The NICE classification for 'Ultra-radical (extensive) surgery for advanced ovarian cancer' guidance does not meaningfully predict postoperative complications: a cohort study

OBJECTIVE

To determine which descriptors of cytoreductive surgical extent in advanced ovarian cancer (AOC) best predict postoperative morbidity.

DESIGN

Retrospective notes review.

SETTING

A gynaecological cancer centre in the UK.

POPULATION

Six hundred and eight women operated on for AOC over a period of 114 months at a tertiary cancer centre, between 16 August 2007 and 16 February 2017.

METHODS

Outcome data were analysed by six approaches to classify the extent of surgery: standard/ultra-radical surgery; standard/radical/supra-radical surgery; presence/absence of gastrointestinal resections; low/intermediate/high surgical complexity score (SCS); presence of bowel anastomoses and/or diaphragmatic surgery; and the presence/absence of multiple bowel resections.

MAIN OUTCOME MEASURES

Major (grades 3-5) postoperative morbidity and mortality.

RESULTS

Forty-three (7.1%) patients experienced major complications. Grade-5 complications occurred in six patients (1.0%). Patients who underwent multiple bowel resections had a relative risk (RR) of 7.73 (95% confidence interval, 95% CI 3.92-15.26), patients with a high SCS had an RR of 6.12 (95% CI 3.25-11.52), patients with diaphragmatic surgery and gastrointestinal anastomosis had an RR of 5.57 (95% CI 2.65-11.72), patients with 'any gastrointestinal resection' had an RR of 4.69 (95% CI 2.66-8.24), patients with ultra-radical surgery had an RR of 4.65 (95% CI 2.26-8.79), and patients with supra-radical surgery had an RR of 4.20 (95% CI 2.35-7.51) of grades 3-5 morbidity, compared with patients undergoing standard surgery as defined by the National Institute for Health and Care Excellence (NICE) in the UK. No significant difference was seen in the rate of major morbidity between standard (6/59, 10.2%) and ultra-radical (9/81, 11.1%) surgery within the cohort who had intermediate complex surgery (P > 0.05).

CONCLUSIONS

The numbers of procedures performed significantly correlate with major morbidity. The number of procedures performed better predicted major postoperative morbidity than the performance of certain 'high risk' procedures. We recommend using SCS to define a higher risk operation. NICE should re-evaluate the use of the term 'ultra-radical' surgery.

TWEETABLE ABSTRACT

Multiple bowel resection is the best predictor of morbidity and is more predictive than 'ultra-radical surgery'.

Venous thromboembolism in cancer patients - magnitude of problem, approach, and management

Cancer is hypercoagulable state. Patients with cancer are at high risk to develop venous thromboembolism (VTE). Relative risk of developing VTE is approximately seven times higher in patients with active cancer. The incidence of occult malignancy is 7%-12% in patients with idiopathic deep vein thrombosis (DVT). However, little research has been focused on cancer with thromboembolism. Lowmolecularweight heparin most frequently used pharmacologic agents as recommended by established guidelines. The aim was to evaluate the magnitude of problem in cancer patients and treatment option as per established guidelines. EMBASE, MEDLINE, and PubMed search of the literature were done to evaluate the association of DVT with various malignancy, magnitude of problem, approach, and various guidelines for the management of DVT. References of all publication were also searched to enrich this article for recent update. Thromboprophylaxis in cancer patient is gray zone area. This need lot of investigational work to find highrisk patients who would benefit from primary thromboprophylaxis.

Medical education in difficult circumstances: analysis of the experience of clinical medical students following the new innovative medical curriculum in Aksum, rural Ethiopia

BACKGROUND

In 2012, 12 medical schools were opened in Ethiopia to tackle the significant shortage of doctors. This included Aksum School of Medicine situated in Aksum, a rural town in Northern Ethiopia. The new Innovative Medical Curriculum (NIMC) is a four-year programme designed by the Ethiopian Federal Ministries of Health and Education. The curriculum is designed to train biomedical science graduates to become doctors in 4 years, with a focus on the healthcare needs of rural people living in poverty.

METHODS

This research was conducted at Aksum School of Medicine and included two hospitals (Aksum Referral Hospital and St Mary's District Hospital). This study focused on medical students during their clinical years across multiple specialities (61 Clerkship 1 students and 13 Clerkship 2 students). We used primarily qualitative research methods supplemented with quantitative measures. There were 3 stages of data collection over a 1 month period, this included qualitative group interviews, direct observation of students in a clinical setting and direct observation of skills sessions followed by a questionnaire on the sessions. We analysed the data by reconstructing the student experience and comparing it with the NIMC.

