The role of radiation therapy in the management of primary retroperitoneal sarcoma: A systematic review and clinical practice guidelines from the Australia and New Zealand Sarcoma Association.

While surgery is the mainstay of treatment for localised retroperitoneal sarcoma, the use of radiotherapy (RT) remains controversial. This systematic review aimed to evaluate the role of RT for retroperitoneal sarcoma. A systematic review using the population, intervention, comparison, and outcome model from 1990 to 2022 identified 66 studies (a mixture of preoperative and postoperative RT); one randomised controlled trial (RCT) with two publications, 18 registry studies, and 46 retrospective studies. In the RCT of preoperative RT, there was no difference in local/abdominal recurrence. The pooled analysis of this RCT and a retrospective study showed a significant abdominal recurrence free survival benefit with preoperative RT in low grade liposarcoma. The RCT and the majority of retrospective series found RT did not improve recurrence free survival (11 of 16 no difference in combined local and distant RFS, 11 of 13 no difference in distant metastasis free survival), disease specific survival (9 of 12 studies) or overall survival (33 of 49 studies). The majority of studies found no association between RT and perioperative morbidity. In summary, preoperative RT may improve local control for low grade (well-differentiated or grades 1-2 dedifferentiated) liposarcoma, but not other histological subtypes. There is no strong evidence that perioperative RT provides an overall survival benefit. Patients with low grade retroperitoneal liposarcoma can be considered for preoperative RT to improve abdominal recurrence free survival. The rationale and level of evidence in this scenario should be carefully discussed by the multidisciplinary team with patients. RT should not be routinely recommended for other histological subtypes.

Surgery at specialised sarcoma centres improves patient outcomes - A systematic review by the Australia and New Zealand sarcoma association clinical practice guidelines working party.

BACKGROUND: Optimal management of sarcoma requires multidisciplinary team input throughout the process of diagnosis, treatment and follow up. This systematic review aimed to evaluate the impact of surgery performed at specialised sarcoma centres on outcomes. METHODS: A systematic review was conducted using the population, intervention, comparison and outcome (PICO) model. Medline, Embase, Cochrane Central databases were queried for publications that evaluated the local control, limb salvage rate, 30-day and 90-day surgical mortality, and overall survival in patients undergoing surgery in a specialist sarcoma centre compared with non-specialist centre. Each study was screened by two independent reviewers for suitability. A qualitative synthesis of the results was performed. RESULTS: Sixty-six studies were identified. The majority of studies were Level III-3 as assessed by the NHMRC Evidence Hierarchy, whilst just over half of the studies were of good quality. Definitive surgery performed at specialised sarcoma centres was associated with improved local control as defined by lower rate of local relapse, higher rate of negative surgical margins, improved local recurrence free survival and higher limb conservation rate. Available evidences show a favourable pattern of lower 30-day and 90-day mortality rates, and greater overall survival when surgery was performed in specialist sarcoma centres compared with non-specialised centres. CONCLUSIONS: Evidences support better oncological outcomes when surgery is performed at specialised sarcoma centre. Patients with suspected sarcoma should be referred early to a specialised sarcoma centre for multidisciplinary management, which includes planned biopsy and definitive surgery.

The benefit for radiotherapy at specialised sarcoma centres: A systematic review and clinical practice guidelines from the Australia and New Zealand Sarcoma Association.

Patients with sarcoma are best managed at specialised sarcoma centres as supported by published literature. Optimal management requires multidisciplinary team input to formulate the diagnosis and treatment sequencing taking into consideration multiple clinical and pathologic factors. This systematic review aimed to evaluate the impact on outcomes of radiotherapy at specialised sarcoma centres. A systematic review was conducted using the population, intervention, comparison and outcome model. A literature search was performed using Medline, Embase, Cochrane Central databases for publications from 1990 to February 2022 that evaluated the local control, survival and toxicity of radiotherapy at specialised sarcoma centres. A total of 21 studies were included (17 cancer registry studies, four retrospective comparative studies). Four studies reported the local recurrence endpoint when radiotherapy was part of limb conservation treatment and showed better conformity to clinical practice guidelines and an improved local recurrence free rate when radiotherapy treatment is supported through, but may not be necessarily delivered at a specialised sarcoma centres. Only one retrospective study analysed toxicity specifically and demonstrated that patients who received preoperative radiotherapy at community centres compared to radiotherapy at a specialised sarcoma centre were more likely to develop a major wound complication. Fourteen studies reported overall survival, and 12 of these showed significantly better 5-year overall survival for patients managed at specialised sarcoma centres, however the specific impact of radiotherapy delivered at sarcoma centres could not be determined. In conclusion, patients with sarcoma should be managed through specialised sarcoma centres for better oncological outcomes. Radiotherapy in specialised sarcoma centre is associated with a lower rate of wound complications and may contribute to improved oncological outcomes as part of the limb conservation treatment at a specialised sarcoma centre.

