Important prognostic significance of a sentinel-node biopsy in patients with malignant melanoma

OBJECTIVE: To determine the prognostic significance of sentinel-node biopsy in patients with malignant melanoma (unlike the United States, a sentinel-node biopsy is still not routinely performed on melanoma patients in the Netherlands, as the outcomes of prospectively randomised clinical trials are being awaited). DESIGN: Retrospective. METHODS: Between 1996 and 2001 a sentinel-node biopsy and a re-excision of the scar of the diagnostic biopsy were performed on all melanoma patients who had a Breslow thickness > or = 1 mm or a Clark level > or = IV. At operation the sentinel node was identified with a gamma probe and patent blue. It was removed and sent for pathological investigation for the presence of melanoma cells. If the sentinel node was tumour positive, a dissection of the regional lymph-node basin was performed. Subsequently, these patients were put forward for the European Organisation for Research and Treatment of Cancer (EORTC) peginterferon alfa(2b) adjuvant treatment study. RESULTS: A sentinel-node biopsy was performed in 61 lymphnode basins in 57 patients (18 male and 39 female; median age: 45 years (range: 9-80)). The median Breslow thickness of the melanomas was 2.2 mm (range: 0.7-13 mm). In 10 of the 61 cases histological examination of the sentinel node demonstrated tumour cells. In 2 additional cases tumour cells were demonstrated only by immunohistochemical studies or complete dissection of the node. Eight regional lymph-node basins were dissected, two of which contained additional metastases. The median follow-up was 36 months (range: 1-68). During follow-up 12 of the 57 patients were found to have metastases, in 8 of these patients the sentinel-node biopsy contained tumour cells. The negative predictive value of a tumourless sentinel node with respect to the later occurrence of distant metastases was 92%. CONCLUSION: The patients with a tumour-positive sentinel node had a poorer prognosis with respect to distant metastases than patients with a tumour-negative node. This is the main reason for performing sentinel-node biopsy: to predict the prognosis of the disease. Therefore sentinel-node biopsy should be incorporated into the treatment of patients with malignant melanoma.     

Epidemiology of malignant melanoma (Clinical experience at the National Institute of Oncology in Hungary)

The National Cancer Registry, which has been running since 1999 in Hungary, supplies more and more precise data about the growing incidence of malignant melanoma although nationwide melanoma database currently does not exist. As in the National Institute of Oncology a notable percentage of patients (20-25%) were treated with newly diagnosed melanoma, conclusions may be drawn for the efficacy of primary prevention for the whole country. Methods: The recent study compares the data of patients presented in the Institute with cutaneous malignant melanoma in 1998 and ten years later, in 2008. The histology parameters of tumors were also analyzed. The two groups were compared according to age, gender, localization and histology parameters (histological types Breslow and Clark numbers). In case of continuous variables the Mann-Whitney test were used to determine significant differences. Categorical variables were checked by χ2 test. Results: 149 and 377 cutaneous melanomas were diagnosed in 1998 and in 2008, respectively, which accounts for 153% increase in ten years. The mean age of patients was 56.3 and 57.2 years in 1998 and in 2008, respectively. The per cent of males was 43% in 1998 and 49% in 2008. Trunk was the most frequent localization in both years: 39% and 46%, then lower limbs (28% and 22%), upper limbs (21% and 18%) and the head and neck region (12% and 14%). Superficial melanoma was found the most frequent histological type (52 and 54%) followed by nodular melanoma (31% and 23%). Rate of in situ melanoma changed from 10% to 15%. The mean of Breslow numbers was 2.2 mm in 1998 and 1.6 mm in 2008, the difference was highly significant (p = 0.0002). Clark numbers were also decreasing, although the difference was not significant (p = 0.08). The majority of patients were presented with Clark III depth melanoma in both years (38% and 32%). Conclusions: It seems that forces emphasizing the importance of early recognition in medical education and in media are not futile considering that principally the early diagnosis can improve the melanoma's prognosis - which is represented mainly by Breslow tumor depth.     

