-103 mL/PD) at the intensive-care unit (ICU) level, and 13 mL/PD (IQR 6-25 mL/PD) at the non-ICU level. Consumption varied by country and hospital type. Most ICUs (86%) had AHRs available at 76-100% of points of care, but only approximately two-thirds (65%) of non-ICUs did. The availability of wall-mounted and bed-mounted AHR dispensers was significantly associated with AHR consumption in both ICUs and non-ICUs. The data show that further improvement in hand hygiene behaviour is needed in Europe. To what extent factors at the national, hospital and ward levels influence AHR consumption must be explored further.


Assuntos
Anti-Infecciosos Locais/administração & dosagem , Desinfecção das Mãos/métodos , Higienizadores de Mão/administração & dosagem , Infecção Hospitalar/prevenção & controle , Europa (Continente) , Inquéritos Epidemiológicos , Hospitais/estatística & dados numéricos , Humanos , Sistemas Automatizados de Assistência Junto ao Leito/estatística & dados numéricos
10.
Eur J Surg Oncol ; 41(7): 927-33, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25913059

RESUMO

BACKGROUND: Gastric cancer is one of most common malignancies in the world. Currently the prognostic prediction is entirely based on the TNM staging system. In this study, we evaluated whether metastatic lymph node ratio (rN) at the time of surgery would improve the prognostic prediction in conjunction with the TNM staging system. METHODS: This retrospective study includes 745 patients, who had been referred for surgery due to gastric cancer between 1995 and 2007 and had at least 15 lymph nodes examined at the time of surgery without preoperative treatment. Clinicopathologic features and overall survival were analyzed using univariate and multivariate modes to identify the risk factors for overall survival. RESULTS: Median overall survival of all patients analyzed is 57.8 months and 5-year overall survival is 49.5%. Tumor site, macroscopic type, pTNM stage, and rN stage are identified as independent prognostic factors. Increased positive lymph node ratio correlates with shorter survival in all patients and in each T and N stage. In stage III gastric cancer patients, rN stage shows additional prognostic value on overall survival (p < 0.001). CONCLUSIONS: rN stage is a simple and promising prognostic factor of gastric cancer after surgery in addition to the TNM stage system especially in stage III patients. But the independent prognostic value of rN stage in stage I, II and IV gastric cancer is yet to be determined.


Assuntos
Gastrectomia , Excisão de Linfonodo , Linfonodos/patologia , Neoplasias Gástricas/mortalidade , Neoplasias Gástricas/patologia , Adulto , Idoso , Análise de Variância , Feminino , Gastrectomia/métodos , Humanos , Estimativa de Kaplan-Meier , Linfonodos/cirurgia , Metástase Linfática/diagnóstico , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Neoplasias Gástricas/cirurgia
11.
Genet Mol Res ; 13(4): 10952-7, 2014 Dec 19.
Artigo em Inglês | MEDLINE | ID: mdl-25526216

RESUMO

Gastric cancer is the fourth most common cancer worldwide and the leading cause of tumor-related death in China. Gastric cancer is a heterogeneous disease and therefore requires different treatments based on the subtype. We describe a patient who had gastric cancer with liver metastases. Biopsy and tumor analysis using the HercepTest revealed a human epidermal growth factor receptor 2 (HER2)-positive adenocarcinoma as confirmed by fluorescence in situ hybridization. The patient was treated with a regimen of trastuzumab, oxaliplatin, and S-1 (six cycles). When positron emission tomography findings suggested that the metastases had resolved, the patient underwent surgery. Histopathologically, no cancer cells were observed in the resected hepatic tissue. The patient underwent tumor resection surgery, during which the tumor and gastric lymph nodes with lesions were removed. The patient has remained disease-free for 3 months. Therefore, trastuzumab may be an effective agent in the chemotherapeutic treatment of liver metastases in patients with HER2-positive gastric adenocarcinoma.


