Conditional recurrence-free survival of clinical complete responders managed by watch and wait after neoadjuvant chemoradiotherapy for rectal cancer in the International Watch & Wait Database: a retrospective, international, multicentre registry study

Background Watch and wait is a novel management strategy in patients with rectal cancer who have a clinical complete response after neoadjuvant chemoradiotherapy. Surveillance of these patients is generally intensive, because local regrowth (with the potential for salvage) occurs in 25% of patients, and distant metastases occur in 10% of patients. It is unclear for how long these patients should be followed up. To address this issue, we did conditional survival modelling using the International Watch & Wait Database (IWWD), which is a large-scale registry of patients with a clinical complete response after neoadjuvant chemotherapy who have been managed by a watch-and-wait strategy.Methods We did a retrospective, multicentre registry study using a dataset from the IWWD, which includes data from 47 clinics across 15 countries. We selected patients (aged >= 18 years) with rectal cancer who had a clinical complete response after neoadjuvant chemotherapy, and who were subsequently managed by a watch-and-wait strategy between Nov 25,1991, and Dec 31,2015. Patients who had not achieved a clinical complete response or who had undergone any surgical procedure were excluded. The criteria used for defining a clinical complete response and the specific surveillance strategies were at the discretion of each participating centre. We used conditional survival modelling to estimate the probability of patients remaining free of local regrowth or distant metastasis for an additional 2 years after sustaining a clinical complete response or being distant metastasis-free for 1,3, and 5 years from the date of the decision to commence watch and wait. The primary outcomes were conditional local regrowth-free survival at 3 years, and conditional distant metastasis-free survival at 5 years.Findings We identified 793 patients in the IWWD with clinical complete response who had been managed by a watch-and-wait strategy. Median follow-up was 55.2 months (IQR 36.0-75.6). The probability of remaining free from local regrowth for an additional 2 years if a patient had a sustained clinical complete response for 1 year was 88.1% (95% CI 85.8-90.9), for 3 years was 97.3% (95.2-98.6), and for 5 years was 98.6% (97.6-100.0). The probably of remaining free from distant metastasis for a further 2 years in patients who had a clinical complete response without distant metastasis for 1 year was 93.8% (92.3-95.9), for 3 years was 97.8% (96.6-99.3), and for 5 years was 96.6% (94.0-98.9).Interpretation These results suggest that the intensity of active surveillance in patients with rectal cancer managed by a watch-and-wait approach could be reduced if they achieve and maintain a clinical complete response within the first 3 years of starting this approach. Copyright (C) 2020 Elsevier Ltd. All rights reserved.Surgical oncolog

'My dreams are shuttered down and it hurts lots'-a qualitative study of palliative care needs and their management by HIV outpatient services in Kenya and Uganda.

BACKGROUND: Despite the huge burden of HIV in sub-Saharan Africa, there is little evidence of the multidimensional needs of patients with HIV infection to inform the person-centred care across physical, psychological, social and spiritual domains stipulated in policy guidance. We aimed to describe the problems experienced by people with HIV in Kenya and Uganda and the management of these problems by HIV outpatient services. METHODS: Local researchers conducted in depth qualitative interviews with HIV patients, caregivers and service staff at 12 HIV outpatient facilities (6 in Kenya, 6 in Uganda). Interview data were analysed thematically. RESULTS: 189 people were interviewed (83 patients, 47 caregivers, 59 staff). The impact of pain and symptoms and their causes (HIV, comorbidities, treatment side-effects) were described. Staff reported that effective pain relief was not always available, particularly in Kenya. Psychosocial distress (isolation, loneliness, worry) was exacerbated by stigma and poverty, and detrimentally affected adherence. Illness led to despair and hopelessness. Provision of counselling was reported, but spiritual support appeared to be less common. Neither pain nor psychosocial problems were routinely reported to service staff. Collaboration with local hospices and income-generation activities for patients were highlighted as useful. CONCLUSIONS: The findings demonstrate the multiple and interrelated problems associated with living with HIV and how psychosocial and spiritual distress can contribute to 'total pain' in this population. In line with the palliative care approach, HIV care requires holistic care and assessment that take into account psychological, socioeconomic and spiritual distress alongside improved access to pain-relieving drugs, including opioids

Contained mobility and the racialization of poverty in Europe: the Roma at the development–security nexus

This paper starts from the observation that, since the collapse of eastern European state socialism, the Roma have become the subject and target of Europe-wide development programs and discourses, while, at the same time, they have been problematized in terms of social, public and national security. Due to the ways in which development and security have ambiguously come together in Europe’s recent history, I will argue that the living conditions of the poorest among the Roma have not only worsened, but also, and more fundamentally, the divide between Europe’s rich and poor has become seriously racialized and almost unbridgeable. I explain how the bio- and geopolitical conditions under which development and security have merged in Europe’s engagement with the Roma have led to a situation in which the official aim of Roma-related development programs – the improvement of their living conditions and life chances – tends to result in a dreadlock

School Leadership and Management: Identifying Linkages with Learning and Structural Inequalities

RLOsThis chapter summarises three phases of research developments in South Africa that have successively brought more reliable quantitative evidence to bear on what we know about the linkages between school leadership and management (SLM) and learning outcomes. A common thread emerging through these studies is the educational value of managing time-on-task and curriculum coverage although more recent evidence suggests that the efficacy of these management practices in raising learning may be mediated through teacher capacity. These linkages are also only informed through mere associations rather than causal evidence. Notwithstanding the lack of rigorous casual evidence in South Africa on how to raise the quality of management in schools, analyses of distributional patterns and trends in school management team (SMT) post-provisioning reflect key areas that could be targeted to at least improve the quantity of SLM in schools and reduce related inequalities. While international evidence on the educational value of leaders and managers supports calls for the capacity development of SMTs, ensuring SMT members are allocated to schools and selecting the best people for these jobs at the outset are the first steps to improve and level differences in the school leadership and management landscape