Prospective evaluation of an enhanced recovery after surgery (ERAS) pathway in a Norwegian cohort of patients with suspected or advanced ovarian cancer.

OBJECTIVE: This prospective cohort study evaluated the introduction of an enhanced recovery after surgery (ERAS) pathway in a tertiary gynecologic oncology referral center. Compliance and clinical outcomes were studied in two separate surgical cohorts. METHODS: Patients undergoing laparotomy for suspected or verified advanced ovarian cancer at Oslo University Hospital were prospectively included in a pre- and post-implementation cohort. A priori, patients were stratified into: cohort 1, patients planned for surgery of advanced disease; and cohort 2, patients undergoing surgery for suspicious pelvic tumor. Baseline characteristics, adherence to the pathway, and clinical outcomes were assessed. RESULTS: Of the 439 included patients, 235 (54%) underwent surgery for advanced ovarian cancer in cohort 1 and 204 (46%) in cohort 2. In cohort 1, 53% of the patients underwent surgery with an intermediate/high Aletti complexity score. Post-ERAS, median fasting times for solids (13.1 hours post-ERAS vs 16.0 hours pre-ERAS, p<0.001) and fluids (3.7 hours post-ERAS vs 11.0 hours pre-ERAS, p<0.001) were significantly reduced. Peri-operative fluid management varied less and was reduced from median 15.8 mL/kg/hour (IQR 10.8-22.5) to 11.5 mL/kg/hour (IQR 9.0-15.4) (p<0.001). In cohort 2 only there was a statistically significant reduction in length of stay (mean (SD) 4.3±1.5 post-ERAS vs 4.6±1.2 pre-ERAS, p=0.026). Despite stable readmission rates, there were significantly more serious complications reported in cohort 1 post-ERAS. CONCLUSIONS: ERAS increased adherence to current standards in peri-operative management with significant reduction in fasting times for both solids and fluids, and peri-operative fluid administration. Length of stay was reduced in patients with suspicious pelvic tumor. Despite serious complications being common in patients with advanced disease undergoing debulking surgery, a causal relationship with the ERAS protocol could not be established. Implementing ERAS and continuous performance auditing are crucial to advancing peri-operative care of patients with ovarian cancer.

Patient-reported nausea after implementation of an enhanced recovery after surgery protocol for gynae-oncology patients.

OBJECTIVES: This study aimed to analyze the adherence to strategies to prevent post-operative nausea and vomiting after implementation of an enhanced recovery after surgery (ERAS) protocol for gynae-oncology patients. Patient-reported nausea before and after ERAS was also studied. METHODS: This prospective observational study included all patients undergoing laparotomy for a suspicious pelvic mass or confirmed advanced ovarian cancer before (pre-ERAS) and after the implementation of ERAS (post-ERAS) at Oslo University Hospital, Norway. Patients were a priori stratified according to the planned extent of surgery into two cohorts (Cohort 1: Surgery of advanced disease; Cohort 2: Surgery for a suspicious pelvic tumor). Clinical data including baseline characteristics and outcome data were prospectively collected. RESULTS: A total of 439 patients were included, 243 pre-ERAS and 196 post-ERAS. At baseline, 27% of the patients reported any grade of nausea. In the post-ERAS cohort, statistically significantly more patients received double post-operative nausea and vomiting prophylaxis (64% pre-ERAS vs 84% post-ERAS, p<0.0001). There was no difference in the need for rescue medication (82% pre-ERAS vs 79% post-ERAS; p=0.17) and no statistically significant difference between pre- and post-ERAS or between the surgical cohorts in patient-reported nausea of any grade on day 2. Patients who reported none/mild nausea on day 2 had significantly less peri-operative fluid administered during surgery than those who reported moderate or severe nausea (median 12.5 mL/kg/hour vs 16.5 mL/kg/hour, p=0.045) but, in multivariable analysis, fluid management did not remain significantly associated with nausea. CONCLUSION: Implementation of an ERAS protocol increased the adherence to post-operative nausea and vomiting prevention guidelines. Nausea, both before and after laparotomy, remains an unmet clinical need of gynae-oncology patients also in an ERAS program. Patient-reported outcome measures warrant further investigation in the evaluation of ERAS.