Guided medication dosing for elderly emergency patients using real-time, computerized decision support.

OBJECTIVE: To evaluate the impact of a real-time computerized decision support tool in the emergency department that guides medication dosing for the elderly on physician ordering behavior and on adverse drug events (ADEs). DESIGN: A prospective controlled trial was conducted over 26 weeks. The status of the decision support tool alternated OFF (7/17/06-8/29/06), ON (8/29/06-10/10/06), OFF (10/10/06-11/28/06), and ON (11/28/06-1/16/07) in consecutive blocks during the study period. In patients ≥65 who were ordered certain benzodiazepines, opiates, non-steroidals, or sedative-hypnotics, the computer application either adjusted the dosing or suggested a different medication. Physicians could accept or reject recommendations. MEASUREMENTS: The primary outcome compared medication ordering consistent with recommendations during ON versus OFF periods. Secondary outcomes included the admission rate, emergency department length of stay for discharged patients, 10-fold dosing orders, use of a second drug to reverse the original medication, and rate of ADEs using previously validated explicit chart review. RESULTS: 2398 orders were placed for 1407 patients over 1548 visits. The majority (49/53; 92.5%) of recommendations for alternate medications were declined. More orders were consistent with dosing recommendations during ON (403/1283; 31.4%) than OFF (256/1115; 23%) periods (p≤0.0001). 673 (43%) visits were reviewed for ADEs. The rate of ADEs was lower during ON (8/237; 3.4%) compared with OFF (31/436; 7.1%) periods (p=0.02). The remaining secondary outcomes showed no difference. LIMITATIONS: Single institution study, retrospective chart review for ADEs. CONCLUSION: Though overall agreement with recommendations was low, real-time computerized decision support resulted in greater acceptance of medication recommendations. Fewer ADEs were observed when computerized decision support was active.

Treatment effects of gabapentin for primary insomnia.

OBJECTIVES: The prevalence of insomnia is very high in our society. Although pharmacological treatment of insomnia is available, most hypnotics have been shown to alter sleep architecture and have many adverse effects. Gabapentin was originally designed for antiepileptic therapy; however, some studies reported that its use increases slow-wave sleep in healthy volunteers or patients. Our goal was to evaluate the benefits of gabapentin in the treatment of primary insomnia in patients. METHODS: Eighteen patients with primary insomnia participated in the study. They received gabapentin treatment for at least 4 weeks. All patients received polysomnography, a biochemical blood test, and neuropsychological tests before and after the treatment period. All measures were analyzed with Student t test to examine the treatment effects of gabapentin, except that the measures of heart rate variability were analyzed with analysis of variance. RESULTS: Polysomnographic study revealed increased sleep efficiency and slow-wave sleep, decreased wake after sleep onset, and spontaneous arousal index after gabapentin treatment. The biochemical blood test revealed decreased prolactin levels in the morning after treatment. Electroencephalographic power spectral analysis showed increased delta-2 and theta power in sleep stage 1 and decreased sigma activity power in sleep stages N2 and N3 after gabapentin treatment. Heart rate variability analyses also showed a significant increase in normalized high frequency percentage in sleep stages N2 and N3 and low frequency-high frequency ratio in sleep stage N2 after treatment. In addition, neuropsychological tests revealed the elevation of visual motor processing speed after gabapentin treatment. CONCLUSIONS: Gabapentin enhances slow-wave sleep in patients with primary insomnia. It also improves sleep quality by elevating sleep efficiency and decreasing spontaneous arousal. The results suggest that gabapentin may be beneficial in the treatment of primary insomnia.

Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care.