Guideline 'Melanoma' (3rd revision)

The guidelines 'Melanoma' (3rd revision) are evidence-based in nature. A number of outcomes are summarised in this article. Dermatoscopy deserves a standard role in the clinical diagnosis of pigmented skin abnormalities. Pathological findings from a diagnostic excision should be recorded meticulously to include anatomical localisation, type of intervention used, excision margin, diagnosis, Breslow thickness, and the completeness of the removal. The sentinel node procedure should be reserved for patients who want to be as informed as possible about their prognosis. The procedure is not considered a part of standard diagnosis. Sentinel node assessment should include stains for specific markers and should be conducted in multiple sections. The following margins of non-affected skin are recommended for therapeutic re-excision of melanoma: in situ melanoma, 0.5 cm; Breslow thickness < or = 2 mm, 1 cm; Breslow thickness > 2 mm, 2 cm. Pathological assessment of a re-excised specimen depends on the completeness of the first excision. Systematic adjuvant treatment of patients with melanoma is not recommended outside the context of a clinical study. Patients with metastatic melanoma are preferably treated within a clinical study. Outside of a clinical study, these patients should be treated with dacarbazine. There is no evidence to suggest that survival is improved by frequent follow-up. However, follow-up can be a useful way to meet the information needs of patients and care requirements for physicians.     

Quality of diagnostic services for cancer: a comparison of open access and conventional outpatient clinics.

OBJECTIVE AND STUDY DESIGN: To assess quality of a quick and early diagnosis route (QED) by determining effectiveness and cost-effectiveness of five clinics compared with three conventional outpatient clinics. Prospective economic evaluation. Six-month cohort of all referrals (November 1996-April 1997). SUBJECTS: All referrals for suspected cancers of: upper gastro-intestinal tract; urinary tract, prostate and testis; skin. EFFECTIVENESS: Median days saved between GP referral and date of: diagnostic appointment; consultant decision; intervention. RESULTS: GP referral to diagnostic appointment: QED was effective (median days) for all clinics. Diagnostic appointment to consultant decision: QED was effective for testicular and haematuria clinics. Consultant decision to intervention: QED was effective for haematuria, testicular and melanoma clinics. COST-EFFECTIVENESS: Extra (incremental) NHS cost per patient diagnosed. RESULTS: Less than 5 Pounds per day saved between GP referral and diagnostic appointment for: endoscopy; haematuria; prostate; testicular; melanoma. Less than 3 Pounds per day saved between GP referral and consultant decision for: testicular; haematuria. Less than 3 Pounds per day saved between GP referral and intervention for: endoscopy; haematuria; testicular; melanoma. CONCLUSION: A "quick and early" diagnostic route provides a higher quality service through improved effectiveness and cost-effectiveness compared to conventional outpatients.     

Description of a chronic heart failure service model and review of pharmacotherapy in a district general hospital in comparison to Scottish Intercollegiate Guideline Network (SIGN) guidelines

BACKGROUND: The Scottish Intercollegiate Guidelines Network (SIGN) guideline 95 on the management of chronic heart failure (CHF) was published in February 2007, superseding SIGN guideline 35 of February 1999. The guideline promotes evidence based management of CHE. AIMS: To describe an existing service model and to review our level of concordance with SIGN guidelines. METHODS: We describe a model of a CHF service based in a district general hospital (DGH) in Scotland. We conducted a retrospective review on consecutive new referrals between August and November 2002, and a prospective review of new attendances between September 2005 and January 2006. RESULTS: In 2002 and 2005/6, 49 and 45 patients were reviewed respectively, with 26 and 28 patients showing left ventricular systolic dysfunction on echocardiography. Median ages of patients were 81 and 79 years respectively. Angiotensin Converting Enzyme Inhibitor (ACEI) or Angiotensin II Receptor Blocker (AIIRB) therapy was in use in 23 (88.5%) and 24 (85.7%) patients respectively. The use of beta-blockers, digoxin and spironolactone was shown to have improved between both reviews. CONCLUSIONS: We have been able to demonstrate an improving level of concordance with SIGN guidelines in a district general hospital (DGH) heart failure service model run by care of the elderly physicians and supported by specialist nurses.     