Cycling-related injuries at Sørlandet Hospital, Kristiansand. / Sykkelrelaterte skader på Sørlandet sykehus Kristiansand.

BACKGROUND: It is a policy objective to increase the percentage of journeys made by bicycle in Norway from the current 5 % to 10 %. Kristiansand is one of the most active cities in Norway in terms of cycling. We wished to identify the extent of injuries among cyclists admitted to the hospital. MATERIAL AND METHOD: We reviewed the medical records of patients with cycling-related injuries who were admitted to Sørlandet Hospital, Kristiansand in the period 1 January 2012 to 31 December 2015. Patient, accident, injury and treatment characteristics were recorded, as well as any sequelae after 12 months. RESULTS: Altogether 224 adults and 53 children (<16 years) were registered with cycling-related injuries, most of which (n=192, 69 %) were mild/moderate. Very severe and critical injuries were recorded in 6 (11 %) children and 22 (10 %) adults. Fractures (n=179, 65 %) and minor head injuries (n= 78, 28 %) dominated the injury panorama. Surgical treatment was undertaken in 107 (48 %) adults and 19 (36 %) children. A total of 12 (4 %) patients were transferred to the trauma centre at Oslo University Hospital Ullevål. Four adults had significant sequelae after 12 months, all related to severe head/neck injury. INTERPRETATION: A considerable proportion of serious and complex injuries require that the national guidelines for use of a trauma team be followed. Systematic and ongoing registration of cyclists' injuries in the form of a national registry could help increase our insight into the circumstances surrounding accidents and the extent of injuries related to these.

Lifestyle changes in cancer patients undergoing curative or palliative chemotherapy: is it feasible?

INTRODUCTION: This study aimed to explore the feasibility of an individualized comprehensive lifestyle intervention in cancer patients undergoing curative or palliative chemotherapy. MATERIAL AND METHODS: At one cancer center, serving a population of 180,000, 100 consecutive of 161 eligible newly diagnosed cancer patients starting curative or palliative chemotherapy entered a 12-month comprehensive, individualized lifestyle intervention. Participants received a grouped startup course and monthly counseling, based on self-reported and electronically evaluated lifestyle behaviors. Patients with completed baseline and end of study measurements are included in the final analyses. Patients who did not complete end of study measurements are defined as dropouts. RESULTS: More completers (n = 61) vs. dropouts (n = 39) were married or living together (87 vs. 69%, p = .031), and significantly higher baseline physical activity levels (960 vs. 489 min.wk-1, p = .010), more healthy dietary choices (14 vs 11 points, p = .038) and fewer smokers (8 vs. 23%, p = .036) were observed among completers vs. dropouts. Logistic regression revealed younger (odds ratios (OR): 0.95, 95% confidence interval (CI): 0.91, 0.99) and more patients diagnosed with breast cancer vs. more severe cancer types (OR: 0.16, 95% CI: 0.04, 0.56) among completers vs. dropouts. Improvements were observed in completers healthy (37%, p < 0.001) and unhealthy dietary habits (23%, p = .002), and distress (94%, p < .001). No significant reductions were observed in physical activity levels. Patients treated with palliative intent did not reduce their physical activity levels while healthy dietary habits (38%, p = 0.021) and distress (104%, p = 0.012) was improved. DISCUSSION: Favorable and possibly clinical relevant lifestyle changes were observed in cancer patients undergoing curative or palliative chemotherapy after a 12-month comprehensive and individualized lifestyle intervention. Palliative patients were able to participate and to improve their lifestyle behaviors.

Scandinavian surveillance follow-up programmes in patients with malignant colorectal polyps.

INTRODUCTION: Following endoscopic removal of malignant colorectal polyps, patients may undergo completion radical resection or surveillance. The optimal surveillance strategy remains unknown. This study included colorectal departments in Scandinavian countries with a focus on follow-up periods and examination modalities for patients with endoscopically removed malignant polyps with a resection margin > 1 mm. METHODS: This study was conducted as an internet-based survey. A questionnaire was sent to all Scandinavian surgical departments performing > 20 colorectal procedures annually. Questions differed between follow-up on rectal and colonic malignant polyps with presence or absence of histological risk factors. The follow-up period was defined as short (one year), intermediate (three years) or long (five years). RESULTS: The majority of the departments used a long (five years) (38-59%) or intermediate (three years) (26-38%) follow-up programme. In patients with rectal malignant polyps and presence of histological risk factors, a significant difference was observed in the use of endoscopy according to length of follow-up. No difference in the use of the different modalities was seen according to length of follow-up in patients with colonic malignant polyps. CONCLUSIONS: The follow-up on patients with endoscopically removed malignant polyps and a surveillance strategy varies both in terms of length and performed modalities. Future studies should compare long-term patient outcomes in departments employing different follow-up strategies. FUNDING: none. TRIAL REGISTRATION: not relevant.

