Patient-centered developments in colon-and rectal cancer with a multidisciplinary international team:From translational research to national guidelines

Rarely,scientific developments centered around the patient as a whole arepublished.Our multidisciplinary group,headed by gastrointestinal surgeons,applied this research philosophy considering the most important aspects of thediseases“colon-and rectal cancer”in the long-term developments.Good expertcooperation/knowledge at the Comprehensive Cancer Center Ulm(CCCU)wereapplied in several phase III trials for multimodal treatments of primary tumors(MMT)and metastatic diseases(involving nearly 2000 patients and 64 centers),fortreatment individualization of MMT and of metastatic disease,for psychooncology/quality of life involving the patients’wishes,and for disease prevention.Most of the targets initially were heavily rejected/discussed in thescientific communities,but now have become standards in treatments andnational guidelines or are topics in modern translational research protocolsinvolving molecular biology for e.g.,“patient centered individualized treatment”.In this context we also describe the paths we had to tread in order to realize ournew goals,which at the end were highly beneficial for the patients from manypoints of view.This description is also important for students and youngresearchers who,with an actual view on our recent developments,might want toknow how medical progress was achieved.

Are Tuberculosis Patients Managed According to the National Guidelines in Lagos State Nigeria?

Setting: Private and public tuberculosis (TB) treatment centers in Lagos State, Nigeria. Objective: To compare adherence of private and public providers of directly observed treatment short course (DOTS) in the Lagos State TB control program, Nigeria (LSTBLCP) with the national TB guidelines. Design: A retrospective review of treatment cards of TB patients managed within the first and second quarter of 2012 in 34 DOTS facilities {23 public, 7 private for profit (PFP), and 4 private not for profit (PNFP)} involved in the private public mix of the LSTBLCP. Results: Of the 1896 treatment cards reviewed, 1524 (80.4%), 132 (7.0%) and 240 (12.6%) were from public, PFP and PNFP DOTS facilities, respectively. About 19%, 25% and none of the patients managed at the public, PNFP, and PFP DOTS facilities were treated in full adherence with the national guidelines respectively. A significantly higher proportion of adults and sputum smear positive TB patients were treated in full adherence with the national guidelines (p < 0.05). Treatment success was associated with full adherence with the national guidelines. Conclusion: There is a need to reorient health care providers in public and private health facilities in Lagos State Nigeria to ensure full adherence with the national TB guidelines.

Recommendations for Acupuncture in Clinical Practice Guidelines of the National Guideline Clearinghouse

Objective： To organize the clinical practice guidelines（CPGs） related to acupuncture included in the National Guideline Clearinghouse（NGC） to systematically summarize the diseases and disorders most commonly treated with acupuncture, the strength of recommendations for acupuncture and the quality of evidence. Methods： The NGC database was systematically searched for guidelines that included acupuncture as an intervention. Two independent reviewers studied the summaries and the full texts of the guidelines and included guidelines based on the inclusion and exclusion criteria. Thirty-nine guidelines were collected with 80 recommendations. The Appraisal of Guidelines for Research and Evaluation（AGREE） Ⅱ instrument was used to assess the quality of these guidelines. Results： Of the 80 recommendations on acupuncture, 49 recommendations were clearly for acupuncture, 25 recommendations were against acupuncture and 6 recommendations did not indicate any clear recommendations, 37 recommendations were for painful diseases/disorders, and 12 recommendations were for non-painful diseases/disorders. Locomotor system disorders were the most common in the painful diseases/disorders category. Out of all the recommendations for acupuncture, most recommendations（87.76%） were weak in strength, and most of the evidence（40.84%） was of low quality. Conclusion： In the National Guideline Clearinghouse, the recommendations for acupuncture focus on painful diseases/disorders. The recommendations in the guidelines are not high in strength, and most of the evidence is moderate or low in quality.

Effect of In-Service Training Program on the Practice of Healthcare Workers toward Malaria Prevention and Treatment Guidelines during Pregnancy in Health Facilities in Jowhar District, Somalia

