Abstract Background Biliary tract cancers (BTCs) include intrahepatic (IHC), hilar, distal bile duct (DBD) and gallbladder carcinoma (GBC). Neutrophil/lymphocyte ratio (NLR), a marker of host ...inflammation, is prognostic in several cancers but has not been reviewed in large BTC series, or advanced BTC (ABTC) at diagnosis. Patients and methods Baseline demographics and NLR at diagnosis were retrospectively evaluated in 864 consecutive patients with BTC treated from January 1987 to December 2012. The association between NLR and overall survival (OS) was determined using a multivariable Cox proportional hazards model. Results Eight hundred and sixty-four patients were included in the analysis, of which 62% had ABTC and 38% had surgery with curative intent. Median age was 65 years, 444 (51%) were male and 727 (84%) had performance status (PS) ⩽2. A NLR ⩾3.0, PS >2, IHC primary, stage, lack of surgery, haemoglobin <110 g/L and albumin <40 g/L were associated with significantly worse OS on multivariable analysis. A NLR ⩾3.0 was an independent prognostic factor for OS for the entire cohort; median OS was 21.6 months versus 12.0 months for patients with NLR <3.0 versus NLR ⩾3.0 respectively (adjusted hazard ratio (HR)-1.26, 95% confidence interval (CI); 1.06–1.50, P = 0.01). NLR was also prognostic in patients with ABTC (HR-1.26, 95% CI; 1.02–1.56, P = 0.035) and hilar cancer: overall group ( N = 149) (HR-1.70, 95% CI; 1.10–2.50, P = 0.01) and advanced group ( N = 111) (HR-1.57, 95% CI; 1.04–2.44, P = 0.048). Conclusion Baseline NLR is a readily available and inexpensive prognostic biomarker in patients with BTC and likely warrants validation in large prospective clinical trials.
There are high rates of recurrence after definitive surgery in biliary tract cancer patients. We reviewed the use and effectiveness of adjuvant therapy (AT; chemotherapy±radiotherapy) in a single ...institution series.
Characteristics, treatment details, and follow-up data of all patients with biliary tract cancer who had definitive surgery from January 1987 to September 2011 were reviewed. The association between baseline variables and disease-free survival/overall survival (OS) were tested using Cox proportional hazard analysis in the univariable and multivariable settings.
Analysis included 296 patients (58% male; median age, 63 y). Negative or microscopically positive resections were reported in 42% and 14%, respectively, with 44% not reported. Node positivity was reported in 35% patients. AT was given in 28% of patients with 59% receiving chemotherapy and 35% concurrent chemotherapy/radiotherapy. Disease recurred in 60% patients. AT was associated with significantly improved OS (hazard ratio, 0.41; P=0.02). Compared with R0 resection, patients with R1 resection derived significantly increased benefit from AT (P for difference 0.02). In the node positive population (n=103), AT was associated with significantly improved OS (hazard ratio, 0.60; 95% confidence interval, 0.38-0.95; P=0.03).
Patients with R1 resection and node positive disease receiving AT after definitive surgery seem to derive OS advantage. Large prospective trials are needed to confirm these data.
Although biliary tract cancers (BTC) are common in older age-groups, treatment approaches and outcomes are understudied in this population.
Data from 913 patients diagnosed with BTC from January 1987 ...to July 2013 and treated at Princess Margaret Cancer Center, Toronto were analyzed. The differences in treatment patterns between older and younger patients were explored and the impact of age, patient and disease characteristics on survival outcomes was assessed.
Three hundred and twenty one patients ≥ 70 years were identified. Older patients were more likely to receive best supportive care, 40% (n = 130), compared to younger patients 26% (n = 154); p < 0.0001. On multivariable analysis, factors associated with receipt of surgery included stage I/II disease (p < 0.0001) and ECOG PS < 2 (p < 0.0001). Older age was not associated with lack of surgical intervention. In comparison, older age was associated with non-receipt of palliative chemotherapy (p = 0.0007). Similar survival benefit from treatment was seen in older and younger patients. Of 626 patients that underwent either surgery or palliative chemotherapy (n = 188), the median survival was 21.1 months (95% CI 19.0-27.9) in patients >70 years of age, and 21.1 months in younger patients (n = 438) (95% CI 19.5-24.5).
In this large retrospective analysis, older patients with BTC are less likely to undergo an intervention. However, active therapy when given is associated with similar survival benefits, irrespective of age.
To implement a pharmacokinetics curriculum that used small-team active learning and assess students’ perceptions.
The course design and delivery were based on delivery of Student Team lecture ...followed by concept reinforcement through problem-based learning sessions. Course faculty members facilitated classroom and problem-based learning discussions to promote an active-learning environment.
An anonymous survey instrument was administered to students prior to and following completion of the pharmacokinetics course. Students reported a significant decrease in anxiety from 67% to 44% related to working in small teams upon completion of the course. However, students maintained negative perceptions related to peer teaching, with 80% of students reporting anxiety related to receipt of course information from peers. The course had a positive impact on students’ ability to apply concepts to case-based scenarios, but little impact on their perceived ability to identify and critically evaluate new material and present that material to their peer team.