Acupuncture for the treatment of hot flashes in breast cancer patients, a randomized, controlled trial.

Acupuncture has been used to treat the problem of hot flashes in healthy postmenopausal women. The object of this study was to investigate the efficacy of acupuncture in women with breast cancer suffering from hot flashes as a result of anti-oestrogen medication. In a prospective, controlled trial, 59 women suffering from hot flashes following breast cancer surgery and adjuvant oestrogen-antagonist treatment (Tamoxifen) were randomized to either 10 weeks of traditional Chinese acupuncture or sham acupuncture (SA). Mean number of hot flashes at day and night were recorded prior to treatment, during the treatment period as well as during the 12 weeks following treatment. A validated health score (Kupperman index) was conducted at baseline, at the end of the treatment period and at 12 weeks following treatment. During the treatment period mean number of hot flashes at day and night was significantly reduced by 50 and almost 60%, respectively from baseline in the acupuncture group, and was further reduced by 30% both at day and night during the next 12 weeks. In the sham acupuncture group a significant reduction of 25% in hot flashes at day was seen during treatment, but was reversed during the following 12 weeks. No reduction was seen in hot flashes at night. Kupperman index was reduced by 44% from baseline to the end of the treatment period in the acupuncture group, and largely maintained 12 weeks after treatment ended. No corresponding changes were seen in the sham acupuncture group. Acupuncture seems to provide effective relief from hot flashes both day and night in women operated for breast cancer, treated with Tamoxifen. This treatment effect seems to coincide with a general health improvement measured with the validated Kupperman index.

Cancer patients participating in a lifestyle intervention during chemotherapy greatly over-report their physical activity level: a validation study.

BACKGROUND: The short form of the International Physical Activity Questionnaire (IPAQ-sf) is a validated questionnaire used to assess physical activity (PA) in healthy adults and commonly used in both apparently healthy adults and cancer patients. However, the IPAQ-sf has not been previously validated in cancer patients undergoing oncologic treatment. The objective of the present study was to compare IPAQ-sf with objective measures of physical activity (PA) in cancer patients undergoing chemotherapy. METHODS: The present study was part of a 12-month prospective individualized lifestyle intervention focusing on diet, PA, stress management and smoking cessation in 100 cancer patients undergoing chemotherapy. During the first two months of the lifestyle intervention, participants were wearing an activity monitor (SenseWear™ Armband (SWA)) for five consecutive days while receiving chemotherapy before completing the IPAQ-sf. From SWA, Moderate-to-Vigorous intensity PA (MVPA) in bouts ≥10 min was compared with self-reported MVPA from the IPAQ-sf. Analyses both included and excluded walking in MVPA from the IPAQ-sf. Results were extrapolated to a wearing time of seven days. RESULTS: Sixty-six patients completed IPAQ-sf and wore the SWA over five days. Mean difference and limit of agreement between the IPAQ-sf and SWA including walking was 662 (±1719) min(.)wk(-1). When analyzing time spent in the different intensity levels separately, IPAQ-sf reported significantly higher levels of moderate (602 min(.)wk(-1), p = 0.001) and vigorous (60 min(.)wk(-1), p = 0.001) PA compared to SWA. CONCLUSIONS: Cancer patients participating in a lifestyle intervention during chemotherapy reported 366 % higher MVPA level from the past seven days using IPAQ-sf compared to objective measures. The IPAQ-sf appears insufficient when assessing PA level in cancer patients undergoing oncologic treatment. Activity monitors or other objective tools should alternatively be considered, when assessing PA in this population.

[Regional cerebral perfusion before and after parathyroidectomy]. / Regional cerebral perfusjon før og etter paratyreoidektomi.