Assuntos
Anticorpos Monoclonais Humanizados/administração & dosagem , Antineoplásicos/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias Hepáticas/secundário , Neoplasias Gástricas/tratamento farmacológico , Neoplasias Gástricas/cirurgia , Combinação de Medicamentos , Feminino , Humanos , Neoplasias Hepáticas/tratamento farmacológico , Neoplasias Hepáticas/genética , Neoplasias Hepáticas/cirurgia , Pessoa de Meia-Idade , Compostos Organoplatínicos/administração & dosagem , Oxaliplatina , Ácido Oxônico/administração & dosagem , Receptor ErbB-2/genética , Neoplasias Gástricas/genética , Neoplasias Gástricas/patologia , Tegafur/administração & dosagem , Trastuzumab , Resultado do Tratamento
12.
HIV Med ; 15(8): 488-98, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24641448

RESUMO

OBJECTIVES: The aim of the study was to assess the incidence and costs of adverse events (AEs) among patients with HIV infection treated with nonnucleoside reverse transcriptase inhibitors (NNRTIs) from the health care system perspective. METHODS: US medical and pharmacy claims during 2004-2009 were examined to select adult new NNRTI users with HIV infection. The incidence of selected AEs and time to occurrence were assessed during the first year. Episodes of care for each AE were identified using claims associated with AE management. For each AE, a propensity score model was used to match patients with an AE to those without (1:4) based on the propensity of having an AE. Mean total health care costs, AE-associated costs and incremental costs per episode, and annual total health care costs per patient were calculated. RESULTS: Of the 2548 NNRTI-treated patients, 29.3% experienced AEs. The incidence ranged from 0.4 episodes/1000 person-years for suicide/self-injury to 14.9 episodes/1000 person-years for dizziness, 49.8 episodes/1000 person-years for depression and 150.3 episodes/1000 person-years for lipid disorder. The mean AE-associated cost (duration) per episode ranged from $586 (88 days) for lipid disorder to $975 (33 days) for rash, $2760 (73 days) for sleep-related symptoms and $4434 (41 days) for nausea/vomiting. The mean incremental cost per episode ranged from $1580 for rash to $2032 for lipid disorder, $8307 for sleep-related symptoms and $12 833 for nausea/vomiting. During the 12 months following NNRTI initiation, the mean annual total health care cost was $27 299 (efavirenz: $26 185; other NNRTIs: $34 993) and AE-associated costs were $608 (efavirenz: $554; other NNRTIs: $979) among all NNRTI users. CONCLUSIONS: With treatment increasing patient survival, comparisons of therapeutic regimens should consider treatment-associated AEs. Findings from this study could be informative for clinicians and payers in managing HIV infection with NNRTIs.


Assuntos
Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/economia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Infecções por HIV/tratamento farmacológico , Inibidores da Transcriptase Reversa/efeitos adversos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Custos de Cuidados de Saúde , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Inibidores da Transcriptase Reversa/administração & dosagem , Estados Unidos , Adulto Jovem
13.
J Hosp Infect ; 83(2): 94-8, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23273963

RESUMO

BACKGROUND: There is increasing interest in public reporting of healthcare-associated infection (HAI) data in Europe, mostly for patient safety reasons. But it is uncertain whether patients and other stakeholders benefit from them. AIM: To obtain the views of European infection control opinion leaders and provide information about public reporting of HAI in Europe. METHODS: European Centre for Disease Prevention and Control HAI surveillance National Contact Points and other opinion leaders in infection control from 34 European countries were invited to complete questionnaires about HAI reporting in their countries and to provide their personal views about public reporting. The issue was discussed during two discussion rounds in 2010 and 2012. FINDINGS: Response rates were 100% and 93.9% for the two surveys. Current practices on publishing HAI data vary widely across Europe. Many experts support the idea of publishing HAI data. All representatives from the seven countries with established public reporting were in favour of such practice. After the first discussion round, 12 experts changed their opinion. Finally, the majority of the experts acknowledged the positive influence on hospitals by increasing competition on the basis of quality, but they are hesitant about publishing infection rates as these can be misinterpreted by patients and need standardization and validation. CONCLUSION: Opinion leaders in infection control in Europe acknowledged the positive influence of public reporting on hospital performance and resulting efforts to reduce infections. They were in favour of reporting of individual hospital data if (i) process indicators rather than outcome data are reported, and (ii) delivery of surveillance is monitored by external audits.


Assuntos
Acesso à Informação , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/prevenção & controle , Controle de Infecções/métodos , Disseminação de Informação/métodos , Europa (Continente)/epidemiologia , Humanos , Inquéritos e Questionários
14.
Eur J Surg Oncol ; 37(4): 319-24, 2011 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-21277730

