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Portfolio to go : 1000+ reflective writing prompts and provocations for clinical learners
\"Preparing a learning portfolio has become a mandatory part of the course work in most clinical professions. Students and educators alike sometimes complain that these mandatory assignments become repetitive and uninspired. However, we all need to be able to speak and write clearly as we work with our colleagues, students and those we care for. In Portfolio To Go, Allan D. Peterkin insists that reflective capacity, critical thinking, creative expression, and narrative competence are attributes that should be developed in every health professional - regardless of the discipline or specialty. Trainees will find over 1000 prompts organized under themes highly relevant to students and educators, including those not formally addressed in class, such as coping with uncertainty and ambiguity, team conflict, and resilience through good self-care. Practical tips for writing effectively and for discussing and evaluating narratives in a helpful, respective manner are provided throughout. Peterkin is a pioneer in emphasizing patient-centered, humanistic care and Portfolio To Go will help to train and develop more reflective practitioners.\"-- Provided by publisher.
Book
Comparison between MRI and pathology in the assessment of tumour regression grade in rectal cancer
Background:
Limited data exist regarding the correlation between MRI tumour regression grade (mrTRG) and pathological TRG (pTRG) in rectal cancer.
Methods:
mrTRG and pTRG were compared in rectal cancer patients from two phase II trials (EXPERT and EXPERT-C). The agreement between radiologist and pathologist was assessed with the weighted
κ
test while the Kaplan–Meier method was used to estimate survival outcomes.
Results:
One hundred ninety-one patients were included. Median time from completion of neoadjuvant treatment to pre-operative MRI and surgery was 4.1 weeks (interquartile range (IQR): 3.7–4.7) and 6.6 weeks (IQR: 5.9–7.6), respectively. Fair agreement was found between mrTRG and pTRG when regression was classified according to standard five-tier systems (
κ
=0.24) or modified three-tier systems (
κ
=0.25). Sensitivity and specificity of mrTRG 1–2 (complete/good radiological regression) for the prediction of pathological complete response was 74.4% (95% CI: 58.8–86.5) and 62.8% (95% CI: 54.5–70.6), respectively. Survival outcomes of patients with intermediate pathological regression (pTRG 2) were numerically better if complete/good regression was also observed on imaging (mrTRG 1–2) compared to poor regression (mrTRG 3–5) (5-year recurrence-free survival 76.9%
vs
65.9%,
P
=0.18; 5-year overall survival 80.6%
vs
68.8%,
P
=0.22).
Conclusions:
The agreement between mrTRG and pTRG is low and mrTRG cannot be used as a surrogate of pTRG. Further studies are warranted to assess the ability of mrTRG to identify pathological complete responders for the adoption of non-operative management strategies and to provide complementary prognostic information to pTRG for better risk-stratification after surgery.
Journal Article
Serum lactate dehydrogenase as an early marker for outcome in patients treated with anti-PD-1 therapy in metastatic melanoma
Background:
Treatment with programmed death receptor-1 (PD-1) antibodies is associated with high response rates in patients with advanced melanoma. Reliable markers for early response and outcome are still sparse.
Methods:
We evaluated 66 consecutive patients with advanced/metastatic melanoma treated with nivolumab or pembrolizumab between 2013 and 2014. The main objectives of this study were to investigate whether, first, serum lactate dehydrogenase (LDH) at baseline (normal
vs
above the upper limit of normal) correlates with overall survival (OS), and, second, whether the change of LDH during treatment predicts response before the first scan and OS in patients with an elevated baseline LDH.
Results:
After a median follow-up of 9 months, patients with an elevated baseline LDH (
N
=34) had a significantly shorter OS compared with patients with normal LDH (
N
=32; 6-month OS: 60.8%
vs
81.6% and 12-month OS: 44.2%
vs
71.5% (log-rank
P
=0.0292). In those 34 patients with elevated baseline LDH, the relative change during treatment was significantly associated with an objective response on the first scan: the 11 (32%) patients with partial remission had a mean reduction of −27.3% from elevated baseline LDH. In contrast, patients with progressive disease (
N
=15) had a mean increase of +39%. Patients with a relative increase over 10% from elevated baseline LDH had a significantly shorter OS compared with patients with ⩽10% change (4.3
vs
15.7 months, log-rank
P
<0.00623).
Conclusions:
LDH could be a useful marker at baseline and during treatment to predict early response or progression in patients with advanced melanoma who receive anti-PD-1 therapy.
