Incurable Stenosing Colorectal Carcinoma: Endoscopic Stent Implantation or Palliative Surgery?

Background Palliative surgery for the treatment of incurable obstructive colorectal carcinoma is associated with a considerable perioperative morbidity and mortality but no substantial improvement of the prognosis. The aim of the present study was to study the effectiveness of colorectal stenting compared with palliative surgery in incurable obstructive colorectal carcinoma. Patients and Methods From April 1999 to April 2005, data of consecutive patients with incurable stenosing colorectal carcinoma, either treated with stent implantation or palliative surgical intervention, were prospectively recorded with respect to age, sex, tumor location (including metastases), ASA-score, peri-interventional morbidity, mortality, rates of complications, and re-interventions as well as survival. Results Of 40 patients, 38 (95%) were successfully treated with a stent. Two patients (5%) underwent surgical intervention after stent dislocation. In contrast, 38 patients primarily underwent palliative surgical intervention. Stent patients were significantly older (P = 0.020), had a higher ASA-score (P = 0.012), and had more frequently distant metastases (P = 0.011). After successful stent implantation, no early complications were observed, but late complications occurred in 11 subjects (29%). Following palliative surgical intervention, postoperative complications occurred in 12 individuals (32%) . Postoperative mortality was 5% in the surgery group, whereas no patient died following stent implantation. There was no significant differences in the survival of both groups (9.9 vs. 7.8 months, respectively; log rank: 0.506). Conclusions Palliative treatment of incurable obstructive colorectal carcinoma using stents is an effective and suitable alternative to palliative surgery with no negative impact on the survival but less peri-interventional morbidity and mortality as well as comparable overall morbidity.     

In situ IGF-1 gene delivery to cells emerging from the injured anterior cruciate ligament

Ruptures of the anterior cruciate ligament (ACL) are common knee injuries that do not heal, even with surgical repair. Our research is directed towards developing novel, biological approaches that enable suture repair of this ligament. One promising strategy involves the insertion of a collagen hydrogel between the severed ends of the ACL. Cells migrate from the damaged ligament into the hydrogel and produce repair tissue. Here we have investigated the potential for augmenting this process by the transfer of insulin like growth factor (IGF) 1 cDNA to the repair cells using an adenovirus vector. The goal is to achieve direct, in situ gene delivery by loading the hydrogel with vector prior to its insertion into the defect. In a step-wise approach towards evaluating this process, we confirmed that monolayers of ACL fibroblasts were efficiently transduced by adenovirus vectors and continued to express transgenes when subsequently incorporated into the hydrogel; indeed, transgene expression persisted longer within collagen gels than in monolayer culture. Transfer of IGF-1 cDNA increased the cellularity of the gels and led to the synthesis and deposition of increased amounts of types I and III collagen, elastin, tenascin, and vimentin. The cells remained viable, even when subjected to high viral loads. Similar results were obtained when collagen hydrogels were preloaded with adenovirus prior to insertion into an experimental ACL lesion in vitro. These data confirm the promise of using vector-laden hydrogels for the in situ delivery of genes to cells within damaged ligaments and suggest novel possibilities for the biological repair of the ACL.     

Remuneration and organization in general practice: Do GPs prefer private practice or salaried positions?

Objective

In Norway the default payment option for general practice is a patient list system based on private practice, but other options exist. This study aimed to explore whether general practitioners (GPs) prefer private practice or salaried positions.

Design

Cross-sectional online survey (QuestBack).

Setting

General practice in Norway.

Intervention

Participants were asked whether their current practice was based on (1) private practice in which the GP holds office space, equipment, and employs the staff, (2) private practice in which the GPs hire office space, equipment, or staff from the municipality, (3) salary with bonus arrangements, or (4) salary without bonus arrangement. Furthermore, they were asked which of these options they would prefer if they could choose.

Subjects

GPs in Norway (n = 3270).

Main outcome measures

Proportion of GPs who preferred private practice.

Results

Responses were obtained from 1304 GPs (40%). Among these, 75% were currently in private practice, 18% in private practice with some services provided by the municipality, 4% had a fixed salary plus a proportion of service fees, whereas 3% had salary only. Corresponding figures for the preferred option were 52%, 26%, 16%, and 6%, respectively. In multivariate logistic regression analysis, size of municipality, specialty attainment, and number of patients listed were associated with preference for private practice.

Conclusion

The majority of Norwegian GPs had and preferred private practice, but a significant minority would prefer a salaried position. The current private practice based system in Norway seems best suited to the preferences of experienced GPs in urban communities.Key Words: Capitation, fee for service, general practice, Norway, private practice, remuneration

• In Norway most GPs are on an activity-based remuneration system of capitation and service fees, where the practices by default are run as private businesses, but other options exist.
• In a survey of Norwegian GPs (n∼1300) 52% preferred the default option, and 26% preferred a modified version in which the municipality provides office space and equipment and/or employs staff for negotiated financial compensation, whereas 22% preferred salaried positions.
• GPs with specialty attainment, large patient lists, and location in large municipalities were more likely to prefer private practice.

     

Poorly differentiated oncocytic thyroid carcinoma--diagnostic implications and outcome

Dettmer M, Schmitt A, Steinert H, Moch H, Komminoth P & Perren A
(2012) Histopathology  60, 1045–1051 Poorly differentiated oncocytic thyroid carcinoma – diagnostic implications and outcome Aims: Poorly differentiated thyroid carcinomas (PDTC) are an ongoing diagnostic challenge. Although the Turin consensus criteria for PDTC excluded consideration of oncocytic tumours, the World Health Organization (WHO) classification does recognise an oncocytic variant of conventional PDTC. The aims of this study were to establish whether the Turin criteria can be applied to oncocytic PDTC, and to determine if there are prognostic differences between conventional and oncocytic PDTC. Methods and results: We applied the Turin criteria to 129 thyroid carcinomas. We identified 18 oncocytic PDTC and 16 conventional PDTC. Kaplan–Meier analysis revealed a significantly worse outcome for oncocytic PDTC with regard to overall and tumour‐specific survival but no difference for relapse‐free survival, all of which were confirmed by multivariate analysis. There was no association of survival with gender, age or tumour stage. Conclusions: The Turin criteria can be applied to oncocytic PDTC and patients with this variant have a decreased survival using conventional radioiodine treatment compared to conventional PDTC and might therefore be candidates for novel treatment modalities.