RESUMO

AIMS: This study aims to determine whether adjuvant treatment with imatinib improves recurrence-free survival (RFS) in Chinese patients undergoing complete resection of localized primary gastrointestinal stromal tumor (GIST) compared with those not receiving adjuvant therapy. We also sought a correlation between c-KIT mutations and RFS. METHODS: Patients who had undergone complete tumor resection with intermediate or high risk of recurrence were enrolled in a single-center, non-randomized, prospective study. Patients either received adjuvant imatinib therapy (400 mg once-daily) for 3 years or did not. Mutation analyses of c-KIT were performed on available archival tumor samples. RESULTS: 105 patients were enrolled: 56 in the treatment group and 49 in the control group. Median follow-up was 45(43.1-46.9) months. RFS at 1, 2 and 3 years were higher in the treatment group than in the control group (100% vs. 90% at 1 year; 96% vs. 57% at 2 years; 89% versus 48% at 3 years, P < 0.001, HR = 0.188). Subgroup analyses showed that adjuvant therapy significantly decreased the risk of recurrence in patients whether at high risk or at intermediate risk compared with control patients (3-year RFS: 95% vs. 72%, in intermediate risk; 85% versus 31% in high risk; P < 0.001). In addition, imatinib adjuvant treatment decreased the risk of death (P = 0.025, [corrected] HR = 0.254). CONCLUSIONS: Adjuvant imatinib can improve 1-, 2- and 3-year RFS rates in patients at intermediate or high risk of recurrence after complete tumor resection. CLINICAL TRIALS REGISTRATION NUMBER: ChiCTR-TCC-00000582.


Assuntos
Antineoplásicos/uso terapêutico , Tumores do Estroma Gastrointestinal/tratamento farmacológico , Tumores do Estroma Gastrointestinal/mortalidade , Mutação , Piperazinas/uso terapêutico , Inibidores de Proteínas Quinases/uso terapêutico , Proteínas Proto-Oncogênicas c-kit/genética , Pirimidinas/uso terapêutico , Antineoplásicos/administração & dosagem , Grupo com Ancestrais do Continente Asiático , Benzamidas , Quimioterapia Adjuvante , China , Intervalo Livre de Doença , Esquema de Medicação , Feminino , Gastrectomia , Tumores do Estroma Gastrointestinal/cirurgia , Humanos , Mesilato de Imatinib , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Piperazinas/administração & dosagem , Modelos de Riscos Proporcionais , Estudos Prospectivos , Inibidores de Proteínas Quinases/administração & dosagem , Pirimidinas/administração & dosagem , Medição de Risco , Fatores de Risco , Resultado do Tratamento
15.
Qual Saf Health Care ; 19(1): 48-54, 2010 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-20172883

RESUMO

CONTEXT: The World Alliance for Patient Safety was formed to accelerate worldwide research progress towards measurably improving patient safety. Although rates of adverse events have been studied in industrialised countries, little is known about the rates of adverse events in developing and emerging countries. PURPOSE: To review the literature on patient safety issues in developing and emerging countries, to identify patient safety measures presently used in these countries and to propose a method of measurably improving patient safety measurement in these countries. METHODS: Using the Medline database for 1998 to 2007, we identified and reviewed 23 English-language articles that examined patient safety measurement in developing and emerging countries. Results Our review included 12 studies that prospectively measured patient safety and 11 studies that retrospectively measured safety. Two studies used measures of structure and the remaining used process measures, outcome measures or both. Whereas a few studies used surveys or direct observation, most studies used chart audits to measure patient safety. Most studies addressed safety at a single facility. CONCLUSIONS: Investigation of patient safety in developing and emerging countries has been infrequent and limited in scope. Establishing fundamental safe patient practices, integrating those processes into routine health services delivery and developing patients' expectations that such processes be present are necessary prerequisites to measuring and monitoring progress towards safe patient care in emerging and developing countries.


Assuntos
Países em Desenvolvimento , Segurança do Paciente/normas , Garantia da Qualidade dos Cuidados de Saúde , Gestão da Segurança/normas , Saúde Global , Humanos
16.
Postgrad Med J ; 85(1003): 244-9, 2009 May.
Artigo em Inglês | MEDLINE | ID: mdl-19520875

RESUMO

In the process of acquiring new skills, physicians-in-training may expose patients to harm because they lack the required experience, knowledge and technical skills. Yet, most teaching hospitals use inexperienced residents to care for high-acuity patients in complex and dynamic environments and provide limited supervision from experienced clinicians. Multiple efforts in the last few years have started to address the problem of patient safety. Examples include voluntary incident-reporting systems and team training workshops for practising clinicians. Fewer efforts have addressed the deficits in training new physicians, especially related to knowledge, skills and competence. The current apprenticeship or "see one, do one, teach one" model is insufficient because trainees learn by practising on real patients, which is particularly an issue when performing procedures. Residents have expressed that they do not feel adequately trained to perform procedures safely by themselves. In this paper, we conduct an informal review of the impact of current training methods on patient safety. In addition, we propose a new training paradigm that integrates competency-based knowledge and clinical skills, with deliberate attitudinal and behavioural changes focused on patient safety in a safe medically simulated environment. We do so with the hope of creating a better marriage between the missions of training and patient safety.