OBJECTIVE: Interruptive alerts within electronic applications can cause "alert fatigue" if they fire too frequently or are clinically reasonable only some of the time. We assessed the impact of non-interruptive, real-time medication laboratory alerts on provider lab test ordering. DESIGN: We enrolled 22 outpatient practices into a prospective, randomized, controlled trial. Clinics either used the existing system or received on-screen recommendations for baseline laboratory tests when prescribing new medications. Since the warnings were non-interruptive, providers did not have to act upon or acknowledge the notification to complete a medication request. MEASUREMENTS: Data were collected each time providers performed suggested laboratory testing within 14 days of a new prescription order. Findings were adjusted for patient and provider characteristics as well as patient clustering within clinics. RESULTS: Among 12 clinics with 191 providers in the control group and 10 clinics with 175 providers in the intervention group, there were 3673 total events where baseline lab tests would have been advised: 1988 events in the control group and 1685 in the intervention group. In the control group, baseline labs were requested for 771 (39%) of the medications. In the intervention group, baseline labs were ordered by clinicians in 689 (41%) of the cases. Overall, no significant association existed between the intervention and the rate of ordering appropriate baseline laboratory tests. CONCLUSION: We found that non-interruptive medication laboratory monitoring alerts were not effective in improving receipt of recommended baseline laboratory test monitoring for medications. Further work is necessary to optimize compliance with non-critical recommendations.

Electronic health records in specialty care: a time-motion study.

BACKGROUND: Electronic health records (EHRs) have great potential to improve safety, quality, and efficiency in medicine. However, adoption has been slow, and a key concern has been that clinicians will require more time to complete their work using EHRs. Most previous studies addressing this issue have been done in primary care. OBJECTIVE: To assess the impact of using an EHR on specialists' time. DESIGN Prospective, before-after trial of the impact of an EHR on attending physician time in four specialty clinics at an integrated delivery system: cardiology, dermatology, endocrine, and pain. MEASUREMENTS: We used a time-motion method to measure physician time spent in one of 85 designated activities. RESULTS: Attending physicians were monitored before and after the switch from paper records to a web-based ambulatory EHR. Across all specialties, 15 physicians were observed treating 157 patients while still using paper-based records, and 15 physicians were observed treating 146 patients after adoption. Following EHR implementation, the average adjusted total time spent per patient across all specialties increased slightly but not significantly (Delta = 0.94 min., p = 0.83) from 28.8 (SE = 3.6) to 29.8 (SE = 3.6) min. CONCLUSION: These data suggest that implementation of an EHR had little effect on overall visit time in specialty clinics.

Correlates of electronic health record adoption in office practices: a statewide survey.

OBJECTIVE: Despite emerging evidence that electronic health records (EHRs) can improve the efficiency and quality of medical care, most physicians in office practice in the United States do not currently use an EHR. We sought to measure the correlates of EHR adoption. DESIGN: Mailed survey to a stratified random sample of all medical practices in Massachusetts in 2005, with one physician per practice randomly selected for survey. MEASUREMENTS: EHR adoption rates. RESULTS: The response rate was 71% (1345/1884). Overall, while 45% of physicians were using an EHR, EHRs were present in only 23% of practices. In multivariate analysis, practice size was strongly correlated with EHR adoption; 52% of practices with 7 or more physicians had an EHR, as compared with 14% of solo practices (adjusted odds ratio, 3.66; 95% confidence interval, 2.28-5.87). Hospital-based practices (adjusted odds ratio, 2.44; 95% confidence interval, 1.53-3.91) and practices that teach medical students or residents (adjusted odds ratio, 2.30; 95% confidence interval, 1.60-3.31) were more likely to have an EHR. The most frequently cited barriers to adoption were start-up financial costs (84%), ongoing financial costs (82%), and loss of productivity (81%). CONCLUSIONS: While almost half of physicians in Massachusetts are using an EHR, fewer than one in four practices in Massachusetts have adopted EHRs. Adoption rates are lower in smaller practices, those not affiliated with hospitals, and those that do not teach medical students or residents. Interventions to expand EHR use must address both financial and non-financial barriers, especially among smaller practices.

Non-interruptive drug-lab alerts in ambulatory care.

