Combining Clinical, Pathological, and Demographic Factors Refines Prognosis of Lung Cancer: A Population-Based Study

In the treatment of lung cancer, an accurate estimation of patient clinical outcome is essential for choosing an appropriate course of therapy. It is important to develop a prognostic stratification model which combines clinical, pathological and demographic factors for individualized clinical decision making.A total of 234,412 patients diagnosed with adenocarcinomas or squamous cell carcinomas of the lung or bronchus between 1988 and 2006 were retrieved from the SEER database to construct a prognostic model. A model was developed by estimating a Cox proportional hazards model on 500 bootstrapped samples. Two models, one using stage alone and another comprehensive model using additional covariates, were constructed. The comprehensive model consistently outperformed the model using stage alone in prognostic stratification and on Harrell's C, Nagelkerke's R(2), and Brier Scores in the whole patient population as well as in specific treatment modalities. Specifically, the comprehensive model generated different prognostic groups with distinct post-operative survival (log-rank P<0.001) within surgical stage IA and IB patients in Kaplan-Meier analyses. Two additional patient cohorts (n = 1,991) were used as an external validation, with the comprehensive model again outperforming the model using stage alone with regards to prognostic stratification and the three evaluated metrics.These results demonstrate the feasibility of constructing a precise prognostic model combining multiple clinical, pathologic, and demographic factors. The comprehensive model significantly improves individualized prognosis upon AJCC tumor staging and is robust across a range of treatment modalities, the spectrum of patient risk, and in novel patient cohorts

Improving the quality and efficiency of follow-up after curative treatment for breast cancer – rationale and study design of the MaCare trial

BACKGROUND: After curative treatment for breast cancer women frequently attend scheduled follow-up examinations. Usually the follow-up is most frequent in the first 2–3 years (2–4 times a year); thereafter the frequency is reduced to once a year in most countries. Its main aim is to detect local disease recurrence, or a second primary breast cancer, but also to provide information and psychosocial support. However, the cost-effectiveness of these frequent visits is under much debate, leading to a search for less intensive and more cost-effective follow-up strategies. In this paper the design of the MaCare trial is described. This trial compares the cost-effectiveness of four follow-up strategies for curatively treated breast cancer patients. We investigate the costs and effects of nurse-led telephone follow-up and a short educational group programme. METHODS/DESIGN: The MaCare trial is a multi centre randomised clinical trial in which 320 breast cancer patients are randomised into four follow-up strategies, focussed on the first 18 months after treatment: 1) standard follow-up; 2) nurse-led telephone follow-up; 3) arm 1 with the educational group programme; 4) arm 2 with the educational group programme. Data is collected at baseline and 3, 6, 12 and 18 months after treatment. The primary endpoint of the trial is cancer-specific quality of life as measured by the global health/QoL scale of the EORTC QLQ-C30. Secondary outcomes are perceived feelings of control, anxiety, patients' satisfaction with follow-up and costs. A cost-effectiveness analysis will be performed from a societal perspective. DISCUSSION: Reduced follow-up strategies for breast cancer have not yet been widely applied in clinical practice. Improvement of psychosocial support and information to patients could lead to a better acceptance of reduced follow-up. The MaCare trial combines a reduced follow-up strategy with additional psychosocial support. Less frequent follow-up can reduce the burden on medical specialists and costs. The educational group programme can improve QoL of patients, but also less frequent follow-up can improve QoL by reducing the anxiety experienced for each follow-up visit. Results of the trial will provide knowledge on both costs and psychosocial aspects regarding follow-up and are expected in 2009

Know-Why and Design: Key differences between craft and profession, Illustrated at orthopaedic shoemaking.