Choosing to biopsy or refer suspicious Melanocytic lesions in general practice

ABSTRACT: BACKGROUND: General practitioners (GPs) are involved in the management of most melanocytic skin lesions in Australia. A high quality biopsy technique is a crucial first step in management, as it is recognized that poor techniques can mislead, delay, or miss a diagnosis of melanoma. There has been little published on the biopsy decisions and techniques of GPs. This study aims to describe the current management choices made by GPs for suspicious melanocytic skin lesions and to compare their choices with the best practice guidelines. METHODS: An anonymous survey of GPs presented with three clinical scenarios with increasing complexity of melanoma in which a referral or biopsy decision was specified. RESULTS: 391 mailed surveys with a 76.3% response rate. Mean biopsy experience was 4.14 biopsies per GP per month. The rates of choosing to refer among the three scenarios were 31%, 52% and 81% respectively, with referral to surgery being the most common choice (81%). Most biopsy techniques (55%) were chosen according to best practice guidelines, although non-guideline biopsy techniques chosen included shave (n = 10), punch biopsy (n = 57), wide excisions (n = 65), and flaps (n = 10). The few GPs (n = 5) who identified themselves as skin specialist GPs were no more likely to adhere to guidelines than their colleagues. CONCLUSION: A majority of referrals and biopsies were chosen by GPs according to best practice guidelines, but concern remains for the high proportion of GPs making non-guideline based choices. How GPs choose to biopsy or refer needs further training, audit, and research if Australia is to improve the outcome of melanoma management in general practice.     

Perceptions of cardiac rehabilitation patients, specialists and rehabilitation programs regarding cardiac rehabilitation wait times

ABSTRACT: BACKGROUND: In 2006, the Canadian Cardiovascular Society (CCS) Access to Care Working Group recommended a 30-day wait time benchmark for cardiac rehabilitation (CR). The objectives of the current study were to: (1) describe cardiac patient perceptions of actual and ideal CR wait times, (2) describe and compare cardiac specialist and CR program perceptions of wait times, as well as whether the recommendations are appropriate and feasible, and (3) investigate actual wait times and factors that CR programs perceive to affect these wait times. METHODS: Postal and online surveys to assess perceptions of CR wait times were administered to CR enrollees at intake into 1 of 8 programs, all CCS member cardiac specialists treating patients indicated for CR, and all CR programs listed in Canadian directories. Actual wait times were ascertained from the Canadian Cardiac Rehabilitation Registry. The design was cross-sectional. Responses were described and compared. RESULTS: Responses were received from 163 CR enrollees, 71 cardiac specialists (9.3% response rate), and 92 CR programs (61.7% response rate). Patients reported that their wait time from hospital discharge to CR initiation was 65.6 [PLUS-MINUS SIGN] 88.4 days (median, 42 days), while their ideal median wait time was 28 days. Most patients (91.5%) considered their wait to be acceptable, but ideal wait times varied significantly by the type of cardiac indication for CR. There were significant differences between specialist and program perceptions of the appropriate number of days to wait by most indications, with CR programs perceiving shorter waits as appropriate (p < 0.05). CR programs reported that feasible wait times were significantly longer than what was appropriate for all indications (p < 0.05). They perceived that patient travel and staff capacity were the main factors negatively affecting waits. The median wait time from referral to program initiation was 64 days (mean, 80.0 [PLUS-MINUS SIGN] 62.8 days), with no difference in wait by indication. CONCLUSIONS: Wait times for access to cardiac rehabilitation are prolonged compared with consensus recommendations, and yet are generally acceptable to most patients. Wait times for percutaneous coronary intervention in particular may need to be shortened. Future research is required to provide an evidence base for wait time benchmarks.     

