Patients' satisfaction after a comprehensive assessment for complex chronic facial pain at a specialised unit: results from a prospective audit.

OBJECTIVE: The aim of this audit was to investigate complex chronic facial pain patients' satisfaction after an initial, comprehensive, 45-60 minute consultation visit. DESIGN: Prospective audit using a post-visit satisfaction survey. SETTING: Specialised outpatient facial pain unit. METHODS: A convenience sample of 50 consecutive new patients were recruited. History, pain and psychosocial functioning were assessed through standard, validated pre-visit questionnaires. A post-visit satisfaction questionnaire was sent (twice if necessary) to patients by mail, and non-responders were contacted by telephone. MAIN OUTCOME MEASURES: Patients' satisfaction scores on pain management processes were evaluated. RESULTS: Response rate for the questionnaire was 63% (32/50) and 12 additional patients who did not respond to the questionnaire replied by telephone. Among questionnaire respondents, mean overall patient satisfaction was 8.1 ± 2.2 on an 11-point scale (best score 10), with no differences based on age, gender, diagnosis, length of symptoms and treatment. There was a trend of higher overall satisfaction among patients referred by dentists and specialists. Patients who had seen at least one specialist before their visit reported higher scores in understanding the reasons for their condition and what to do to treat their condition. CONCLUSIONS: A consultation with adequate time for history taking, addressing patients' goals and thorough explanation accompanied by written information, results in high satisfaction among patients with chronic facial pain.

Radiation-induced intestinal injury.

Radiation therapy is administered to approximately one third of patients with cancer as part of their treatment plan. Radiation-induced bowel injury is a major cause of morbidity in these patients. The pathophysiology of this condition as well as recommendations for the management of acute and chronic radiation enteritis are discussed. In general, except for patients presenting with signs of an acute abdomen, conservative management yields the best clinical results.

Intraoperative liver radiation after partial hepatectomy in a rat model.

Hepatic resection of metastatic tumor is a treatment option in selected patients. Resection margin is a prognostic factor of hepatic recurrence and survival. Although intraoperative radiation therapy (IORT) has been clinically useful in some gastrointestinal cancers, there is little information regarding its use following hepatic metastasectomy. In this study, a rat model was employed to evaluate histological changes and DNA synthesis as an indication of hepatic regenerative capacity following hepatectomy and liver IORT. All rats (N = 40) had a partial hepatectomy and were divided into four random groups: a nonradiated group and three groups of 1000, 2000, and 3000 cGy given by IORT. The only deaths occurred in the 3000 cGy group. Routine H and E staining of liver sections after 3, 6, and 10 days suggested progressive hepatocyte damage notably in the 3000 cGy group. Comparison of the final average liver weights at 10 days confirmed a diminished liver mass in the 2000 and 3000 cGy animals. DNA synthesis in hepatocytes measured by [3H]-thymidine label incorporation 3, 6, and 10 days after hepatectomy and IORT indicated a comparative and overall decrease in Day 6 peak activity between the three IORT groups. This study demonstrated delayed but substantial hepatic regeneration in the post-resected liver within the clinically useful IORT dose range (1000-2000 cGy) needed to control minimal residual tumor. This model has importance concerning the feasibility of IORT to the hepatic resection bed for patients where resection margins are inadequate.

Gastric cancer--surgical approach.

Although the incidence of carcinoma of the stomach has steadily declined over the last 50 years, approximately 23,000 new cases will be diagnosed in the United States this year and 13,700 patients will die. Despite marked improvement in operative techniques, fewer than 20 per cent of those diagnosed with gastric cancer beyond the most superficial levels of invasion will survive for over five years. Gastric tumours spread by local, lymphatic, and aggressive intra-peritoneal routes as well as hematogenous dissemination. Over 87 per cent of recurrences have local or regional components. Radiation therapy may decrease local and regional recurrences in those patients with transmural tumours. The neoadjuvant use of etoposide, adriamycin, and platinum may yield complete clinical and pathologic responses in patients found to have 'unresectable' tumours. Other chemotherapy regimens have been shown to have some effect on advanced disease and may have a role in the neoadjuvant setting. Our current recommendations for the treatment of gastric cancer in a controlled trial setting would be neoadjuvant chemotherapy followed by R2 resection, postoperative +/- intraoperative radiation therapy with the possibility of postoperative chemotherapy. Hopefully, this aggressive multimodality approach will significantly improve the five year survival for this disease.

Increased resectability of locally advanced pancreatic and periampullary carcinoma with neoadjuvant chemoradiotherapy.

A prospective neoadjuvant trial utilizing chemotherapy (CTX) and radiotherapy (XRT) prior to pancreatectomy was established to determine the feasibility of resection after aggressive pretreatment and its effect on survival. Fifteen patients with pancreatic cancer (14 head, 1 body) and 1 patient with duodenal cancer, (with paraaortic adenopathy), were subjected to combination treatment with infusional 5-FU, bolus injection of mitomycin-C, and XRT (4 patients were treated off the protocol). Patients were restaged 3 wk after XRT, and those deemed resectable underwent a pancreatic resection. Three patients did not undergo exploration after the neoadjuvant therapy, although two of these were deemed resectable by CT scan. The remaining 13 patients underwent exploration and 10 underwent resection. Three did not undergo resection because of extrapancreatic disease, although their primary tumors were resectable. One patient had no residual tumor in the specimen. The others had residual tumor with evidence of necrosis and hyalinization, but all margins were free of tumor. There were two perioperative deaths from sepsis. Of the remaining patients who underwent resection, one died of a myocardial infarction at 9 mo. One patient died with recurrent disease at 19 mo. The remaining patients are alive 40, 32, 11, 11, 10, and 4 mo since diagnosis and are currently free of disease. Aggressive neoadjuvant chemoradiotherapy can be performed safely, allows successful resection, and may yield long-term survival or curve.

Asherman's syndrome. A comparison of therapeutic methods.

The authors compared two methods of managing Asherman's syndrome. One group (nine patients) was treated with dilatation and curettage (D & C), followed by conjugated estrogens and progestin therapy. A second group (26 patients) was treated with hysteroscopic evaluation of therapy, followed by placement of an intrauterine contraceptive device (IUD) and antibiotics in addition to a D & C and hormonal therapy. Although the series was small, the pregnancy rate was higher in the second group. This is felt to be related to the hysteroscopic localization of synechiae as well as the postoperative insertion of an IUD.