BACKGROUND: Single photon emission computerised tomography (SPECT) is used to study cerebral blood-flow and cerebral metabolism in various neuropsychiatric disorders. Reduced regional cerebral blood flow has been demonstrated in patients with depression and chronic fatigue, symptoms that are common in primary hyperparathyroidism. The aim of this study was to reveal possible changes in regional cerebral blood flow in patients with primary hyperparathyroidism before and after operative treatment. METHODS: Prospective study of regional cerebral blood flow in 16 consecutive women of median age 72 (range 50-82 years) using SPECT with 99m Tc-labelled hexamethylpropylenamine oxime. The measurements were performed before and two, four and twelve months after parathyroidectomy. The Montgomery and Asberg depression rating scale (MADRS) was used as a parallel clinical test. RESULTS: Reduced (pathological) regional cerebral blood flow was seen before operation in 14 patients, 13 with solitary adenoma and one with double adenoma. After surgery, this improved to normal values in 13, but was further reduced in one. In two patients with preoperative normal regional cerebral blood flow, both of them asymptomatic and with diffuse hyperplasia, a slight reduction was demonstrated. Eight patients had a pathological preoperative MADRS score, which normalised in seven after surgical treatment. CONCLUSION: The finding of reduced regional cerebral blood flow in patients with primary hyperparathyroidism followed by significant improvement after operation might have bearing upon the case for surgical treatment.

[Inguinal and femoral hernia repair in Norway 1990-2003]. / Operasjon for lyske- og lårbrokk i Norge 1990-2003.

BACKGROUND: The purpose of this study was to chart changes in surgical treatment of inguinal or femoral hernia in Norway from 1990-91 to 1999-2003. METHODS: Data were compiled from the Norwegian Patient Registry based on procedure coding for inguinal and femoral hernia repair. RESULTS: The annual number of femoral hernia repair procedures was constant throughout the study period. From 1990-91 to 2003, the mean age dropped from 66 for both sexes to 63 among men and 62 among women. The female-to-male ratio was constant at 2/1. Emergency admittances went down from 56% to 43% and mean hospitalisation was down from five to four days. The use of mesh repairs increased from 3% (1990-91) to 37% (2003). Incidence rates for inguinal hernia repair increased throughout the period, from 1.8 to 2.3 per 10,000 women and from 20.6 to 32.1 per 10,000 men. Mean age was as down from 63 (both sexes) to 59 among men and 57 among women. The female-to-male ratio remained constant at 1/12. Emergency admittances dropped from 13% to 6%. Mean days of hospitalisation fell from 4 in 1990-91 to 1 in 2003. Two out of three inguinal hernia repairs were done ambulatory in the last year of the study period. The use of mesh repairs increased from 1% in 1990-91 to 78% in 2003. Laparoscopic procedures were rarely used (2% in 2003). INTERPRETATION: In 2003, the majority of inguinal hernia repairs were performed as day surgery with open mesh techniques, in line with European guidelines.

Individualized Comprehensive Lifestyle Intervention in Patients Undergoing Chemotherapy with Curative or Palliative Intent: Who Participates?

OBJECTIVE: Knowledge about determinants of participation in lifestyle interventions in cancer patients undergoing chemotherapy, particularly with palliative intent, remains poor. The objective of the present study was to identify determinants of participating in a 12 month individualized, comprehensive lifestyle intervention, focusing on diet, physical activity, mental stress and smoking cessation, in cancer patients receiving chemotherapy with curative or palliative intent. The secondary objective was to identify participation determinants 4 months into the study. METHODS: Newly diagnosed cancer patients starting chemotherapy at the cancer center in Kristiansand/Norway (during a 16 month inclusion period) were screened. Demographic and medical data (age, sex, body mass index, education level, marital status, smoking status, Eastern Cooperative Oncology Group performance status (ECOG), diagnosis, tumor stage and treatment intention) was analyzed for screened patients. RESULTS: 100 of 161 invited patients participated. There were more females (69 vs. 48%; P = 0.004), breast cancer patients (46 vs. 25%; P = 0.007), non-smokers (87 vs. 74%; P = 0.041), younger (mean age 60 vs. 67 yrs; P < 0.001) and fitter (82 vs. 64% with EGOC 0; P = 0.036) participants vs. non-participants included. In multivariate logistic regression analyses, age (Odds Ratio 0.94, 95% Confidence Interval 0.91, 0.97) and smoking (0.42, 0.18, 0.99) were negatively associated with participation. After 4 months, 63 participants were still participating. Cancer type, smoking and age increased the probability of dropping out. Multivariate logistic regression revealed that age was the only significant determinant of 4 month participation (0.95, 0.91, 0.99). Patients aged >70 years were less likely to participate at baseline and 4 months. CONCLUSION: Individualized lifestyle interventions in cancer patients undergoing chemotherapy appear to facilitate a high participation rate that declines with increasing age; both during the enrollment process and completing the intervention. Neither oncologic nor socioeconomic variables deterred participation.