Assuntos
Educação Médica Continuada/métodos , Ensino/métodos , Algoritmos , Competência Clínica/normas , Modelos Educacionais
17.
Qual Saf Health Care ; 18(1): 63-8, 2009 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-19204135

RESUMO

In the process of acquiring new skills, physicians-in-training may expose patients to harm because they lack the required experience, knowledge and technical skills. Yet, most teaching hospitals use inexperienced residents to care for high-acuity patients in complex and dynamic environments and provide limited supervision from experienced clinicians. Multiple efforts in the last few years have started to address the problem of patient safety. Examples include voluntary incident-reporting systems and team training workshops for practising clinicians. Fewer efforts have addressed the deficits in training new physicians, especially related to knowledge, skills and competence. The current apprenticeship or "see one, do one, teach one" model is insufficient because trainees learn by practising on real patients, which is particularly an issue when performing procedures. Residents have expressed that they do not feel adequately trained to perform procedures safely by themselves. In this paper, we conduct an informal review of the impact of current training methods on patient safety. In addition, we propose a new training paradigm that integrates competency-based knowledge and clinical skills, with deliberate attitudinal and behavioural changes focused on patient safety in a safe medically simulated environment. We do so with the hope of creating a better marriage between the missions of training and patient safety.


Assuntos
Internato e Residência/métodos , Modelos Educacionais , Ensino/métodos , Hospitais de Ensino , Humanos
18.
AIDS Care ; 20(2): 161-9, 2008 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-18293124

RESUMO

A randomised trial compared two instruments for assessing self-reported adherence to antiretroviral medications: (1) a day-by-day recall instrument that elicited the number of missed doses in each of the prior three days (3-day instrument; n=64) and (2) a general recall instrument that elicited an estimate of proportion of pills taken during the prior seven days (7-day instrument; n=70). Adherence was measured at study visits over 12 months among participants in a clinical trial assessing treatment strategies for individuals with virologic failure and multidrug-resistant HIV. Participants had a median (interquartile range) of 133 (41-264) CD4 cells/ml(3) and a median of 10 major HIV resistance mutations at baseline. Mean adherence levels were 90-98% throughout the study. There was a greater trend in the likelihood of 100% adherence when measured by the 3-day versus the 7-day instrument (odds ratio (OR)=1.45; p=0.06). The likelihood of consistent 100% adherence measured by either instrument decreased over time (p<0.001). Participants reporting 100% adherence at more than half of study visits had better virologic and immunologic outcomes at month-12 compared to those reporting 100% adherence at half or fewer visits (HIV RNA decline of 0.96 versus 0.51 log, respectively, p=0.02; and CD4 cell increase of 51.0 versus 17.8 cells, p=0.04). This study demonstrated the utility of the general 7-day recall adherence self-report instrument as well as the 3-day day-by-day recall adherence self-report instrument for measuring antiretroviral adherence. Self-reported adherence was significantly associated with virologic and immunologic outcomes in this population with advanced drug-resistant HIV disease.


Assuntos
Terapia Antirretroviral de Alta Atividade/psicologia , Infecções por HIV/psicologia , Cooperação do Paciente/psicologia , Projetos de Pesquisa , Autoadministração/psicologia , Adulto , Fármacos Anti-HIV/uso terapêutico , Terapia Antirretroviral de Alta Atividade/métodos , Esquema de Medicação , Feminino , Seguimentos , Infecções por HIV/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade
19.
Cochrane Database Syst Rev ; (4): CD005047, 2007 Oct 17.
Artigo em Inglês | MEDLINE | ID: mdl-17943834

