Breast cancer liver metastases: systematic review and time to event meta-analysis with comparison between available treatments

INTRODUCTION

The current gold standard treatment for breast cancer liver metastases (BCLM) is systemic chemotherapy and/or hormonal therapy. Nonetheless, greater consideration has been given to local therapeutic strategies in recent years. We sought to compare survival outcomes for available systemic and local treatments for BCLM, specifically surgical resection and radiofrequency ablation.

METHODS

A review of the PubMed (MEDLINE), Embase and Cochrane Library databases was conducted. Data from included studies were extracted and subjected to time-to-event data synthesis, algorithmically reconstructing individual patient-level data from published Kaplan-Meier survival curves.

FINDINGS

A total of 54 studies were included, comprising data for 5,430 patients (surgery, n=2,063; ablation, n=305; chemotherapy, n=3,062). Analysis of the reconstructed data demonstrated survival rates at 1, 3 and 5 years of 90%, 65.9% and 53%, respectively, for the surgical group, 83%, 49% and 35% for the ablation group and 53%, 24% and 14% for the chemotherapy group (p<0.0001).

CONCLUSION

Local therapeutic interventions such as liver resection and radiofrequency ablation are effective treatments for BCLM, particularly in patients with metastatic disease localised to the liver. Although the data from this review support surgical resection for BCLM, further prospective studies for managing oligometastatic breast cancer disease are required.

Platform-Based Internationalization of Smaller Firms: The Role of Government Policy

Governments are recognizing anticompetitive concerns and market distortions associated with the rise of e-commerce platforms. Thus, policies are being crafted to level the playing field between large platform operators and small platform sellers. In addition, policies mitigating barriers to internationalization associated with using e-commerce platforms are also being developed. This study aims to explore these policy actions impacting the platform-based internationalization of small and micro enterprises (SMEs). The case study method is adopted to provide rich insights into the Indian Government policy actions impacting the e-commerce platform-based internationalization of Indian SMEs. More specifically, this investigation analyzes the extent to which the Indian Government policy actions have mitigated the home market and industry-level barriers to export for SMEs leveraging e-commerce platforms for their internationalization efforts. Study findings provide rich policy implications and fodder for future empirical testing of key qualitative insights uncovered in this study.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11575-022-00492-z.

73 An Audit Evaluating the Management of Pre-Operative Anaemia in Elective Bowel Resections at Frimley Park Hospital

Introduction

Pre-operative anaemia is common within the surgical population, particularly those scheduled for elective bowel resections. National and local guidelines recommend the treatment of pre-operative anaemia, as it is an independent risk factor for poor post-operative outcomes, including length of stay in hospital.

Method

A retrospective study of all NHS patients over the age of 18 scheduled for an elective bowel resection at Frimley Park Hospital between 1st May-31st October 2019.

Results

85 patients met the inclusion criteria, with 29 recorded as anaemic. Of these patients, 55% (n = 16) received iron replacement, all of which were intravenous and did not include mildly anaemic patients. The median rise in haemoglobin post-infusion was 14g/L, with only one patient achieving a normal haemoglobin. The median length of stay for patients with a normal haemoglobin was six days, which increased to eight for those with anaemia of any severity. A statistically significant relationship was found between severity of anaemia and increased length of stay, particularly in the female population.

Conclusions

Pre-operative anaemia was linked to increased length of stay in hospital. The findings support the intravenous treatment of all severities of anaemia pre-operatively and therefore suggest treating mild anaemia patients, as normalising their haemoglobin will improve outcomes.

Systemic neoadjuvant chemotherapy in modern pancreatic cancer treatment: a systematic review and meta-analysis

BACKGROUND

Pancreatic ductal adenocarcinoma remains a disease with a poor prognosis despite advances in surgery and systemic therapies. Neoadjuvant therapy strategies are a promising alternative to adjuvant chemotherapy. However, their role remains controversial. This meta-analysis aims to clarify the benefits of neoadjuvant therapy in resectable pancreatic ductal adenocarcinoma.

