Palliative radiotherapy: Evolving role and policy challenges

Radiotherapy remains a key modality in the palliation of advanced malignancy managing both local primary tumour effects such as pain and bleeding as well as the sequelae of metastatic disease. Its role continues to evolve in line with advances in radiation technology, which have facilitated dose escalation and reduced toxicity. Injudicious use of such advancements has the potential to magnify the cost of delivering palliative radiotherapy without achieving significant gains in terms of outcomes, and therefore well-designed trials to assess the clinical efficacy are essential. From a policy perspective a key concern remains the heterogeneity in dose fractionation schedules currently utilised internationally which lack a strong evidence base and may be influenced by reimbursement policy that incentivises longer, more complex and less cost-effective schedules. International consensus is required on study end-points in palliative radiotherapy research to enable comparison between case series and facilitate randomised controlled trial design. Patient reported outcome measures should be developed that capture the value of radiation treatment for different indications both in achieving symptom control but also improving quality of life. The timing and appropriate use of radiation therapy are generally guided by the clinical assessment of the radiation oncologist, once a referral has been made. An analysis of outcomes from national-level epidemiological studies has the potential to guide appropriate utilisation and identify those patients most likely to derive benefit from radiotherapy in different tumour types. Lastly education and training remain at the heart of reducing inequalities in access to radiotherapy for patients who would benefit. This includes both radiation oncologists for whom many training schemes do not prioritise palliative care and the wider multidisciplinary team who are involved in the management of cancer patients at all stages. (C) 2016 Elsevier Ltd. All rights reserved

Effect of teriparatide in fracture healing of intertrochanteric fracture: a prospective study

Background: Intertrochanteric fracture is a relatively common and serious medical issue in geriatric trauma result in serious health problems and decrease health related quality of life. Faster time-to-union is important for early return to daily activities and reduction of complications. Teriparatide has been shown to accelerate fracture-healing. The purpose of the present prospective, randomized, controlled study was to evaluate the effect of teriparatide on the course of intertrochanteric fracture-healing.Methods: Forty patients of intertrochanteric fractures who underwent surgical intervention between June 2016 and May 2017 were enrolled in this prospective study and followed for minimum of six months. Group A included patients who received only calcium supplementation; patients in Group B received teriparatide along with calcium supplementation postoperatively.Results: The mean time to fracture healing was between 8-12 weeks for the treatment group, compared with 12-16 weeks for the control group. There was also significant effectiveness with regards to Parker and Palmer mobility score at 6 months.Conclusions: Postoperative use of teriparatide for 6 months appears to be an effective adjunct therapy in the treatment of patients with intertrochanteric fractures. However, because of the limited power of the study a large-scale cohort study is still required for determining the efficacy of teriparatide

Nifedipine versus nitroglycerin for acute tocolysis in preterm labour: a randomised controlled trial

Background: To compare the safety & efficacy of oral nifedipine with transdermal nitroglycerin in the inhibition of preterm labour.Methods: This study included 84 women in preterm labour, randomly divided into two groups, 43 receiving oral nifedipine and 41, transdermal nitroglycerin (NTG). Patients in preterm labour with a single gestation, between the 26th and the 34th week and no contraindication for tocolysis were selected. Women with fetal malformation and medical or obstetric diseases were excluded. The variables analyzed were: delay in delivery for 48 hours, 7 days or more than 7 days, period of gestation at delivery, side effect profile of drugs & neonatal outcomes.Results: Mean prolongation of pregnancy with NTG (29.04 days) was similar to that of nifedipine (34.46 days). Nifedipine was significantly more successful in prolonging pregnancy beyond 48 hours, especially in women with advanced cervical dilatation (>3 cm). Failure of acute tocolysis, defined as delivery within 48 hours, was significantly more common with NTG (31.7 %) as compared to nifedipine (11.6 %). Headache was significantly higher in the NTG group (41.5 %) compared to nifedipine group (4.7 %). The neonatal outcomes in terms of the mean birth weight, incidence of low birth weight and very low birth weight babies, need and duration of neonatal intensive care was similar in both groups.Conclusions: Oral nifedipine is a safe and effective tocolytic with a lower failure rate and better side effect profile as compared with transdermal nitroglycerin