[Internal rectal invagination treated with rectopexy and sigmoid resection]. / Intern invaginasjon i rectum behandlet med rektopeksi og sigmoideumreseksjon.

BACKGROUND: Internal rectal intussusception, usually occurring in women, causes constipation and incomplete evacuation of stool. MATERIALS AND METHODS: Twenty-one women and one man (median age 48) were operated with suture rectopexy and sigmoid resection. The patients were examined with anoscopy and defecography, and symptomatic outcome, patients' satisfaction and morbidity were evaluated. Outcome was based mainly on the validated KESS score for constipation. RESULTS: There was a significant reduction in all ten symptoms. Faecal incontinence improved in the two afflicted patients after operation. The number of patients with constipation was reduced from 20 to 8 (p < 0.01); none became constipated. Mean (95 % CI) colonic transit times in ten constipated patients was reduced from 5.3 (4.1-6.4) to 4.0 (2.6-5.4) days (p = 0.08); seven of these patients had a reduction of transit time as well as constipation score. INTERPRETATION: Rectopexy with sigmoid resection improved symptoms, including constipation and feeling of incomplete rectal emptying.

[Secondary anterior sphincteroplasty for anal incontinence after delivery]. / Sekundaer sfinkterplastikk ved anal inkontinens etter fødsel.

BACKGROUND: The prevalence of anal sphincter rupture at vaginal delivery is from 0.5 to 2.5 %. More than 50 % of these patients may need a secondary anterior sphincteroplasty because of anal incontinence. MATERIALS AND METHODS: We present prospective series of 29 women (median age 45 years) operated with an overlapping anterior sphincteroplasty from 1996 to 2001. The patients were examined with anal ultrasonography (n = 23), manometry (n = 19) and neurophysiologically (n = 13), and divided into group 1 (n = 19) with anal sphincter rupture and group 2 (n = 10) with sphincter rupture as well as pudendal neuropathy. All patients (n = 29) were examined with the Cleveland Clinic incontinence score before and median eight (2-64) months after operation. RESULTS: Median incontinence score before and after operation was 11.0 (0-22) versus 5.0 (0-16) (p = 0.002) for group 1; 18.0 (15-24) versus 15.5 (11-24) (p = 0.034) for group 2. There was also a significant difference between the groups concerning incontinence scores both preoperatively (p = 0.045) and postoperatively (p = 0.028). An improvement of continence was seen in 15 (79 %) of the patients in group 1 compared to 4 patients (40 %) in group 2. In group 1 a significant increase of median resting and squeeze pressures was seen. INTERPRETATION: Anterior sphincteroplasty improves anal continence considerably in patients with isolated sphincter rupture. However, patients with evidence of pudendal neuropathy must be informed that they should expect only a minor improvement in continence after operation.

[Do-not-resuscitate orders and cardiopulmonary resuscitation at a Norwegian department of surgery]. / Vedtak om å unnlate eventuell hjerte-lunge-redning i en norsk kirurgisk avdeling.