Journal Article
Tumour-infiltrating inflammatory and immune cells in patients with extrahepatic cholangiocarcinoma
Background:Inflammation and immune characteristics of the tumour microenvironment have therapeutic significance. The aim of this study was to investigate the clinical impact on disease progression in human extrahepatic cholangiocarcinoma (ECC).Methods:A total of 114 consecutive ECC patients with curative resection between 2000 and 2014 were enrolled. Tumour infiltrating CD66b+ neutrophils (TANs; tumour associated neutrophils), CD163+ M2 macrophages (TAMs; tumour associated macrophages), CD8+ T cells, and FOXP3+ regulatory T cells (Tregs) were assayed by immunohistochemistry, and their relationships with patient clinicopathological characteristics and prognosis were evaluated.Results:Tumour associated neutrophils were inversely correlated with CD8+ T cells (P=0.0001) and positively correlated with Tregs (P=0.001). High TANs (P=0.01), low CD8+ T cells (P=0.02), and high Tregs (P=0.04) were significantly associated with poor overall survival (OS). A high-risk signature, derived from integration of intratumoural inflammatory and immune cells, was significantly associated with poor recurrence-free survival (P=0.01) and OS (P=0.0008). A high-risk signature was correlated with postoperative distant metastases. Furthermore, a high-risk signature was related to the resistance to gemcitabine-based chemotherapy used after recurrence.Conclusions:Our data showed that tumour infiltrating inflammatory and immune cells may play a pivotal role in ECC progression and a high-risk signature predicted poor prognosis in ECC patients.
Journal Article
Relationship between paediatric CT scans and subsequent risk of leukaemia and brain tumours: assessment of the impact of underlying conditions
Background:
We previously reported evidence of a dose–response relationship between ionising-radiation exposure from paediatric computed tomography (CT) scans and the risk of leukaemia and brain tumours in a large UK cohort. Underlying unreported conditions could have introduced bias into these findings.
Methods:
We collected and reviewed additional clinical information from radiology information systems (RIS) databases, underlying cause of death and pathology reports. We conducted sensitivity analyses excluding participants with cancer-predisposing conditions or previous unreported cancers and compared the dose–response analyses with our original results.
Results:
We obtained information from the RIS and death certificates for about 40% of the cohort (n∼180 000) and found cancer-predisposing conditions in 4 out of 74 leukaemia/myelodysplastic syndrome (MDS) cases and 13 out of 135 brain tumour cases. As these conditions were unrelated to CT exposure, exclusion of these participants did not alter the dose–response relationships. We found evidence of previous unreported cancers in 2 leukaemia/MDS cases, 7 brain tumour cases and 232 in non-cases. These previous cancers were related to increased number of CTs. Exclusion of these cancers reduced the excess relative risk per mGy by 15% from 0.036 to 0.033 for leukaemia/MDS (
P
-trend=0.02) and by 30% from 0.023 to 0.016 (
P
-trend<0.0001) for brain tumours. When we included pathology reports we had additional clinical information for 90% of the cases. Additional exclusions from these reports further reduced the risk estimates, but this sensitivity analysis may have underestimated risks as reports were only available for cases.
Conclusions:
Although there was evidence of some bias in our original risk estimates, re-analysis of the cohort with additional clinical data still showed an increased cancer risk after low-dose radiation exposure from CT scans in young patients.
Journal Article
Anlotinib as a third-line therapy in patients with refractory advanced non-small-cell lung cancer: a multicentre, randomised phase II trial (ALTER0302)
Background:Anlotinib (AL3818) is a novel multitarget tyrosine kinase inhibitor, inhibiting tumour angiogenesis and proliferative signalling. The objective of this study was to assess the safety and efficacy of third-line anlotinib for patients with refractory advanced non-small-cell lung cancer (RA-NSCLC).Methods:Eligible patients were randomised 1 : 1 to receive anlotinib (12 mg per day, per os; days 1-14; 21 days per cycle) or a placebo. The primary end point was progression-free survival (PFS).Results:A total of 117 eligible patients enrolled from 13 clinical centres in China were analysed in the full analysis set. No patients received immune check-point inhibitors and epidermal growth factor receptor status was unknown in 60.7% of the population. PFS was better with anlotinib compared with the placebo (4.8 vs 1.2 months; hazard ratio (HR)=0.32; 95% confidence interval (CI), 0.20-0.51; P<0.0001), as well as overall response rate (ORR) (10.0%; 95% CI, 2.4-17.6% vs 0%; 95% CI, 0-6.27%; P=0.028). The median overall survival (OS) was 9.3 months (95% CI, 6.8-15.1) for the anlotinib group and 6.3 months (95% CI, 4.3-10.5) for the placebo group (HR=0.78; 95% CI, 0.51-1.18; P=0.2316). Adverse events were more frequent in the anlotinib than the placebo group. The percentage of grade 3-4 treatment-related adverse events was 21.67% in the anlotinib group.Conclusions:Anlotinib as a third-line treatment provided significant PFS benefits to patients with RA-NSCLC when compared with the placebo, and the toxicity profiles showed good tolerance.