The team-based structure defined herein for delivery of a pharmacokinetics curriculum offers students a tangible method to increase their comfort and confidence in the application of pharmacokinetic concepts in therapy.
Drug Information: From Education to Practice Bernknopf, Allison C.; Karpinski, Julie P.; McKeever, Andrea L. ...
Pharmacotherapy,
March 2009, Letnik:
29, Številka:
3
Journal Article
Recenzirano
Drug information is a specialty area within the realm of clinical pharmacy that has evolved as technology and clinical practice have changed. Drug information specialists are trained individuals who ...have clinical knowledge and skills that allow them to provide clear, concise, and accurate recommendations regarding drug use. The constant changing culture of drug information and health care in general has prompted the need for continual growth and refinement of the standards that govern drug information practice. This article outlines specific standards to help ensure that the education and practice of drug information will continue to meet the needs of the health care community. This opinion paper is divided into two sections: Education and Training, and Practice Areas. The Education and Training section is organized to describe the role of drug information and that of the drug information specialist in the training of all pharmacy students and advanced trainees, as well as to describe the role of focused training for those individuals wishing to specialize in drug information. This article also affirms the recommendations for the standards‐based approach to drug information education and specialty training. The Practice Areas section is organized to describe the role of the drug information specialist within various practice settings, to identify some of the challenges faced by the drug information specialist within those settings, and to provide recommendations for the different practice areas. The areas found within this section include academia, institutional health systems, managed care, industry, medical writing, and informatics.
Introduction to Pulmonary Medicine Tackett, Kimberly L.; McKeever, Andrea L.
Journal of pharmacy practice,
02/2013, Letnik:
26, Številka:
1
Journal Article
This multicenter study sought to evaluate the shortterm efficacy and safety of prolonged, low dose, direct urokinase infusion in recanalization of chronically occluded saphenous vein bypass grafts in ...a large sample of patients, as well as to determine the 6-month patency rates for this procedure.
Patients with chronically occluded aortocoronary vein grafts and uncontrolled angina pectoris have limited options for therapy. Previous work has shown that chronically occluded vein grafts can be recanalized by thrombolysis.
A coaxial infusion of urokinase (100,000 U/h) was given directly into occluded vein grafts in 107 patients. Balloon angioplasty was performed after lysis was achieved. Patients were discharged with warfarin and aspirin therapy. Six-month clinical follow-up data were obtained, and repeat angiography was encouraged.
Initial patency was achieved in 74 patients (69%). Mean duration of infusion was 25.4 h, and mean urokinase dosage was 3.70 million U. Acute adverse events included acute myocardial infarction in 5 patients (5%), enzyme level elevation in 18 (17%), emergency coronary artery bypass graft surgery in 4 (4%), stroke in 3 (3%) and death in 7 (6.5%). Recanalization was unsuccessful in all seven patients who died. Six-month follow-up angiograms were obtained for 40 patients (54%), 16 of whom maintained a patent graft (40%). Angina was present in 13 patients with successful (22%) and 12 with unsuccessful (71%) recanalization at 6-month follow-up.
Chronically occluded aortocoronary vein grafts can be recanalized in ∼70% of appropriately selected patients. Complications are similar to those observed with repeat operations. Clinical follow-up shows an improvement in angina. This procedure is intended for patients with only one occluded vein graft. Strict adherence to the protocol will improve patency and reduce complications.
Chronic occlusion of saphenous vein aortocoronary bypass grafts is a common problem. Although percutaneous transluminal angioplasty of a saphenous vein with a stenotic lesion is feasible, angioplasty ...alone of a totally occluded vein graft yields uniformly poor results. Patients with such occlusion are often subjected to repeat aortocoronary bypass surgery. Experience with a new technique that allows angioplasty to be performed in a totally occluded saphenous vein bypass graft is reported. This technique utilizes infusion of prolonged low dose urokinase directly into the proximal portion of the occluded graft.
Forty-six consecutive patients with 47 totally occluded grafts were studied. Patients had undergone end to side saphenous vein bypass grafting 1 to 13 (mean 7) years previously. All patients presented with new or worsening angina pectoris with ST-T changes or non-Q wave acute myocardial infarction and all had a totally occluded saphenous vein bypass graft. The new technique entailed the positioning of an angiographic catheter into the stub of the occluded graft and the advancement of an infusion wire into the graft. Patients were returned to the coronary care unit, where urokinase was delivered at a dose of 100,000 to 250,000 U/h. The total dose of urokinase ranged from 0.7 to 9.8 million U over 7.5 to 77 h (mean 31). After therapy, recanalization was seen in 37 (79%) of the 47 grafts.
In 20 successfully treated patients, angiography was performed 1 to 24 (mean 11) months after treatment; 13 (65%) of these grafts were patent. It is concluded that direct, extended, low dose infusion of urokinase in a totally occluded saphenous vein bypass graft offers a promising alternative to repeat bypass surgery.
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