Preoperative short-course radiotherapy and long-course radiochemotherapy for locally advanced rectal cancer: Meta-analysis with trial sequential analysis of long-term survival data

<div><p>Background and purpose</p><p>The role of preoperative short-course radiotherapy (SCRT) in rectal cancer treatment, when compared to long-course radiochemotherapy (LCRT), is still controversial. Thus the meta-analysis with trial sequential analysis (TSA) was performed to evaluate the long-term survival of SCRT and LCRT as therapeutic regimens for locally advanced rectal cancer.</p><p>Material and methods</p><p>PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched up to August 2017 for eligible studies. Hazard ratios (HRs) or odds ratios (ORs) of overall survival (OS), disease free survival (DFS) and local recurrence (LR) with the corresponding 95% confidence intervals (CIs) were calculated and TSA was applied.</p><p>Results</p><p>11 studies with 1984 patients were included. There was no significant difference in OS (HR = 0.92, 95% CI: 0.75–1.13, <i>p</i> = 0.44), DFS (HR = 0.94, 95% CI: 0.79–1.12, <i>p</i> = 0.50) and LR (OR = 0.73, 95% CI: 0.49–1.08, <i>p</i> = 0.11) between SCRT and LCRT groups. TSA suggested firm evidence for lacking on average a -10% relative risk reduction (RRR) in 4-year OS but no statistical significance in 4-year DFS.</p><p>Conclusions</p><p>Preoperative SCRT is as effective as LCRT for locally advanced colorectal cancer in long-term survival. SCRT could be preferential while facing long waiting lists or lacking medical resource.</p></div

Performance of Physical Examination Skills in Medical Students during Diagnostic Medicine Course in a University Hospital of Northwest China

<div><p>This study was conducted to evaluate the performance of physical examination (PE) skills during our diagnostic medicine course and analyze the characteristics of the data collected to provide information for practical guidance to improve the quality of teaching. Seventy-two fourth-year medical students were enrolled in the study. All received an assessment of PE skills after receiving a 17-week formal training course and systematic teaching. Their performance was evaluated and recorded in detail using a checklist, which included 5 aspects of PE skills: examination techniques, communication and care skills, content items, appropriateness of examination sequence, and time taken. Error frequency and type were designated as the assessment parameters in the survey. The results showed that the distribution and the percentage in examination errors between male and female students and among the different body parts examined were significantly different (<i>p</i><0.001). The average error frequency per student in females (0.875) was lower than in males (1.375) although the difference was not statistically significant (<i>p</i> = 0.167). The average error frequency per student in cardiac (1.267) and pulmonary (1.389) examinations was higher than in abdominal (0.867) and head, neck and nervous system examinations (0.917). Female students had a lower average error frequency than males in cardiac examinations (<i>p</i> = 0.041). Additionally, error in examination techniques was the highest type of error among the 5 aspects of PE skills irrespective of participant gender and assessment content (<i>p</i><0.001). These data suggest that PE skills in cardiac and pulmonary examinations and examination techniques may be included in the main focus of improving the teaching of diagnostics in these medical students.</p></div

Error types in the students and error types according to body parts examined.

<p>Data are calculated as error frequency/total error frequency (n). Comparison in gender: Pearson chi square, <i>p</i> = 0.405. Comparison of techniques with communication and care skills, items, appropriateness of physical examination sequence and time taken in pairwise: Pearson chi square, <i>p</i> = 0.001, <0.001, <0.001 and <0.001, respectively. Comparison among assessment content (body parts), Pearson chi square <i>p</i> = 0.367.</p><p>Error types in the students and error types according to body parts examined.</p

Meta-analysis of cumulative disease free survival.

<p>No significant difference was found (HR = 0.94, 95% CI: 0.79–1.12, <i>p</i> = 0.50) in disease free survival. Subgroup analysis showed that the difference remained insignificant when RCTs and non-RCTs were analyzed separately.</p

Characteristics and Jadad scores of included studies.

<p>Characteristics and Jadad scores of included studies.</p

Trial sequential analysis of 4-year overall survival.

<p>5a, Trial sequential analysis of 4-year overall survival. The required heterogeneity-adjusted information size using 5% risk of type I error and 20% risk of type II error. The cumulative z curve crossed the futility boundary, suggesting firm evidence for lack of on average a -10% relative risk reduction in 4-year OS. <b>5b,</b> Trial sequential analysis of 4-year disease free survival. When compared with LCRT treatment in 4-year DFS, neither the traditional boundary nor the trial sequential monitoring boundary was crossed for a -10% relative risk reduction with SCRT. In addition, the futility boundary was not crossed.</p

Error frequency of five error types in the students.

<p>Average error frequency per student: Pearson chi square, <i>p</i> = 0.167; Error frequency of physical examination skills: Wilcoxon rank sum test, <i>p</i><0.001.</p><p>Error frequency of five error types in the students.</p

Flowchart of eligible studies identification.

<p>11 studies (4 RCTs and 7 non-RCTs) with a total of 1984 patients were included in this meta-analysis.</p

Meta-analysis of cumulative overall survival.

<p>There was no significant difference in OS between SCRT and LCRT groups (HR = 0.92, 95% CI: 0.75–1.13, <i>p</i> = 0.44). The subgroup analysis of RCTs or non-RCTs found similar results.</p

Error frequency in physical examination skills of cardiac and pulmonary examinations.

<p>Data are calculated as error frequency/total error frequency (n). Comparison of cardiac examination: Pearson chi square, <i>p</i> = 0.009. Comparison of pulmonary examination: Pearson chi square, <i>p</i> = 0.736.</p><p>Error frequency in physical examination skills of cardiac and pulmonary examinations.</p