"What if I do nothing?" The natural history of operable cancer of the alimentary tract.

INTRODUCTION: "Natural history", or anticipated survival without treatment, is critical for patients weighing risks and benefits of cancer surgery. Current estimates concerning the natural history of cancer includes patients whose poor health precludes treatment; a cohort whose fate is likely distinctly worse than those eligible for surgery ("operable"). The study objective was to evaluate survival among patients recommended for cancer surgery but went untreated, to determine the natural history of "operable" alimentary tract cancer. METHODS: The NCDB was queried for untreated patients with clinical stage I-III esophageal, gastric, colon, and rectal cancer diagnosed between 2003 and 2009. Untreated patients who were recommended for surgery were considered "operable," while patients coded as surgically ineligible for health reasons were "inoperable." RESULTS: 5-year survival of untreated, "operable" alimentary tract cancers varied by clinical stage: esophageal cI = 10.0%, cII = 9.8%, cIII = 4.6%; gastric cI = 9.2%, cII = 5.8%, cIII = 4.3%; colon cI = 18.4%, cII = 5.0%, cIII = 10.4; and rectal cI = 17.1%, cII = 14.0%, cIII = 19.9%. At every timepoint, stage-specific survival of "operable" patients was superior to inoperable patients (p < 0.05). Additionally, median survival among "operable" patients at least doubled "inoperable" patients for each tumor. CONCLUSION: Natural history of patients with "operable" alimentary tract cancer is superior to that of "inoperable" patients. Preoperative counseling should be refined to reflect this distinction.

Effects of a multifaceted psychiatric intervention targeted for the complex medically ill: a randomized controlled trial.

BACKGROUND: This study evaluated a multifaceted psychiatric intervention targeted at the complex medically ill identified by means of the INTERMED, an instrument to assess case complexity. METHODS: Of 885 rheumatology inpatients and diabetes outpatients who were assessed for eligibility, 247 were identified as complex (INTERMED score >20) and randomized to the intervention (n = 125, 84 rheumatology and 41 diabetes patients) or care as usual (n = 122, 78 rheumatology and 44 diabetes patients). For the majority of the cases the multifaceted intervention consisted of an intervention conducted by a psychiatric liaison nurse and/or of referral to a liaison psychiatrist, followed by advice to the treating physician or organization of a multidisciplinary case conference. Baseline and follow-up at months 3, 6, 9 and 12 measured prevalence of major depression (Mini-International Neuropsychiatric Interview), depressive symptoms (Center for Epidemiological Studies Depression Rating Scale), physical and mental health (SF-36), quality of life (EuroQol), health care utilization and HbA(1c) levels (diabetic patients). RESULTS: Prevalence of major depression was reduced from 61% (T0) to 28% (T4) in the intervention group and remained stable in care as usual (57% at T0 to 50% at T4). Compared to care as usual, significant improvement over time was observed in the intervention group with regard to depressive symptoms (F = 11.9; p = 0.001), perception of physical (F = 5.7; p = 0.018) and mental health (F = 3.9; p = 0.047) and quality of life (F = 21.8; p < 0.001). Effects tended to be stronger in diabetes patients, in patients with baseline major depression and in patients with moderate INTERMED scores. Finally, hospital admissions occurred less often in the intervention group, reaching statistical significance for the period between 6 and 9 months of follow-up (p = 0.02). CONCLUSIONS: The results suggest that a psychiatric intervention targeted for complex medical patients can improve health outcomes.

Effect of prosthetic material on adhesion formation after laparoscopic ventral hernia repair in a porcine model.

Intraperitoneal placement of prosthetic mesh causes adhesion formation after laparoscopic incisional hernia repair. A prosthesis that prevents or reduces adhesion formation is desirable. In this study, 21 pigs were randomized to receive laparoscopic placement of plain polypropylene mesh (PPM), expanded polytetrafluoroethylene (ePTFE), or polypropylene coated on one side with a bioresorbable adhesion barrier (PPM/HA/CMC). The animals were sacrificed after 28 days and evaluated for adhesion formation. Mean area of adhesion formation was 14% (SD+/-15) in the PPM/HA/CMC group, 40% (SD+/-17) in the PPM group, and 41% (SD+/-39) in the ePTFE group. The difference between PPM/HA/CMC and PPM was significant ( P=0.013). A new visceral layer of mesothelium was present in seven out of seven PPM/HA/CMC cases, six out of seven PPM cases, and two out of seven ePTFE cases. Thus, laparoscopic placement of PPM/HA/CMC reduces adhesion formation compared to other mesh types used for laparoscopic ventral hernia repairs.