Quality of care management decisions by multidisciplinary cancer teams: a systematic review

BACKGROUND

Factors that affect the quality of clinical decisions of multidisciplinary cancer teams (MDTs) are not well understood. We reviewed and synthesised the evidence on clinical, social and technological factors that affect the quality of MDT clinical decision-making.

METHODS

Electronic databases were searched in May 2009. Eligible studies reported original data, quantitative or qualitative. Data were extracted and tabulated by two blinded reviewers, and study quality formally evaluated.

RESULTS

Thirty-seven studies were included. Study quality was low to medium. Studies assessed quality of care decisions via the effect of MDTs on care management. MDTs changed cancer management by individual physicians in 2-52% of cases. Failure to reach a decision at MDT discussion was found in 27-52% of cases. Decisions could not be implemented in 1-16% of cases. Team decisions are made by physicians, using clinical information. Nursing personnel do not have an active role, and patient preferences are not discussed. Time pressure, excessive caseload, low attendance, poor teamworking and lack of leadership lead to lack of information and deterioration of decision-making. Telemedicine is increasingly used in developed countries, with no detriment to quality of MDT decisions.

CONCLUSIONS

Team/social factors affect management decisions by cancer MDTs. Inclusion of time to prepare for MDTs into team-members' job plans, making team and leadership skills training available to team-members, and systematic input from nursing personnel would address some of the current shortcomings. These improvements ought to be considered at national policy level, with the ultimate aim of improving cancer care.

Simultaneous presentation of branch retinal artery occlusion and vitreomacular traction

PURPOSE

To report a case of simultaneous presentation of branch retinal artery occlusion and vitreomacular traction and the auxiliary role of optical coherence tomography and fluorescein angiogram in the management of this case.

METHODS

A 42-year-old female patient presented with diminution of vision in the left eye. Visual acuity was 20/200. Ocular examination revealed the presence of whitening of the retina along the superotemporal arcade, suggestive of branch retinal artery occlusion. Fluorescein angiogram showed delayed filling of the superotemporal artery consistent with branch retinal artery occlusion along with uncharacterisitic leakage at the fovea. Optical coherence tomographic scan through the fovea revealed vitreomacular traction with distortion of foveal contour. The patient was diagnosed as a case of branch retinal artery occlusion with vitreomacular traction. The patient underwent vitrectomy for the hyaloidal traction on the macula.

RESULTS

Postoperatively, the visual acuity in the left eye improved to 20/20 with resolution of dye leakage on fluorescein angiogram with normal foveal contour on optical coherence tomography.

CONCLUSION

Branch retinal artery occlusion and vitreomacular traction can present simultaneously, and fluorescein angiogram with optical coherence tomography has a complementary role in the management of such cases.

Improved bioavailability through floating microspheres of lovastatin

BACKGROUND AND THE PURPOSE OF THE STUDY

Lovastatin is an antihyperlipidemic agent which has low bioavailability due to the extensive first pass metabolism. It was sought to increase gastric retention of lovastatin by development of a sustained release gastroretentive drug delivery system leading to reduced fluctuation in the plasma concentration and improved bioavailability. MEHODS: Floating microspheres were prepared by emulsion solvent diffusion technique, using various polymers and their blends. The in vitro performance was evaluated for drug-polymer compatibility, percent yield, particle size, drug entrapment efficiency, in vitro onset and duration of floatation, in vitro drug release as well as in vivo determination of serum cholesterol level.

RESULTS

The mean particle size of microspheres was observed to be between 6.9 to 9.5 µm and the maximum particle size was around 50 µm. In vivo studies of the selected batches indicated lower level of serum cholesterol compared to the marketed tablet at the same dose but was not significant.

MAJOR CONCLUSION

The data obtained in this study suggested that a microparticulate floating dosage form of lovastatin can be successfully designed to yield controlled delivery with improved therapeutic efficacy.

Diabetes resolution and hyperinsulinaemia after metabolic Roux-en-Y gastric bypass

The global prevalence of type 2 diabetes mellitus and impaired glucose metabolism continues to rise in conjunction with the pandemic of obesity. The metabolic Roux-en-Y gastric bypass operation offers the successful resolution of diabetes in addition to sustained weight loss and excellent long-term outcomes in morbidly obese individuals. The procedure consists of the physiological BRAVE effects: (i) Bile flow alteration; (ii) Reduction of gastric size; (iii) Anatomical gut rearrangement and altered flow of nutrients; (iv) Vagal manipulation and (v) Enteric gut hormone modulation. This operation provides anti-diabetic effects through decreasing insulin resistance and increasing the efficiency of insulin secretion. These metabolic outcomes are achieved through weight-independent and weight-dependent mechanisms. These include the foregut, midgut and hindgut mechanisms, decreased inflammation, fat, adipokine and bile metabolism, metabolic modulation, shifts in gut microbial composition and intestinal gluconeogenesis. In a small minority of patients, gastric bypass results in hyperinsulinaemic hypoglycaemia that may lead to nesidioblastosis (pancreatic beta-cell hypertrophy with islet hyperplasia). Elucidating the precise metabolic mechanisms of diabetes resolution and hyperinsulinaemia after surgery can lead to improved operations and disease-specific procedures including 'diabetes surgery'. It can also improve our understanding of diabetes pathogenesis that may provide novel strategies for the management of metabolic syndrome and impaired glucose metabolism.