RESULTS

The proposed typical week set out in the NIMC tended to differ from the real clinical experience of these students. Through qualitative group interview and direct observation of teaching, the main theme that was consistent throughout was the lack of doctors with specialist postgraduate training. Clinical need often took priority over education. However, students enjoyed taking early responsibility and gaining practical experience. Through direct observation of skills sessions and short questionnaires, these sessions were highly valuable to the students and they felt confident in carrying out the taught procedures in the future.

CONCLUSIONS

The combination of poorly resourced hospitals and lack of specialist doctors provides a challenging environment for medical students to learn. However, it is a unique clinical experience that is rarely seen in developed countries and facilitates the acquirement of skills from an early stage. Supervision and specialist input is fundamental in enabling students to learn and this is a key area that was lacking in the students' clinical experience.

Synthesis and antiplasmodial activity of purine-based C-nucleoside analogues

A series of homologous C-nucleoside mimics have been synthesized via an efficient and facile synthetic protocol involving the conjugate addition of purine to sugar derived olefinic ester in good yields. The synthesized compounds were evaluated for their antiplasmodial activity in vitro against both the CQ-sensitive and resistant strains of P. falciparum. Interestingly, all the synthesized nucleoside analogs exhibited an IC₅₀ of <5 μM, while compounds 22a, 23a, and 23b showed promising antiplasmodial activity with an IC₅₀ of 1.61, 0.88, and 1.01 μM against the CQ-sensitive Pf3D7 strain and 1.14, 1.01, and 2.57 μM against the CQ-resistant PfK1 strain, respectively.

Practical consensus recommendations on management of triple-negative metastatic breast cancer

Patients with breast cancer along with metastatic estrogen and progesterone receptor (ER/PR)- and human epidermal growth factor receptor 2 (HER2)-negative tumors are referred to as having metastatic triple-negative breast cancer (mTNBC) disease. Resistance to current standard therapies such as anthracyclines or taxanes limits the available options for previously treated patients with metastatic TNBC to a small number of non-cross-resistant regimens, and there is currently no preferred standard chemotherapy. Clinical experience suggests that many women with triple-negative metastatic breast cancer (MBC) relapse quickly. Expert oncologist discussed about new chemotherapeutic strategies and agents used in treatment of mTNBC and the expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Bilateral medial rectus palsy due to midbrain infarction following concussion head injury

Here, we report a rare case of bilateral medial rectus palsy following closed head injury. An adult male had an accidental fall which rendered him unconscious. This was followed by diplopia and restricted ocular motility. He received supportive medical therapy. He was examined for systemic medical and ophthalmic findings. Routine laboratory tests and imaging techniques were employed as per the symptoms. Diffusion-weighted imaging on magnetic resonance imaging proved it to be a rare presentation of small bilateral midbrain infarct. He recovered fully after 8 months.

A prospective randomized trial comparing capecitabine-based chemoradiotherapy with 5-FU-based chemoradiotherapy in neoadjuvant setting in locally advanced carcinoma rectum

INTRODUCTION

Fluorouracil (FU)based chemoradiotherapy is regarded as a standard perioperative treatment in locally advanced rectal cancer. Capecitabine is an oral fluoropyrimidine that generates 5FU preferentially at the tumor site by exploiting the higher activity of the enzyme thymidine phosphorylase in tumor tissue compared with healthy tissue. As an oral agent, capecitabine can be administered in the outpatient setting, potentially providing FU exposure similar to a lowdose continuous infusion of 5FU.

AIMS AND OBJECTIVES

To compare capecitabine with 5FU, with regard to efficacy and toxicity when used in neoadjuvant setting along with radiotherapy for locally advanced carcinoma rectum.

MATERIALS AND METHODS

Thirty patients were enrolled, 14 in 5FU and 16 in capecitabine arm. All patients were planned for 45 Gy/25#/5 weeks pelvic radiotherapy followed by a boost of 5.4 Gy/3#/3 days. 5FU was prescribed at a dose of 500 mg/m2 #1-#5 and #21-#25 of RT and capecitabine was given at 1650 mg/m2 on RT days throughout the course of radiotherapy. A magnetic resonance imaging/computerized tomography scan was done at the start of treatment and 1 month after completion of treatment, followed by surgery. Toxicity was assessed weekly during treatment and on the first followup.

RESULTS

Response rates and toxicity profile of capecitabinebased cathode ray tube (CRT) was similar to 5FUbased CRT with nonsignificant P values.

CONCLUSION

Capecitabine may be used as an alternative in patients who do not tolerate 5FU.