Providing care for older adults in the Emergency Department: expert clinical recommendations from the European Task Force on Geriatric Emergency Medicine.

PURPOSE: Despite the rapidly expanding knowledge in the field of Geriatric Emergency Medicine in Europe, widespread implementation of change is still lacking. Many opportunities in everyday clinical care are missed to improve care for this susceptible and growing patient group. The aim was to develop expert clinical recommendations on Geriatric Emergency Medicine to be disseminated across Europe. METHODS: A group of multi-disciplinary experts in the field of Geriatric Emergency Medicine in Europe was assembled. Using a modified Delphi procedure, a prioritized list of topics related to Geriatric Emergency Medicine was created. Next, a multi-disciplinary group of nurses, geriatricians and emergency physicians performed a review of recent guidelines and literature to create recommendations. These recommendations were voted upon by a group of experts and placed on visually attractive posters. The expert group identified the following eight subject areas to develop expert recommendations on: Comprehensive Geriatric Assessment in the Emergency Department (ED), age/frailty adjusted risk stratification, delirium and cognitive impairment, medication reviews in the ED for older adults, family involvement, ED environment, silver trauma, end of life care in the acute setting. RESULTS: Eight posters with expert clinical recommendations on the most important topics in Geriatric Emergency Medicine are now available through https://posters.geriemeurope.eu/ . CONCLUSION: Expert clinical recommendations for Geriatric Emergency Medicine may help to improve care for older patients in the Emergency Department and are ready for dissemination across Europe.

Incidence of axillary recurrence in 344 sentinel node negative breast cancer patients after intermediate follow-up. A prospective study into the accuracy of sentinel node biopsy in breast cancer patients.

Sentinel lymph node biopsy (SLNB) has been validated in the treatment of breast carcinoma and is considered to stage the axilla adequately in this disease. However, long-term follow-up data are scarce. We evaluated the results of SLNB with respect to loco-regional failures in the axilla in SN-negative patients with invasive breast carcinoma and analysed their causal factors. Between 1997 and May 2004, 656 patients without clinically palpable lymph nodes were included in our study. Data with regard to demographics, diagnostics, therapy and follow up were gathered prospectively from all patients. Patients treated after May 2004 were excluded from this study to permit at least one year of follow-up. Out of the 656 patients, 344 patients with a negative sentinel lymph node biopsy did not undergo axillary dissection and were followed up clinically. Median follow up was 43 months. In 3 patients (0.9%) axillary recurrences developed. All three patients subsequently underwent a completion axillary dissection, chemotherapy and radiotherapy. The low rate of clinical axillary recurrence after an intermediate follow up period suggests that a negative SN biopsy accurately reflects the nodal stage in patients with breast cancer.

Incidence of axillary recurrence in 344 sentinel node negative breast cancer patients after intermediate follow-up. A prospective study into the accuracy of sentinel node biopsy in breast cancer patients.

Sentinel lymph node biopsy (SLNB) has been validated in the treatment of breast carcinoma and is considered to stage the axilla adequately in this disease. However, long-term follow-up data are scarce. We evaluated the results of SLNB with respect to loco-regional failures in the axilla in SN-negative patients with invasive breast carcinoma and analysed their causal factors. Between 1997 and May 2004, 656 patients without clinically palpable lymph nodes were included in our study. Data with regard to demographics, diagnostics, therapy and follow up were gathered prospectively from all patients. Patients treated after May 2004 were excluded from this study to permit at least one year of follow-up. Out of the 656 patients, 344 patients with a negative sentinel lymph node biopsy did not undergo axillary dissection and were followed up clinically. Median follow up was 43 months. In 3 patients (0.9%) axillary recurrences developed. All three patients subsequently underwent a completion axillary dissection, chemotherapy and radiotherapy. The low rate of clinical axillary recurrence after an intermediate follow up period suggests that a negative SN biopsy accurately reflects the nodal stage in patients with breast cancer.

A Belgian Survey on Geriatric Assessment in Oncology Focusing on Large-Scale Implementation and Related Barriers and Facilitators.

OBJECTIVES: The aim of this study is to describe a large-scale, Belgian implementation project about geriatric assessment (=GA) in daily oncology practice and to identify barriers and facilitators for implementing GA in this setting. Design / setting / participants: The principal investigator of every participating hospital (n=22) was invited to complete a newly developed questionnaire with closed- and open-ended questions. The closed-ended questions surveyed how GA was implemented. The open-ended questions identified barriers and facilitators for the implementation of GA in daily oncology practice. Descriptive statistics and conventional content analysis were performed as appropriate. RESULTS: Qualifying criteria (e.g. disease status and cancer type) for GA varied substantially between hospitals. Thirteen hospitals (59.1%) succeeded to screen more than half of eligible patients. Most hospitals reported that GA data and follow-up data had been collected in almost all screened patients. Implementing geriatric recommendations and formulating new geriatric recommendations at the time of follow-up are important opportunities for improvement. The majority of identified barriers were organizational, with high workload, lack of time or financial/staffing problems as most cited. The most cited facilitators were all related to collaboration. CONCLUSION: Interventions to improve the implementation of GA in older patients with cancer need to address a wide range of factors, with organization and collaboration as key elements. All stakeholders, seeking to improve the implementation of GA in older patients with cancer, should consider and address the identified barriers and facilitators.