The role of single-incision laparoscopic surgery in abdominal and pelvic surgery: a systematic review

OBJECTIVE

This review aimed to determine the role of single-incision laparoscopic surgery (SILS) in abdominal and pelvic operations.

DATA SOURCES

The Medline, EMBASE, and PsycINFO databases were systematically searched until October 2009 using "single-incision laparoscopic surgery" and related terms as keywords. References from retrieved articles were reviewed to broaden the search

STUDY SELECTION

The study included case reports, case series, and empirical studies that reported SILS in abdominal and pelvic operations.

DATA EXTRACTION

Number of patients, type of instruments, operative time, blood loss, conversion rate, length of hospital stay, length of follow-up evaluation, and complications were extracted from the reviewed items

DATA SYNTHESIS

The review included 102 studies classified as level 4 evidence. Most of these studies investigated SILS in cholecystectomy (n=34), appendectomy (n=24), and nephrectomy (n=17). For these procedures, operative time, hospital stay, and complications were comparable with those of conventional laparoscopy. Conversion to conventional laparoscopy was seldom performed in cholecystectomy (range, 0-24%) and more frequent in appendectomy (range, 0-41%) and nephrectomy (range, 0-33%).

CONCLUSION

The potential benefits of SILS include superior cosmesis and possibly shorter operative time, lower costs, and a shortened time to full physical recovery. Careful case selection and a low threshold of conversion to conventional laparoscopic surgery are essential. Multicenter, randomized, prospective studies are needed to compare short- and long-term outcome measures against those of conventional laparoscopic surgery.

Surgery: a risky business

The advancement of surgical technology has made surgery an increasingly suitable management option for an increasing number of medical conditions. Yet there is also a growing concern about the number of patients coming to harm as a result of surgery. Studies show that this harm can be prevented by better teamwork and communication in operating theatres. This article discusses the extent of adverse events in surgery and how effective teamwork and communication can improve patient safety. It also highlights the role checklists and briefing in improving teamwork and reducing human error in surgery.

Current status of robotic assisted pelvic surgery and future developments

AIMS

The aim of this review is to assess the role of robotics in pelvic surgery in terms of outcomes. We have also highlighted the issues related to training and future development of robotic systems.

MATERIALS AND METHODS

We searched MEDLINE, EMBASE and the Cochrane Databases from 1980 to 2009 for systematic reviews of randomised controlled trials, prospective observational studies, retrospective studies and case reports assessing robotic surgery.

RESULTS

During the last decade, there has been a tremendous rise in the use of robotic surgical systems for all forms of precision operations including pelvic surgery. The short-term results of robotic pelvic surgery in the fields of urology, colorectal surgery and gynaecology have been shown to be comparable to the laparoscopic and open surgery. Robotic surgery offers an opportunity where many of these obstacles encountered during open and laparoscopic surgery can be overcome.

CONCLUSIONS

Robotic surgery is a continually advancing technology, which has opened new horizons for performing pelvic surgery with precision and accuracy. Although its use is rapidly expanding in all surgical disciplines, particularly in pelvic surgery, further comparative studies are needed to provide robust guidance about the most appropriate application of this technology within the surgical armamentarium.

Surgical choroidal neovascular membrane removal in the era of anti-vascular endothelial growth factor agents

Intravitreal anti-vascular endothelial growth factor (VEGF) agents have obtained acceptance as the mainstay in the management strategy of subfoveal choroidal neovascular membranes (CNVM) due to varying etiologies. Few drawbacks include need for repeated intravitreal injections, with its adjunct risks, and the lack of a predefined treatment end point, which can cause doubts and uncertainty in the mind of the patient. Furthermore, it remains a significant financial burden for the patient.

Herein we report our data of three patients who were reluctant for further re-injections of anti-VEGF agents and were therefore offered surgical removal of the CNVM by submacular surgery as an alternative treatment plan.

A comparative debate on the various anti-vascular endothelial growth factor drugs: pegaptanib sodium (Macugen), ranibizumab (Lucentis) and bevacizumab (Avastin)

Wet age-related macular degeneration and diabetic retinopathy are pathological consequences of vascular endothelial growth factor (VEGF) release as a reaction to deficiency of oxygen and nutrients in the macular cells. Conventional treatment modalities have been constrained by limited success. Convincing evidence exists that targeting VEGF signaling is a significant approach for the therapy of these ocular angiogenesis-dependent disorders. We have come a long way since the approval of the first angiogenesis inhibitors in medicine. The clinical use of these drugs has provided enormous tempo to clinical and pharmacological research. It has also significantly altered patient outcome and expectations. In the following brief, we will discuss the development and emergence of these drugs as well as the anticipated future course based on evidence.