BACKGROUND: A previous publication indicates a lack of clear guidelines for DNAR orders in Norwegian hospitals. The Norwegian Board of Health has recently published strict requirements for such a procedure. MATERIAL AND METHODS: Patients discharged from a surgical department from 1 March to 31 May 2001 with complicated or advanced cancer and/or a postoperative stay of minimum ten days. The patient files were studied for information on DNAR orders and/or cardiac arrest. RESULTS: 13 out of 69 patients had a DNAR order. In eight of them there was either no explanatory note in the files or no correct signature. Three of the five other patients had taken part in the discussion, so had next-of-kin in two circumstances. Resuscitation was not initiated in any of 14 patients with cardiac arrest. Six of these, who had no DNAR order, all had advanced, inoperable cancer or serious chronic cardiac and respiratory failure. There were no signs that a DNAR order had influenced any other treatment decision. INTERPRETATION: The department had a clear procedure for writing DNAR orders but it was followed in less than half of the cases.

[Pain and rehabilitation after inguinal hernia repair in adult male patients]. / Smerter og rehabiliteringsforløp etter lyskebrokkirurgi hos voksne menn.

BACKGROUND: Increased awareness of post-hernia repair pain motivated a study of pain and rehabilitation after day surgery. MATERIAL AND METHODS: Forty male patients were prospectively randomized to conventional (McVay) or open mesh repair. Self-assessment of postoperative pain was based on a four-step verbal scale. Patients and the physicians conducting the study were blinded to the surgical method. Clinical follow-up was performed twice, after four weeks and median 21 months. RESULTS: The open mesh technique generated less pain during the first postoperative week. Chronic light to moderate pain occurred in 20% of patients irrespective of surgical method. A sick leave of one to three weeks was sufficient in 20 out of 27 patients. INTERPRETATION: The study showed no clinical advantage of a tension-free method in terms of rehabilitation and post-hernia repair after the first postoperative week. Because of the relatively high incidence of late treatment-related pain, non-symptomatic adult patients should not be referred for inguinal hernia surgery. The primary sick leave period should not exceed three weeks.

[Cholecystectomy in Norway 1990-2002]. / Kolecystektomi i Norge i 1990-2002.

BACKGROUND: The purpose of this study was to investigate cholecystectomy incidence and laparoscopy rates in Norway (1990-2002). METHODS: Data were compiled from the Norwegian Patient Registry based on codes for cholecystectomy. RESULTS: From 1990 to 2000-02, age-adjusted incidence rate (per 10,000 inhabitants) for cholecystectomy increased from 2.9 to 4.1 for men and from 7.0 to 11.8 for women. Incidence rates varied between counties. The proportion undergoing laparoscopic surgery increased from 1% in 1990 to 89% in 2000-02. Over the same period the length of postoperative inpatient stay decreased from 7.3 days to 3.3 days. 94% of electively admitted patients were operated by laparoscopic technique in 2000-02. Among patients admitted on an emergency basis, women below 50 were more often operated by laparoscopic technique than older women and men. CONCLUSION: Substantial changes in the treatment of gallstone disease occurred in Norway over the period 1990 -2002. Increased incidence rates for cholecystectomy and reduced length of postoperative inpatient stay were observed after the introduction of cholecystectomy by laparoscopic technique.

[Appendicitis and appendectomy in Norway 1990-2001]. / Appendisitt og appendektomi i Norge 1990-2001.

BACKGROUND: The purpose of this study was to examine the incidence of appendicitis and appendectomy in Norway from 1990 to 2001. METHODS: Data were compiled from the Norwegian Patient Registry based on ICD-9 and ICD-10 codes for appendicitis and appendectomy. Re-admissions after appendectomy were selected based on institution and allocation numbers for hospitalisation. RESULTS: Age-adjusted incidence rates for appendectomy were 117 per 100 000 for men and 116 per 100 000 for women. Incidence rates were highest among patients aged 10-29. Diagnostic accuracy increased from 81% to 86% in men and from 60% to 71% in women over the study period. Perforation ratio increased from 12% to 21% in men and from 9% to 17% in women. Appendectomy by laparoscopic technique increased during 1998 to 2001 from 5% to 10% of cases for men and from 9% to 15% of cases for women. The proportion of laparoscopic appendectomy was considerably higher in two counties (50% and 28% in 2000-2001). Length of hospital stay was shorter after laparoscopy (median two days) than after open surgery (median three days), with no difference in the rate of re-admission of 4%. INTERPRETATION: Diagnostic accuracy and perforation ratio increased over the 1990s. Patients operated upon with laparoscopic technique had shorter hospital stays and the same re-admission rate compared to patients undergoing conventional surgery. Though the proportion of appendectomies done by laparoscopy doubled from 1998 to 2001, the procedure is not in commonly use in Norway.