Use of parenteral nutrition in hospitals in the North of England

BACKGROUND: Parenteral nutrition (PN) is a costly technology used widely to provide nutrition to patients who have an inaccessible or nonfunctioning intestine. A prospective survey was designed to collect data on PN for inpatients to study the current use of PN, its complications and outcomes in the north of England. The study objectives were to use the Northern Nutrition Network to collect data from all acute hospital inpatients prospectively receiving PN, for 3 months and to provide evidence for current PN practice, and to establish whether this is in line with recognized published clinical guidelines. METHODS: Using a paper-based collection tool information was recorded on aspects of PN including: total inpatient episodes, patient demographics, indications, duration, venous access used, complications, number returning to enteral feeding and mortality. The presence of a nutrition support team was also recorded. RESULTS: Data on 193 patient PN episodes were recorded totalling 1708 patient days. The median age of the patients was 67 years. Of these, 158 (82%) were deemed to have a clear indication for PN using the indications cited in the NICE guidelines (http://www.nice.org.uk). The median duration of PN was 7 days (range 1-93). Thirty (16%) patients developed complications due to PN, 23 (12%) had catheter infections which were most common on medical wards. Thirty-nine (20%) patients died within 28 days of PN starting; no deaths were attributable to PN. A total of 118 (61%) patients returned to full enteral feeding. Only three hospitals had nutrition support teams, which had no significant effect on outcomes. CONCLUSIONS: Parenteral nutrition practice in the north of England is generally in line with current guidelines, however, only three of 15 hospitals had nutrition support teams. Eighteen per cent of patients did not have a clearly documented indication for PN and 15% developed a complication, most often a catheter-related infection.     

Evidence-based clinical guidelines--implementation plans in Scotland

Presents a study which investigates how it was planned to implement guidelines from the Scottish intercollegiate guidelines network (SIGN). The study aimed to describe the activity in planning the implementation of SIGN guidelines in Scottish Health Service Trusts in 1996, and to provide a baseline for evaluation. A postal questionnaire was sent to the Clinical Audit lead person in 46 Scottish Health Service Trusts. The response rate after two reminders ranged from 60-72 per cent across different categories of Trust. The questionnaire asked for plans to implement individual guidelines, adaptation, professions involved, timeframes, dissemination, and evaluation methods. Reveals that local consensus was the main factor in deciding priorities. Most Trusts wished to see other local versions of guidelines produced, and to evaluate implementation collaboratively. Most expected to have reviewed baseline practice before implementation.     

Stereotactic body radiation therapy for head and neck tumor: disease control and morbidity outcomes

We evaluated the efficacy and safety of stereotactic body radiation therapy (SBRT) for patients with head and neck tumors. From April 2005 through April 2008, 34 patients with head and neck tumors were treated with CyberKnife SBRT. Twenty-one of them had prior radiotherapy. Treatment sites were orbit (n = 7), cervical lymph nodes (n = 6), nasopharynx (n = 5), oropharynx (n = 4) and others (n = 12). The prescribed dose ranged from 19.5 to 42 Gy (median, 30 Gy) in 3-8 fractions for consecutive days. The target volume ranged from 0.7 to 78.1 cm(3) (median, 11.6 cm(3)). The median follow-up was 16 months. Treatment was well tolerated without significant acute complications in any cases. Complete response rate and partial response rate were 32.4% and 38.6%, respectively. The overall survival rates were 70.6% and 58.3% at 12 and 24 months, respectively. The overall survival was better in patients without prior radiotherapy within the previous 24 months or in case of smaller target volume. Six patients suffered severe late complications. All these patients had prior radiotherapy, and 2 of them developed massive hemorrhage in the pharynx and both died of this complication 5 and 28 months, respectively, after SBRT. Our preliminary results suggest that SBRT is an effective treatment modality for head and neck tumors. However, re-irradiation has significant risk of severe and even fatal late complications in the form of necrosis and hemorrhage in re-irradiated areas.     

Percutaneous Gastrostomy Tube Placement Using a Balloon Catheter in Patients With Head and Neck Cancer