Evaluation of intestinal mucosal permeability function in patients with acute pancreatitis

This study aims to evaluate the intestinal mucosal permeability in patients with acute pancreatitis. The lactulose:mannitol (L:M) ratio was used to assess permeability. It is an inexpensive and quite reliable method. The intestinal permeability was increased in patients with acute pancreatitis compared with the controls. In addition, patients with severe pancreatitis had higher intestinal barrier dysfunction compared with patients with mild pancreatitis, the L:M ratio being .2 and .029, respectively. It was also concluded that the permeability increased gradually over the course of pancreatitis and was maximum at day 7 (P < .01). This provides a window of opportunity for therapeutic intervention to prevent the late observed increase in intestinal permeability.

Sex hormone receptors in the human eye

Dissimilarities in ocular physiopathology exist between human males and females. These differences can be observed in the lacrimal and other eye-associated glands, the ocular surface, the crystalline lens, and the retinochoroid complexes. Literature on the subject revealed that because of sex steroid hormone (estrogen, progesterone, and androgen) actions, various physiological conditions, such as age, menstrual cycles, pregnancy, and menopause or andropause, where the hormone milieu changes, affect vision. Well-designed scientific studies are lacking on the subject, although such studies hold much potential value. This review analyzes the relatively new area of hormones and vision.

Role of Early Radial Optic Neurotomy in Central Retinal Vein Occlusion

PURPOSE

To determine safety, clinical and visual results, and potential complications of early radial optic neurotomy (RON) surgery in eyes with central retinal vein occlusion (CRVO), with relative afferent pupillary defect and visual acuity

MATERIALS AND METHODS

This prospective, interventional case-series included 24 patients of CRVO who underwent RON within 2 months of disease onset. The preoperative examination included slitlamp biomicroscopy, fundus photography and fluorescein angiography. Foveal thickness was measured using optical coherence tomography (OCT) in the last 6 eyes only. In each case, RON was performed after informed consent. Two radial incisions were placed in the nasal quadrant of the optic disc, using a micro-vitreoretinal blade. The postoperative change in vision, clinical picture, fundus photographs, angiograms and foveal thickness by OCT were the main outcome variables studied. The Wilcoxan signed test was used to assess the results.

RESULTS

Average symptom duration was 37.8 +/- 15.2 days (range 15-60 days, median: 34.5 days) and follow-up 7.7 +/- 2.1 months (range 1-12 months, median: 8 months). Visual outcome: 2 (8.33%) eyes each had fall and preservation of pre-RON visual acuity respectively. Twenty eyes (83.33%) showed increase in vision (of average 3 lines). Pre and postoperative vision ranged from 0.017-0.1 (average:0.061) and 0.017-0.667 (average: 0.17) respectively (P < 0.05). Clinical and angiographic outcome: decline in macular oedema, decreased or resolved intraretinal haemorrhages, resolution of venous dilatation and disc oedema could be appreciated in all cases. Foveal thickness: average pre and postoperative foveal thickness was 834.17 microm and 556.17 microm respectively (P < 0.05) in the 6 eyes where it was measured before and after RON. One eye developed retinal-detachment.

CONCLUSION

Radial optic neurotomy is better than the natural course in eyes with CRVO, with vision < 6/60.

Juvenile rhegmatogenous retinal detachment

PURPOSE

To review the clinical features, evaluate visual, and anatomical outcomes and potential complications following surgery for rhegmatogenous retinal detachment (RRD) in juveniles.

METHODS

Retrospective, consecutive case series of children and young adults (birth through 18 years) who underwent surgerys for RRD between February 1999 and January 2002.

RESULTS

The authors reviewed a consecutive series of 111 eyes of 105 juveniles [86 (77.47%) eyes belonged to male and 25 (22.52%) to female subjects] operated for RRD. The mean age of patients was 13.62 years. Bilateral retinal detachment was present in 12 (10.8%); 51 (46%) patients had some form of bilateral ocular pathology at initial presentation. The two most common aetiologies were non-penetrating trauma (45.04%) and myopia (41.44%). Decreased vision was the most frequent symptom. The mean duration of symptoms was 165.36 days. The commonest retinal break was a retinal hole (34.23%). Late diagnosis was common, evidenced by high frequency of macular detachment (97.29%) and proliferative vitreoretinopathy (PVR) (45.94%) at initial presentation. The most commonly performed primary surgery was scleral buckle (61.26%). The average postoperative follow-up after the first procedure was 10 months (range 8-19 months). Final retinal reattachment was accomplished in 78.37% (87/111) with a mean of 1.29 surgeries per eye. Improvement, no change and decline in vision was seen in 50 (48%), 32 (31%) and 22 (21%) eyes respectively.

CONCLUSION

Non-penetrating injury and myopia were the most common cause for RRD in juveniles. Fellow eyes commonly had vision-threatening abnormalities. Final anatomical and visual recovery rates were encouraging despite late initial presentation and high rates of macular detachment, and PVR at initial presentation.