Abstract 1 Im Laufe der Jahre haben die Orthopädieschuhmacher ihr Handwerk als eine Spezialisierung der traditionellen Schuhmacherei entwickelt. Im Gegensatz zu regulären Schuhmachern, die Schuhe für gesunde Füße machen, helfen Orthopädieschuhmacher Menschen mit Fußproblemen, welche ihre Mobilität behindern. Die Orthopädie-schuhmacher tun dies durch die Anpassung oder Änderung von Schuhen, je nach Schwere des Mangels des Fußes, in einem Bereich von einfachen Modifikationen der Standard-Schuhen bis zu vollständig maßgeschneiderten Schuhlösungen. In der Vergangenheit wurden die Orthopädieschuhmacher im Rahmen einer Lehre in der Berufspraxis ausgebildet. Auf diese Weise wurden berufliche Kenntnisse, Fähigkeiten und Fertigkeiten des Schuhmachermeisters an die Lehrlinge/Gesellen von Generation zu Generation übertragen. Diese Basiskenntnis wurde übertragen wie eine Katalog an Erfahrungswissen, zusammen gestellt aus: 1) Wissen über bekannte Probleme und 2) die dazu gehörige Lösungen. Weiterhin wurden 3) die Kenntnisse, Fähigkeiten und Erfahrungswissen formuliert und als prozedurales Wissen gelehrt, um effektive Lösungen zu entwickeln. Folge war, dass verschiedene Schuhmacher-Gruppen verschiedene Lösungen für die gleichen Probleme entwickelten, wofür jede "empirische Gültigkeit“ beanspruchte. Diese Kenntnisbasis von Orthopädieschuhmachern kann man charakterisieren als: Herstellung orientiert an impliziten, durch Tradition bestimmten Lösungsentwürfen. Da die empirischen Lösungen der Nachfrage entsprachen, waren die Begründung der Lösung und der methodische Entwurf der Orthopädieschuhe keine explizit geforderte Aktivität. Vor kurzem wurde in den Niederlanden diese traditionsbestimmte Kenntnisbasis der Orthopädieschuhmacher durch die Krankenkassen in Frage gestellt, da die Kassen wissen wollten, ob und warum ein Lösungsvorschlag wirksam wäre. Erfolgt diese Begründung nicht, wird nur die preiswerteste Lösung zurückerstattet. Die Kassen stellten die Begründungsfrage und forderten also eine akzeptable wissenschaftliche Erklärung für die Lösung des Mobilitätsproblems. Diese Erklärung ist im Prinzip erreichbar, als zum Beispiel innovative Imaging-und Messmethoden zur Verfügung stehen. Es gab großen Widerstand in den Reaktionen auf die Aufforderung, traditionelles Wissen wissenschaftlich zu begründen. Es gab abwehrende (in Zusammenhang mit den Kosten) aber auch pro-aktive / innovative Reaktionen. Fontys University of Applied Sciences nahm die innovative Perspektive und identifizierte Möglichkeiten um das Orthopädieschuhmacher-Handwerk qualitativ aufzuwerten zu einem modernen, mehr professionellen und mit wissenschaftlichen Einsichten unterstützten Beruf. Aus dieser Perspektive hat Fontys einen neuen Lehrplan gestaltet und die Schlüsselperspektiven: 1) Begründung und 2) methodischer Entwurf inkorporiert. Der Lehrplan wird die vorläufigen IVO Kriterien für eine Cat-II Akkreditierung erfüllen. Derzeit wird die Gestaltung von Lehrplänen in Vietnam als Teil der internationalen Kooperationsprojekte pilotiert. Keywords: Vom Handwerk zur Profession, Wissensarten, Methodischer Entwurf Abstract 2 Over the years, orthopaedic shoemakers developed their craft as specialisation of traditional shoemaking. In contrast of shoemakers who make shoes for the healthy feet, the orthopaedic shoemakers assist people with foot related problems causing mobility disabilities. They do this by adapting and modifying shoes in a range from simple modifications of standard shoes to complete bespoke shoe solutions depending on the severity of the deficiency of the foot. In the past, orthopaedic shoemakers were trained in a craft-apprenticeship model which was used to transfer the professional knowledge of the master shoemaker to the apprentice, from generation to generation. This transferred knowledgebase can be perceived as an catalogue of empirical knowledge consisting of 1) knowledge of known problems and 2) associate solutions (know –how). In addition, 3) the knowledge, skills, tricks and traps, formulated in procedural knowledge (do this-do that) was taught to produce the solutions. Consequently, different groups of shoemakers had different solutions for the same issues and each claimed empirical success. This orthopaedic shoemakers knowledgebase can be characterised as manufacture driven with implicit tradition based designs. As the traditional empirical solutions met the demand, explanatory knowledge and explicit methodological shoe design were no issues. In the Netherlands, recently the knowledgebase -know how- of the orthopaedic shoemakers was challenged as the insurance companies wanted to know whether and why a proposed solution is effective. If not, the cheapest solution was refunded. They requested an acceptable scientific explanation – know why- which in principle became achievable as innovative imaging- and measurement methods became available. As a result, the orthopaedic shoe branch was challenged when their mode 2 knowledge was questioned. The reactions were contrasting, from reactive(follow the money) to pro active/innovative. Fontys University of Applied Sciences took an innovative perspective and perceived possibilities to upgraded the craft of orthopaedic shoemakers into a modern, more academic, profession. Therefore, Fontys designed a new curriculum and added the key characteristic: 1) explanatory knowledge (mode 1 knowledge) and 2) methodical design. The curriculum is set up to meet the provisional IVO guidelines for a cat-II accreditation. At present, the curriculum design is piloted in Vietnam as part of international cooperation project. Keywords: from craft to profession, types of knowledge, methodical desig

Philosophical reflections on the relationship between man and technology

In the pursuit of better products and more satisfied patients, the orthotic field is constantly evolving by improving existing and developing new devices. Despite many efforts by professionals in development and innovation of orthopaedic devices, three important problems can be defined: non-use, dissatisfaction, and underexposed problems. This study investigates the orthopaedic practice from a philosophical perspective. At first, a distinction is introduced between professional and user practices. After that, the relationship between man-technology and the aspects of the user practice will be explained. Finally we will discuss our view on successful use of technology as a result of considering the user practice from the perspective of the different aspects

Development and external validation of a nomogram for prediction of radiation-induced dysphagia in 493 lung cancer patients treated with chemo-radiotherapy or radiotherapy alone

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