Looking For Niches In All The Right Places: Designing An MBA Program For The Next Decade

In an over-built, mature industry as is graduate management education it is increasingly important that schools find the right niche at which to target their MBA programs.  However, the literature is largely silent as to how a school might go about the process of finding the right niche for its MBA.  Using gap analysis and data from Occupational Outlook Handbook, we develop a process for identifying future employment trends as a means of identifying promising niches toward which to orient an MBA program.  This is an important exercise for those who design MBA programs, especially in light of the AACSB/International’s current focus upon continuous improvement among its member institutions.  Even if accreditation standards did not require it, the rapidly changing business climate makes continually upgrading MBA programs a necessity

Early cancer diagnosis: reaching targets across whole populations amidst setbacks.

Early diagnosis of cancer, followed by timely and appropriate therapy, are the cornerstones of the secondary prevention of cancer, thus the NHS has set a 2028 target to achieve 75% early stage (TNM I/II) at cancer diagnosis. In this context, Barclay et al. evaluated overall, sex, age and deprivation-group-specific progress towards this target based on 202,000 cancer patients diagnosis in 2015. Herein, we discuss their findings which form a valuable pre-COVID-19 pandemic status. We discuss the impact of the pandemic and the efforts being made in innovative early detection and diagnosis research

Laproscopic intravesical vesicovaginal fistula repair after removal of an old vaginal drain tube-a rare case

The management of vesicovaginal fistula is difficult and challenging We are presenting a rare case of a 24-year-old unmarried girl with history of vaginoplasty and multiple surgeries done in the past, with a vaginal drain tube kept for 12 years and a Vesicovaginal fistula at the bladder trigone. Patient was successfully treated with a laproscopic Intravesical vesicovaginal Fistula repair. As advances in understanding the etiology of VVF have been made, the laproscopic approach has become the gold standard. Laparoscopy allows an excellent view, good exposure of pelvic structures, provides direct access to the fistula and for repair of complex VVF that may not be amenable to vaginal repair

Patient Mobility for Elective Secondary Health Care Services in Response to Patient Choice Policies: A Systematic Review.

Our review establishes the empirical evidence for patient mobility for elective secondary care services in countries that allow patients to choose their health care provider. PubMed and Embase were searched for relevant articles between 1990 and 2015. Of 5,994 titles/abstracts reviewed, 26 studies were included. The studies used three main methodological models to establish mobility. Variation in the extent of patient mobility was observed across the studies. Mobility was positively associated with lower waiting times, indicators of better service quality, and access to advanced technology. It was negatively associated with advanced age or lower socioeconomic backgrounds. From a policy perspective we demonstrate that a significant proportion of patients are prepared to travel beyond their nearest provider for elective services. As a consequence, some providers are likely to be "winners" and others "losers," which could result in overall decreased provider capacity or inefficient utilization of existing services. Equity also remains a key concern

Application of pediatric risk of mortality-III score to predict outcome in critically sick children admitted in a tertiary care pediatric unit in a developing country

Objective: The aim of this study is to assess the utilization of the pediatric risk of mortality-(PRISM)-III score to predict mortality in critically sick children and determination of mortality risk factors in a tertiary care pediatric unit. Materials and Methods: In this cross-sectional descriptive study, 100 children admitted during an 18-month period were enrolled in the study. PRISM-III score and mortality risk were calculated. Follow-up was noted as death or survival. Results: Of 100 patients, 27 died and 73 survived. The 47% of the patients were males. The PRISM-III score was 0-9 in 75%, 10-19 in 15% and 20-29 in 8%, ≥30 in 2% of patients. PRISM-III score showed an increase of mortality from 8% in 0-9 score patients to 100% in ≥20 score. PRISM-III score was significantly associated with study variables such as duration of hospital stay, mental status (Glasgow Coma scale <8), and blood pH <7.28 (p<0001). Conclusion: PRISM-III score showed good predictive value (94.5%) and adequate discriminatory capacity (area under receiver operating characteristics curve 90.8%), and thus constitutes a useful tool for the assessment of prognosis for pediatric patients