METHODS

Eligible studies were identified from MEDLINE, Embase, Web of Science and the Cochrane Library. Studies comparing neoadjuvant therapy with a surgery first approach (with or without adjuvant therapy) in resectable pancreatic ductal adenocarcinoma were included. The primary outcome assessed was overall survival. A random-effects meta-analysis was performed, together with pooling of unadjusted Kaplan-Meier curve data.

RESULTS

A total of 533 studies were identified that analysed the effect of neoadjuvant therapy in pancreatic ductal adenocarcinoma. Twenty-seven studies were included in the final data synthesis. Meta-analysis suggested beneficial effects of neoadjuvant therapy with prolonged survival compared with a surgery-first approach, (hazard ratio 0.72, 95% confidence interval 0.69-0.76). In addition, R0 resection rates were significantly higher in patients receiving neoadjuvant therapy (relative risk 0.51, 95% confidence interval 0.47-0.55). Individual patient data analysis suggested that overall survival was better for patients receiving neoadjuvant therapy (P = 0.008).

CONCLUSIONS

Current evidence suggests that neoadjuvant chemotherapy has a beneficial effect on overall survival in resectable pancreatic ductal adenocarcinoma in comparison with upfront surgery and adjuvant therapy. Further trials are needed to address the need for practice change.

Health Insurance in India—A Study of Provider’s Perceptions in Delhi & the NCR

This study examines the Indian health insurance market by empirically observing the provider’s perceptions and its relationship with the insured, the insurer and the third party administrators (TPAs). The study tries to find out the awareness level among the insured population and their attitude towards treatment cost. It then examines the role of TPAs and the impact of cashless services on the cost of treatment by studying a few cost drivers. Apart from studying the provider’s per-ceptions it also tries to look at some of the evidence of moral hazards and that of fraudulent activity. The findings suggest that the awareness level regarding policy terms and condition is low among the insured population and most of them do not care for the cost of treatment. The providers increase their rates quite frequently and prefer the middle income group for extending cashless benefits. The TPA model has not been successful in bringing down the claim cost but has helped in providing unbiased services including cashless benefits. The price structure of healthcare services are linked to the room rent category and most of the insured patients, who are more demanding, prefer staying in higher category rooms. The concept of cost-sharing by the insured will help tackle this issue to some degree. The Indian health insurance market is not immune from supply-side moral hazards and fraudulent activities and there is a need to craft different strategies to tackle them. There exists an opportunity for the insurance companies to build long-term relationships with the preferred healthcare providers by using technology and by understanding each other’s roles in serving the common client.

Blood transfusion practices at a level one trauma centre: a one-year retrospective review

INTRODUCTION

Knowledge of blood usage patterns helps to address major issues such as the management of massive transfusion events, minimisation of transfusion risks, as well as in dealing with blood shortages. The aim of our study was to audit blood component usage at a Level I trauma centre blood bank.

METHODS

A retrospective analysis of the transfusion data of 4,320 patients who were admitted to the General Surgery, Neurosurgery, Orthopaedics and Emergency Medicine departments during a one-year period was conducted.

RESULTS

A total of 4,054 patients underwent transfusion. 88 percent, 94 percent, 80 percent and 100 percent of patients admitted to the General Surgery, Orthopaedics, Neurosurgery and Emergency Medicine departments, respectively, received transfusions. Packed cells were the most commonly utilised component, followed by fresh frozen plasma (FFP) and platelets in the ratio 3:2:1. The highest number of FFPs (2,052 units) and platelet concentrates (950 units) were used in the General Surgery and Neurosurgery departments, respectively. The calculated cross-match to transfusion (C:T) ratio did not exceed 2.5 in any of the departments. Among those transfused, the massive blood transfusion rate was low (1.77 percent). The rates of transfusion reactions and non-group-specific transfusions were also low (0.42 percent and 0.07 percent, respectively).

CONCLUSION

The rate of transfusion of trauma patients was high (94 percent). Using the C:T ratio as a marker, optimal blood utilisation was noted in all departments. The methods of reporting transfusion reactions need to be revised. Future studies on the appropriateness of blood use and blood ordering schedules are required.