Background: Patients with head and neck cancer frequently require gastrostomy feeding. The aim of this study was to evaluate the safety and feasibility of percutaneous radiologic gastrostomy with push‐type gastrostomy tubes using a rupture‐free balloon (RFB) catheter under computed tomography (CT) and fluoroscopic guidance in patients with head and neck cancer with swallowing disturbance or trismus. Methods: Percutaneous CT and fluoroscopic gastrostomy placement of push‐type gastrostomy tubes using a RFB catheter was performed in consecutive patients with head and neck cancer between April 2007 and July 2010. The technical success, procedure duration, and major or minor complications were evaluated. Results: Twenty‐one patients (14 men, 7 women; age range, 55–78 years; mean age, 69.3 years) underwent gastrostomy tube placement. The tumor location was the pharynx (n = 8), oral cavity (n = 7), and gingiva (n = 6). Gastrostomy was performed in 15 patients during treatment and 6 patients after treatment. Percutaneous radiologic gastrostomy was technically successful in all patients. The median procedure time was 35 ± 19 (interquartile range) minutes (range, 25–75). The average follow‐up time interval was 221 days (range, 10–920 days). No major complications related to the procedure were encountered. No tubes failed because of blockage, and neither tube dislodgement nor intraperitoneal leakage occurred during the follow‐up periods. Conclusion: Percutaneous CT and fluoroscopic‐guided gastrostomy with push‐type tubes using a RFB catheter is a relatively safe and effective means of gastric feeding, with high success and low complication rates in patients with head and neck cancer in whom endoscopy was not feasible.     

Postsurgery enteral nutrition in head and neck cancer patients

OBJECTIVE: Patients with head and neck cancer undergoing surgery have a high incidence of postoperative complications. The aim of our study was to investigate whether postoperative nutrition of head and neck cancer patients, using an arginine-enriched diet, could improve nutritional variables as well as clinical outcomes. DESIGN: Randomized clinical trial. SETTING: Tertiary care. SUBJECTS: A population of 47 patients with oral and laryngeal cancer were enrolled. INTERVENTIONS: At surgery patients were randomly allocated to two groups: (a) patients receiving an enteral diet supplemented with arginine and fiber (group I); (b) patients receiving an isocaloric, isonitrogenous enteral formula (group II). RESULTS: No significant intergroup differences in the trend of the three plasma proteins and lymphocytes were detected. Gastrointestinal tolerance (diarrhea) of both formulas was good (17.4% group I and 8.3% group II; NS). During the 3 months after hospital discharge five patients died; no differences were detected between groups (13% group I and 8.3% group II; NS). The incidences postoperative infection complications were similar (nine patients) in both groups (21.7% group I and 16.7% group II; NS). Fistula were less frequent in enriched nutrition group (0% group I and 20.8% group II; P<0.05); wound infection was more frequent in group II, but without statistical difference (4.3% group I and 12.5% group II; NS). The length of postoperative stay was 22.8+/-11.8 days in the enriched group and 31.2+/-19.1 days in the control group (P=0.07). CONCLUSIONS: In conclusion, enriched formula improves local wound complications in postoperative head and neck cancer patients. Our results suggest that these patients could benefit from an immunonutrient-enhanced enteral formula.     

Randomized phase III trial of concurrent chemoradiotherapy vs accelerated hyperfractionation radiotherapy in locally advanced head and neck cancer

The aim of this study was to compare the efficacy and safety of concurrent chemoradiotherapy (CCRT) vs accelerated hyperfractionation with concomitant boost (CCB) as a primary treatment for patients with Stage III–IV squamous cell carcinoma of head and neck (SCCHN). A total of 85 non-metastatic advanced SCCHN patients were accrued from January 2003 to December 2007. Of these, 48 and 37 patients received CCRT and CCB, respectively. The patients were randomized to receive either three cycles of carboplatin and 5-fluorouracil plus conventional radiotherapy (CCRT, 66 Gy in 6.5 weeks) or hybrid accelerated radiotherapy (CCB, 70 Gy in 6 weeks). The primary endpoint was determined by locoregional control rate. The secondary endpoints were overall survival and toxicity. With a median follow-up of 43 months (range, 3–102), the 5-year locoregional control rate was 69.6% in the CCRT arm vs 55.0% in the CCB arm (P = 0.184). The 5-year overall survival rate was marginally significantly different (P = 0.05): 76.1% in the CCRT arm vs 63.5% in the CCB arm. Radiotherapy treatment interruptions of more than three days were 60.4% and 40.5% in the CCRT arm and CCB arm, respectively. The median total treatment time was 55.5 days in the CCRT arm and 49 days in the CCB arm. The rate of Grade 3–4 acute mucositis was significantly higher in the CCB arm (67.6% vs 41.7%, P = 0.01), but no high grade hematologic toxicities were found in the CCB arm (27.2% vs 0%). CCRT has shown a trend of improving outcome over CCB irradiation in locoregionally advanced head and neck cancer.     