Long term follow up of breast cancer patients treated with acupuncture for hot flashes.

OBJECTIVE: Short term effects of acupuncture treatment for hot flashes (HF) in breast cancer patients have been demonstrated in several studies, including a randomized controlled trial, by the present authors. Results for the first 59 Tamoxifen medicated women receiving a 10 week course of acupuncture treatment have already been published. A significant reduction in the number of hot flashes was demonstrated both day and night, for up to three months following treatment in the women receiving traditional Chinese acupuncture. The control group receiving sham (minimal acupuncture) demonstrated a HF reduction only at night during treatment, however the effect did not remain significant during the following 12 weeks. The study was continued in order to investigate longer term effects of acupuncture treatment, and patient's quality of life two years after treatment. METHODS AND MATERIALS: Eighty patients, who had 2 years previously been randomized to either a course of 15 acupuncture treatments or sham acupuncture (control) over a period of 10 weeks, were asked to fill out a Kupperman index (KI) indicating health related quality of life. RESULTS: Sixty one women returned KI questionnaires. A mixed models procedure with diagonal covariance matrix was used for statistical analyses. Baseline values between the sham-group and acupuncture group were not significantly different. However scores at the end of treatment and after 3 months showed a statistically significant difference between the groups, this difference lost its significance when scores were analyzed after 2 years. CONCLUSION: Acupuncture seems to have a positive effect on health related quality of life for up three months post-treatment, this study suggests that these effects may be longer-term, however there was no significant effect 2 years later.

Does in-house availability of multidisciplinary teams increase survival in upper gastrointestinal-cancer?

AIM: To investigate the effect of the establishment of in-house multidisciplinary team (MDT) availability (iMDTa) on survival in upper gastrointestinal cancer (UGI) patients. METHODS: In 2001, a cancer centre with irradiation and chemotherapy facilities was established in the Norwegian county of West Agder with a change of iMDTa (WA/MDT-Change). "iMDTa"-status was defined according to the availability of the necessary specialists within one institution on one campus, serving the population of one county. We compared survival rates during 2000-2008 for UGI patients living in counties with (MDT-Yes), without (MDT-No), with a mix (MDT-Mix) and WA/MDT-Change. Survival was calculated with Kaplan-Meier method. Cox model was used to uncover differences between counties with different MDT status when adjusted for age, sex and stage. RESULTS: We analyzed 395 patients from WA/MDT-Change and compared their survival to 12 135 UGI patients from four other Norwegian regions. Median overall survival for UGI patients in WA/MDT-Change increased from 129 to 300 d from 2000-2008, P = 0.001. The regions with the highest level of iMDTa achieved the largest decrease in risk of death for UGI cancers (compared to the county with MDT-Mix: MDT-Yes 11%, P < 0.05 and WA/MDT-Change 15%, P < 0.05). Analyzing the different tumour entities separately, patients living in the WA/MDT-Change county reached a statistically significant reduction in the risk of death [hazard ratios (HR)] compared to patients in the county with MDT-Mix for oesophageal and gastric, but not for pancreatic cancer. HR for the study period 2000-2004 are given first and then for the period 2005-2008: The HR for oesophageal cancers was reduced from [HR = 1.12; 95%CI: 0.75-1.68 to HR = 0.60, 95%CI: 0.38-0.95] and for gastric cancers from [HR = 0.87, 95%CI: 0.66-1.15 to HR = 0.63, 95%CI: 0.43-0.93], but not for pancreatic cancer [HR = 1.04-, 95%CI: 0.83-1.3 for 2000-2004 and HR = 1.01, 95%CI: 0.78-1.3 for 2005-2008]. UGI patients treated during the second study period in the county of WA/MDT-Change had a higher probability of receiving chemotherapy. In the first study period, only one out of 43 patients (2.4%, 95%CI: 0-6.9) received chemotherapy, compared to 18 of 42 patients diagnosed during 2005-2008 (42.9%, 95%CI: 28.0-57.8). CONCLUSION: Introduction of iMDTa led to a two-fold increase of UGI patients, whereas no increase in survival was found in the MDT-No or MDT-Mix counties.