Malaria is generally considered a major public health problem in Somalia. Providing early diagnosis and effective treatment is the key element of malaria control strategies in malaria-endemic countries, including Somalia. This required to advocate and ensure health worker’s adherence to the national malaria guidelines at all levels of health care service. A well-designed in-service training program may improve the level of health worker’s adherence to national malaria treatment guidelines, although results have been inconsistent. This is an interventional health facility-based pre and post comparative study aimed to assess the effect of an in-service training program on the practice of healthcare workers toward malaria prevention and treatment guidelines, during in pregnancy in health facilities in Jowhar district, Middle Shabelle region of Somalia. The study was implemented in three phases: pre-intervention phase, intervention phase and post-intervention phase. The sample size consisted of (n = 150) health workers who were selected from ten public health facilities using proportional to size sampling;the data collection adopted in this research is composed of a structured interview questionnaire and observational checklist. Data was analyzed through the application of descriptive statistical analysis that includes frequency and percentage and the Chi-square (x2) test was used to test the associations among variables using SPSS software version 25. The study showed that the level of health workers’ awareness of the national malaria guidelines in the treatment and prevention of malaria in pregnancy was found to be good before the intervention 89 (59.3%) and this proportion increased to 150 (100%) post-intervention of the training program. A significance difference has been observed between health workers’ awareness and their adherence to the malarial guidelines at pre-test and post-test with a p-value 0.000. The proportion of health workers who attended previous training on national malaria guidelines in the treatment and prevention of malaria in pregnancy increased from 46 (30.7%) at the pre-test to 150 (100%) after the post-test. A significant difference was observed in the training status among different categories of health worker and their adherence to the guidelines during the pre- and post-intervention of the training program, with a p-value of 0.000. The result showed that health workers were adhering to the guidelines at the pre-test 33 (22%), this increased after the post-test to 87 (58%). The knowledge of the need to adhere led to an increase in the adherence rate after the training program intervention. The study reveals that inadequate awareness was most reason for the non-adherence in the majority of the health workers as indicated by 89 (59.3%) at the pre-test and 56 (37.3%) in the post-test. However, difference was not significant between the availability of anti-malaria drugs in the facilities and the health workers’ adherence to the guidelines p-value 0.355 at the pretest and p-value 0.258 at post-test. The study concluded that the in-service training program significantly improved health workers’ knowledge and practice to the national malaria guidelines in the treatment, and prevention of malaria in pregnancy. The researcher recommends that the national malaria control programme (NMCP) of the Federal Ministry of Health should provide continuous regular in-service training to frontline healthcare workers at (facility and Community-based) to upgrade their skills and knowledge towards the malaria guidelines, disseminate job aids to the health facilities and undertake regular monitoring to ensure effective implementation of the national malaria treatment guidelines in the treatment and prevention of malaria in pregnancy in achieving desired proper case-management practices of malaria in pregnancy at all levels of health care service.

Problems faced by evidence-based medicine in evaluating lymphadenectomy for gastric cancer

Gastric cancer surgical management differs between Eastern Asia and Western countries. Extended lymphadenectomy (D2) is the standard of care in Japan and South Korea since decades, while the majority of United States patients receive at most a limited lymphadenectomy (D1). United States and Northern Europe are considered the scientific leaders in medicine and evidence-based procedures are the cornerstone of their clinical practice. However, surgeons in Eastern Asia are more experienced, as there are more new cases of gastric cancer in Japan (107898 in 2012) than in the entire European Union (81592), or in South Korea (31269) than in the entire United States (21155). For quite a long time evidence-based medicine (EBM) did not solve the question whether D2 improves long-term prognosis with respect to D1. Indeed, eastern surgeons were reluctant to perform D1 even in the frame of a clinical trial, as their patients had a very good prognosis after D2. Evidence-based surgical indications provided by Western trials were questioned, as surgical procedures could not be properly standardized. In the present study we analyzed indications about the optimal extension of lymphadenectomy in gastric cancer according to current scientific literature (2008-2012) and surgical guidelines. We searched PubMed for papers using the key words “lymphadenectomy or D1 or D2” AND “gastric cancer” from 2008 to 2012. Moreover, we reviewed national guidelines for gastric cancer management. The support to D2 lymphadenectomy increased progressively from 2008 to 2012: since 2010 papers supporting D2 have achieved a higher overall impact factor than the other papers. Till 2011, D2 was the procedure of choice according to experts’ opinion, while three meta-analyses found no survival advantage after D2 with respect to D1. In 2012-2013, however, two meta-analyses reported that D2 improves prognosis with respect to D1. D2 lymphadenectomy was proposed as the standard of care for advanced gastric cancer by Japanese National Guidelines since 1981 and was adopted as the standard procedure by the Italian Research Group for Gastric Cancer since the Nineties. D2 is now indicated as the standard of surgical treatment with curative intent by the German, British and ESMO-ESSO-ESTRO guidelines. At variance American NCCN guidelines recommend a D1+ or a modified D2 lymph node dissection. In conclusion, D2 lymphadenectomy, originally developed by Eastern surgeons, is now becoming the procedure of choice also in the West. In gastric cancer surgery EBM is lagging behind national guidelines, rather than preceding and orienting them. To eliminate this lag, EBM should value to a larger extent Eastern Asian literature and should evaluate not only the quality of the study design but also the quality of surgical procedures.

The evolving landscape of biliary tract cancers:comparing French and US National Comprehensive Cancer Network guidelines

Biliary tract cancers(BTCs)constitute a heterogeneous group of hepatobiliary malignancies originating along the biliary tree.Approximately up to 20%of primary hepatobiliary tumors consist of BTCs(1).The primary risk factors include cholelithiasis,chronic inflammatory diseases of the bile ducts,non-alcoholic steatohepatitis(NASH),liver cirrhosis,tobacco use,and chronic viral hepatitis B and C infections(2).