To monitor potential adverse drug events, we devised a non-interruptive alert within our electronic medical record that prompted outpatient providers to order labs along with new prescriptions. When comparing control to intervention occurrences, we found the intervention had a non-significant impact on lab prescribing. The results of our prospective, randomized, controlled trial suggest that non-interruptive alerts are ineffective.

Comparison of outcomes after laparoscopic adjustable gastric banding in African-Americans and whites.

BACKGROUND: Race may affect outcomes after bariatric surgery. This study compares outcomes in terms of weight loss and comorbidity resolution between African-Americans and whites after laparoscopic adjustable gastric banding (LAGB). METHODS: Data from 959 patients undergoing LAGB between July 2001 and July 2004 were prospectively collected and entered into an electronic registry. Propensity score matching analysis was used to match whites to African-Americans on the basis of age, gender, and preoperative body mass index (BMI). Preoperative comorbidities (diabetes, hypertension, obstructive sleep apnea, hypercholesterolemia, and hypertriglyceridemia) were also compared. Operative time (OR), length of stay (LOS), comorbidity resolution, and percent excess weight loss (%EWL) at 1, 2, and 3 years were analyzed. All data were updated through May 2006. RESULTS: A total of 65 white LAGB patients were matched to 58 African-American LAGB patients on the basis of age, gender, and preoperative BMI. The preoperative mean age and BMI were 37 +/- 19 years and 47 +/- 7 kg/m2, respectively. A total of 55% of the white group and 64% of the African-American group had one or more comorbidities (P = NS). Median OR time and LOS were similar in both groups: 50 minutes and 23 hours, respectively. The majority of patients in both groups had major improvement or resolution of one or more comorbidities (61% whites vs 77% African-Americans, P = NS). There was, however, a significant difference in %EWL between whites and African-Americans at each time interval (49% vs 39% at 1 year; 55% vs 44% at 2 years; 52% vs 41% at 3 years; P < .05 for all values.). CONCLUSION: Despite the disparity in weight loss with the LAGB in African-Americans and whites, both patient populations experienced a similar improvement/resolution of obesity-related comorbidities.

Concepts for building inter-organizational systems in healthcare: lessons from other industries.

A centerpiece of the nation's healthcare information technology vision is the implementation of health information exchanges (HIEs). HIEs have the significant potential to improve the quality of patient care, reduce care costs, and enhance patient safety. These kinds of exchanges are new to healthcare in the United States. While more than 200 communities are in various stages of implementing them, there is little mature experience with the factors that contribute to the successful formation and sustainability of these exchanges. The creation and management of mechanisms to support the exchange of data between organizations has been used in other industries. There are many examples of interorganizational systems that have been established in industries as diverse as banking, manufacturing, government, and retail. This paper examines some of these experiences and attempts to glean the concepts and guidance healthcare can learn from other industries.

Stump appendicitis: a comprehensive review of literature.

Appendectomy for appendicitis is one of the most common procedures performed in the United States. Residual tissue left after an initial appendectomy risks the development of stump appendicitis. A comprehensive review of the English-language literature revealed 36 reported cases of stump appendicitis. Typically, patients present with signs and symptoms similar to acute appendicitis; however, due to prior surgery, the diagnosis is difficult and the rate of appendiceal stump perforation is extremely high. Herein, we present a case of a 32-year-old female presenting with right lower quadrant pain, nausea, and fever 5 months after laparoscopic appendectomy. Upon surgery, an appendiceal stump was discovered.

Modified herpes simplex virus delivery of enhanced GFP into the central nervous system.

Controlled expression of proteins is a key experimental approach to a deeper understanding of the molecular basis of neuronal function. Here we evaluate the HSV-1 (herpes simplex virus) amplicon vector for gene delivery into the brains of living rats. We demonstrate that HSV-1 amplicon vectors expressing enhanced green fluorescent protein (EGFP) can reliably infect neurons after it is injected into cortex, striatum and thalamus in rats, producing sufficient numbers of infected neurons for electrophysiological experiments in acute brain slices. Expression of EGFP delivered by the HSV-1 amplicon was detected for up to 5 weeks post-infection. We detected no changes in the morphology or the electrophysiological properties of thalamic, striatal or cortical neurons within a period of at least 2 weeks after HSV-1 amplicon injection. We conclude that the HSV-1 amplicon is a valuable tool for gene delivery in the rat central nervous system.