Patients' attitudes towards mydriasis for diabetic eye disease screening

AIMS: The purpose of the questionnaire was to explore attitudes of patients towards mydriasis for diabetic retinopathy screening. METHODS: Two groups of patients were invited to take part: group 1 comprised patients attending the diabetic clinic and had previous experience of mydriasis, group 2 patients attending the mobile screening unit for non-mydriatic digital retinal photograph and who were not previously used to receiving mydriatic eye drops. Basic demographic data was recorded and the volunteers invited to complete a questionnaire. RESULTS: 292 patients were recruited into group 1 (median age 63 years range 20-94) and 103 into group 2 (median age 68 years range 29-96). 42% of patients in group 2 indicated that they were unhappy with the use of dilating eye drops and 26% of this group reported that they may be discouraged from attending screening for diabetic retinopathy if drops were introduced. These figures were statistically lower in group 1 at 8% and 1-8% respectively (p < 0.001). Blurring of vision was identified as the most troublesome feature of the use of mydriasis for patients. A large proportion of patients drove themselves to their last screening appointment; 58% in group 2 and 39% in group 1. A third of all patients (33%) indicated that they worked outside the home. CONCLUSIONS: Many patients attending diabetic eye screening return to driving and work immediately after the appointment. Introduction of the use of routine drops may discourage attendance. Education and experience may have an important role in improving acceptability of mydriatic eye drops. Retinal screeners need to have clear guidelines with which to advise patients.     

Randomized clinical trial with an enteral arginine-enhanced formula in early postsurgical head and neck cancer patients

OBJECTIVE: Patients with head and neck cancer undergoing surgery have a high incidence of postoperative complications. The aim of our study was to investigate whether postoperative nutrition of head and neck cancer patients using an arginine-enhanced formula could improve nutritional variables as well as clinical outcomes. DESIGN: Randomized clinical trial. SETTING: Tertiary care. SUBJECTS: A population of 90 patients with oral and laryngeal cancer was enrolled. INTERVENTIONS: At surgery, patients were randomly allocated to two groups: (a) patients receiving an arginine-enhanced formula with arginine and fiber (group I) and (b) patients receiving an isocaloric, isonitrogenous formula with fiber enteral formula (group II). RESULTS: No significant intergroup differences in the trend of the three plasma proteins (albumin, transferrin, prealbumin) and lymphocytes were detected. Gastrointestinal tolerance (diarrhea) was better in group II than I (40% group I and 13% group II: P<0.05). The postoperative complications due to infections were similar in both groups (4% group I and 9% group II: ns). Fistula (wound complication) was less frequent in the enriched nutrition group (5% group I and 11% group II: P<0.05); wound infection was similar in both groups. The length of postoperative stay was better in group I than II (25.8+/-15 days vs 35+/-24.6 days; P<0.05). CONCLUSIONS: In conclusion, arginine-enhanced formula improves fistula rates in postoperative head and neck cancer patients and decreases length of stay.     

A prospective study of health care resource utilisation and selected costs of schizophrenia in France