Prognostic value of nodal micrometastases in patients with cancer of the gastro-oesophageal junction.

AIMS: Aim of this study was to examine the presence and the prognostic impact of immunohistochemically identified nodal micrometastases in patients with gastro-oesophageal junction (GEJ) carcinomas. METHODS: Between January 1988 and December 2000, 148 patients underwent a radical (R0) resection with a two-field lymphadenectomy for a GEJ carcinoma. Specimens of 60 patients in whom conventional haematoxylin and eosin (H & E) examination did not demonstrate lymph-node metastases (pN0) were available for immunohistochemical (IHC) analysis using antibodies AE1/AE3 directed against cytokeratins. Paraffin embedded material of all retrieved lymph nodes in these patients were serially sectioned and analysed by one pathologist after H & E examination for the presence of micrometastases by IHC. RESULTS: In 60 resection specimens initially staged as pN0 a total of 524 lymph nodes were available for IHC analyses. Micrometastases were detected in 126 out of 524 lymph nodes (24%), corresponding with 18 of the 60 patients (30%) who were upstaged by this technique. Compared with the pN0 group, the disease free survival (DFS) was significantly lower in patients with nodal involvement at IHC (p<0.001). Survival of patients with IHC identified micrometastatic disease was comparable to those with H & E positive lymph nodes. CONCLUSIONS: Micrometastases in regional nodes were detected by cytokeratin-specific IHC in 30% of radical resected GEJ tumours without overt nodal involvement. Their presence conveys a worse prognosis with a significant reduced DFS, suggesting that the finding of micrometastases should be included in the staging system.

Traumatic abdominal wall hernia: delayed presentation in two cases and a review of the literature.

Blunt and penetrating abdominal traumas are an important source of morbidity and mortality in the western world, especially in the young populations. Although most attention during the (primary) diagnostic process is directed toward the detection of internal injuries of the abdomen, blunt or penetrating trauma to the abdomen may result in defects of the abdominal wall. The diagnosis of traumatic abdominal wall hernia (TAWH) is rarely made. Morbidity due to TAWH, however, may be significant. In this article we report the delayed diagnosis of a TAWH in two patients after abdominal wall trauma and present a review of the literature concerning the diagnostic workup and treatment.

Visceral artery aneurysms.

Visceral artery aneurysms (VAAs) are a rare condition, in case of a rupture they have a high mortality rate up to 70%. Visceral artery aneurysms are seen more often these days with the more widespread use of computed tomography and angiography. There are various options for treating VAAs; open surgical repair, endovascular treatment, and laparoscopic surgery. We report 5 cases of visceral aneurysms, all treated differently--ligation, aneurysmectomy (with splenectomy), emergency and elective coil embolization, and conservatively. We will further give a review of the literature on etiology, diagnosis, and treatment options.

Influence of tumor characteristics on the accuracy of endoscopic ultrasonography in staging cancer of the esophagus and esophagogastric junction.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasonography (EUS) is the most accurate method of assessing the locoregional extent of cancer of the esophagus and esophagogastric junction. The aim of this study was to evaluate the influence of tumor-related factors such as length and location on the accuracy of EUS in staging these tumors. PATIENTS AND METHODS: Between January 1997 and September 2002, 280 consecutive patients underwent preoperative EUS for staging cancer of the esophagus and esophagogastric junction. The influence of histopathology, the presence of Barrett's dysplasia or stenosis, and the location and length of the primary tumor on the accuracy of EUS for T, N, and M staging were studied. RESULTS: The overall accuracy rates of EUS for assessing the T, N, and M stages were 73 %, 80 %, and 78 %, respectively. The influence of the tumor's histopathology and the presence of Barrett's dysplasia or stenosis was minimal. The accuracy of EUS was greater in tumors 5 cm or less in size than in tumors larger than 5 cm (82 % vs. 52 % for the T stage, P < 0.05; 88 % vs. 59 % for the N stage, P < 0.05; and 92 % vs. 56 % for the M stage, P < 0.001). The low accuracy of T staging in larger tumors may be due to the exclusion of patients with local unresectability or distant metastases. EUS was also significantly better in esophageal tumors, particularly for identifying celiac trunk metastases (93 % vs. 63 %; P < 0.001). CONCLUSIONS: The accuracy of EUS for staging esophageal cancer is lower in tumors larger than 5 cm and in esophagogastric junction tumors than in tumors 5 cm in size or less and in esophageal tumors. These findings should be considered when treatment decisions are being taken.