RESUMO

BACKGROUND: Gastric cancer is a major cause of cancer death, and many patients are only diagnosed when the cancer has reached an advanced stage. Neoadjuvant chemotherapy (NAC), that is, chemotherapy administered shortly before surgical treatment, could provide a method of increasing the possibility of complete resection and survival. OBJECTIVES: To evaluate the effect of neoadjuvant chemotherapy versus none for patients with resectable gastric cancer in terms of efficacy and toxicity. SEARCH STRATEGY: Electronic databases including Cochrane Library, MEDLINE, EMBASE, CancerLit, Chinese Biomedical Literature Database (CBMDISC) and ongoing clinical trials as well as handsearching of conference proceedings, were searched to retrieve relevant data. SELECTION CRITERIA: Randomized controlled clinical trials of neoadjuvant chemotherapy on resectable gastric cancer. DATA COLLECTION AND ANALYSIS: We identified a total of 36 published citations or meeting abstracts. Thirty-two items were excluded. Of the four remaining studies, three stated random allocation but the method of randomization was unclear. Two of these employed allocation concealment by sealed envelope which was controlled by an independent party. None of the trials was double blind. All trials presented a detailed description of the number of withdrawals, dropouts and losses to follow-up. MAIN RESULTS: Of the four clinical trials enrolled, there were 250 and 332 cases in total, with 106 and 126 deaths at the end of follow-up in the NAC and control group, respectively. The OR (odds ratio) was 1.05 (95%CI: 0.73-1.50), which was not statistically significant. Of the evaluable 129 patients receiving NAC, 28.7% demonstrated either a complete or a partial response. Two studies of NAC in resectable gastric cancer had resection rate data available for analysis The R0 resection rate in the NAC group was comparable to that in the control (OR: 0.96 (95%CI: 0.51-1.83)). The morbidity and mortality of NAC varied with the regimens used preoperatively. Of the 129 patients included in the analyzed studies, some acceptable toxicity was observed. AUTHORS' CONCLUSIONS: There is no definite evidence of the effectiveness of NAC in resectable gastric cancer, in terms of improvements in patient survival, in the trials we reviewed. Neoadjuvant chemotherapy should not be used routinely in clinical setting until further results from randomized clinical are available. Neoadjuvant chemotherapy of gastric cancer should be applied under the framework of clinical trials.


Assuntos
Neoplasias Gástricas/tratamento farmacológico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Quimioterapia Adjuvante , Humanos , Terapia Neoadjuvante , Ensaios Clínicos Controlados Aleatórios como Assunto , Neoplasias Gástricas/cirurgia
20.
Cochrane Database Syst Rev ; (2): CD005047, 2007 Apr 18.
Artigo em Inglês | MEDLINE | ID: mdl-17443566

RESUMO

BACKGROUND: Gastric cancer is a major cause of cancer death, and many patients are only diagnosed when the cancer has reached an advanced stage. Neoadjuvant chemotherapy (NAC), that is, chemotherapy administered shortly before surgical treatment, could provide a method of increasing the possibility of complete resection and survival. OBJECTIVES: To evaluate the effect of neoadjuvant chemotherapy versus none for patients with resectable gastric cancer in terms of efficacy and toxicity. SEARCH STRATEGY: Electronic databases including Cochrane Library, MEDLINE, EMBASE, CancerLit, Chinese Biomedical Literature Database (CBMDISC) and ongoing clinical trials as well as handsearching of conference proceedings, were searched to retrieve relevant data. SELECTION CRITERIA: Randomized controlled clinical trials of neoadjuvant chemotherapy on resectable gastric cancer. DATA COLLECTION AND ANALYSIS: We identified a total of 36 published citations or meeting abstracts. Thirty-two items were excluded. Of the four remaining studies, three stated random allocation but the method of randomization was unclear. Two of these employed allocation concealment by sealed envelope which was controlled by an independent party. None of the trials was double blind. All trials presented a detailed description of the number of withdrawals, dropouts and losses to follow-up. MAIN RESULTS: Of the four clinical trials enrolled, there were 250 and 332 cases in total, with 106 and 126 deaths at the end of follow-up in the NAC and control group, respectively. The OR (odds ratio) was 1.05 (95%CI: 0.73-1.50), which was not statistically significant. Of the evaluable 129 patients receiving NAC, 28.7% demonstrated either a complete or a partial response. Two studies of NAC in resectable gastric cancer had resection rate data available for analysis The R0 resection rate in the NAC group was comparable to that in the control (OR: 0.96 (95%CI: 0.51-1.83)). The morbidity and mortality of NAC varied with the regimens used preoperatively. Of the 129 patients included in the analyzed studies, some acceptable toxicity was observed. AUTHORS' CONCLUSIONS: There is no definite evidence of the effectiveness of NAC in resectable gastric cancer, in terms of improvements in patient survival, in the trials we reviewed. Neoadjuvant chemotherapy should not be used routinely in clinical setting until further results from randomized clinical are available. Neoadjuvant chemotherapy of gastric cancer should be applied under the framework of clinical trials.


Assuntos
Neoplasias Gástricas/tratamento farmacológico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Quimioterapia Adjuvante , Humanos , Terapia Neoadjuvante , Ensaios Clínicos Controlados Aleatórios como Assunto , Neoplasias Gástricas/cirurgia
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