ABSTRACT: BACKGROUND: Schizophrenia is among the most burdensome and costly illnesses worldwide. To estimate the cost of schizophrenia in France, a longitudinal study was carried out between 1998 and 2002. The main objective of this study was to describe and update the cost of schizophrenia in a longitudinal, representative sample of French patients. The second objective was to identify cost drivers in the treatment of schizophrenia. METHODS: Based on a cohort of 288 French schizophrenic patients during 2 years of prospective follow-up, this study collected clinical, patient reported outcomes, quality of life, functioning, patient management, care giver involvement and resource utilisation data every 6 months. For each service, information was collected on the type of service, the frequency of attendance and type of intervention provided to the patient. Unit costs were based on available French databases. Mean service use and costs over the five time points were estimated using between-effects regression models. RESULTS: In the total sample of 288 patients aged 18-64 years, the mean total cost ([EURO SIGN] 3 534) was mainly accounted for by the cost of inpatient treatment ([EURO SIGN] 1 390) and day care ([EURO SIGN] 1 331). The estimate of the annual cost for direct medical health care for all French schizophrenic patients was [EURO SIGN] 1 581 million, including [EURO SIGN] 621 million for inpatient treatment and [EURO SIGN] 595 million for day care (77 %). The costs for medication accounted for 16.1 % of total annual costs. The remaining costs (6.9 %) included visits to psychiatrists, general practitioners, other physicians and psychologists. The direct resource allocation showed inpatient treatment as the main direct cost. Unemployment was identified as a major indirect cost of schizophrenia treatment. Positive and depressive schizophrenia symptoms at baseline and relapse occurrence during the follow-up period were associated with a higher cost of treatment. Health satisfaction or negative symptoms of schizophrenia at baseline were associated with lower costs. CONCLUSION: Several cost drivers were identified. Based on the results obtained in France, we suggest further analysis of mechanisms that influence the service-specific costs for schizophrenia in other areas of the world.     

Audit of nutritional guidelines for head and neck cancer patients undergoing radiotherapy

BACKGROUND: Head and neck cancer patients being treated with radiotherapy are at an increased risk of malnutrition due to the severe side-effects, e.g. mucositis, odynophagia and xerostomia, impacting on the ability to eat and drink. Effective dietetic management involves identifying those patients malnourished or at risk of becoming so and incorporating nutritional intervention into their treatment plan. The use of gastrostomy tubes in this patient group has been shown to be acceptable. By placing them prophylactically, the aim is to prevent a disruption to treatment and avoid an unnecessary admission for feeding. This audit was carried out to determine whether the implementation of locally produced nutritional guidelines improved the dietetic management of this patient group. METHOD: A prospective audit tool was used to collect data on 32 head and neck cancer patients undergoing radiotherapy. Data was collected weekly during the course of treatment and compared with data from previous audits. Weight change was the nutritional outcome measured. RESULTS: More patients underwent combined treatment (radiotherapy postoperatively or with concurrent weekly chemotherapy) when compared with previous audits. However, implementation of the guidelines appeared to contribute to an improvement in dietetic management, as fewer patients lost weight over the course of radiotherapy and there were no admissions for feeding. The presence of a dietitian at the multidisciplinary head and neck clinic improved access and communication and this is also likely to have contributed to the improved management. CONCLUSIONS: Implementation of the guidelines led to an improvement in the nutritional management of this patient group. Implementation may be more likely if a dietitian is present at the combined head and neck clinic.     

Osteoporosis assessment and treatment in older patients who have sustained a hip fracture

BACKGROUND AND AIMS: Currently fracture sufferers are not being assessed or treated for osteoporosis. Osteoporosis guidelines differ in their secondary prevention recommendations, with the Scottish Intercollegiate Guideline Network (SIGN) advocating bone densitometry in all fracture patients and anti-resorptive treatment only if evidence-based criteria are confirmed, but the National Institute of Clinical Excellence (NICE) technology appraisal recommends treatment for all older females without this bone densitometry confirmation. We aimed to determine the rate of referral for bone densitometry, the numbers achieving SIGN criteria for anti-resorptive therapy, and the rate of osteoporosis treatment in patients with hip fracture METHODS: A retrospective review of all patients older than 65 years who had sustained a hip fracture in Tayside between April 2003 and July 2005 was performed RESULTS: Only 8.6% of hip fracture patients underwent bone densitometry, of which 90.6% of females older than 75 years met SIGN criteria for anti-resorptive treatment. 74.3% of all patients referred for bone densitometry were treated with an anti-resorptive agent, compared to only to 12.7% of the large majority group who were not assessed for osteoporosis CONCLUSION: Osteoporosis investigation and therefore treatment remains sub-optimal in hip fracture patients. Almost all females, older than 75 years, with a hip fracture met evidence-based criteria for anti-resorptive treatment. NICE guidance, recommending anti-resorptive treatment without bone densitometry confirmation of reduced bone mineral density, should maybe be implemented for this specific group of patients in an attempt to increase osteoporosis treatment rates.