Journal Article
The impact of comprehensive geriatric assessment interventions on tolerance to chemotherapy in older people
Background:
Although comorbidities are identified in routine oncology practice, intervention plans for the coexisting needs of older people receiving chemotherapy are rarely made. This study evaluates the impact of geriatrician-delivered comprehensive geriatric assessment (CGA) interventions on chemotherapy toxicity and tolerance for older people with cancer.
Methods:
Comparative study of two cohorts of older patients (aged 70+ years) undergoing chemotherapy in a London Hospital. The observational control group (
N
=70, October 2010–July 2012) received standard oncology care. The intervention group (
N
=65, September 2011–February 2013) underwent risk stratification using a patient-completed screening questionnaire and high-risk patients received CGA. Impact of CGA interventions on chemotherapy tolerance outcomes and grade 3+ toxicity rate were evaluated. Outcomes were adjusted for age, comorbidity, metastatic disease and initial dose reductions.
Results:
Intervention participants undergoing CGA received mean of 6.2±2.6 (range 0–15) CGA intervention plans each. They were more likely to complete cancer treatment as planned (odds ratio (OR) 4.14 (95% CI: 1.50–11.42),
P
=0.006) and fewer required treatment modifications (OR 0.34 (95% CI: 0.16–0.73),
P
=0.006). Overall grade 3+ toxicity rate was 43.8% in the intervention group and 52.9% in the control (
P
=0.292).
Conclusions:
Geriatrician-led CGA interventions were associated with improved chemotherapy tolerance. Standard oncology care should shift towards modifying coexisting conditions to optimise chemotherapy outcomes for older people.
Journal Article
Basic study design influences the results of orthodontic clinical investigations
Meta-analysis is the gold standard for synthesizing evidence on the effectiveness of health care interventions. However, its validity is dependent on the quality of included studies. Here, we investigated whether basic study design (i.e., randomization and timing of data collection) in orthodontic research influences the results of clinical trials.
This meta-epidemiologic study used unrestricted electronic and manual searching for meta-analyses in orthodontics. Differences in standardized mean differences (ΔSMD) between interventions and their 95% confidence intervals (CIs) were calculated according to study design through random-effects meta-regression. Effects were then pooled with random-effects meta-analyses.
No difference was found between randomized and nonrandomized trials (25 meta-analyses; ΔSMD = 0.07; 95% CI = −0.21, 0.34; P = 0.630). However, retrospective nonrandomized trials reported inflated treatment effects compared with prospective (40 meta-analyses; ΔSMD = −0.30; 95% CI = −0.53, −0.06; P = 0.018). No difference was found between randomized trials with adequate and those with unclear/inadequate generation (25 meta-analyses; ΔSMD = 0.01; 95% CI = −0.25, 0.26; P = 0.957). Finally, subgroup analyses indicated that the results of randomized and nonrandomized trials differed significantly according to scope of the trial (effectiveness or adverse effects; P = 0.005).
Caution is warranted when interpreting systematic reviews investigating clinical orthodontic interventions when nonrandomized and especially retrospective nonrandomized studies are included in the meta-analysis.
Journal Article
Systemic therapies for recurrent or metastatic nasopharyngeal carcinoma: a systematic review
Background:
The majority of published studies in recurrent or metastatic nasopharyngeal carcinoma (RM-NPC) are single-arm trials. Reliable modelling of progression-free survival (PFS) and overall survival (OS) outcomes, therefore, is difficult. This study aim to analyse existent literature to estimate the relative efficacy of available systemic regimens in RM-NPC, as well as provide estimates of aggregate OS and PFS.
Methods:
We conducted a systematic search of MEDLINE, EMBASE and the Cochrane Library to March 2015. Clinical trials (in English only) investigating cytotoxic and molecularly targeted agents in adult patients with RM-NPC were included. All relevant studies were assessed for quality using Downs and Blacks (DB) checklist (maximum quality score of 27). Aggregate data analysis and Student’s
t
-test were performed for all identified studies (model A). For studies that published analysable Kaplan−Meier curves, survival data were extracted and marginal proportional hazards models were constructed (model B).
Results:
A total of 56 studies were identified and included in model A, 26 of which had analysable Kaplan−Meier curves and were included in model B. The 26 studies in model B had significantly higher mean DB scores than the remaining 30 (17.3
vs
13.7,
P
=0.002). For patients receiving first line chemotherapy, the estimated median OS was 15.7 months by model A (95% CI, 12.3–19.1), and 19.3 months by model B (95% CI, 17.6–21.1). For patients undergoing second line or higher therapies (2nd+), the estimated median OS was 11.5 months by model A (95% CI 10.1–12.9), and 12.5 months by model B (95% CI 11.9–13.4). PFS estimates for patients undergoing first-line chemotherapy by model A was 7.6 months (95% CI, 6.2–9.0), and 8.0 months by model B (95% CI, 7.6–8.8). For patients undergoing therapy in the 2nd+ setting, the estimated PFS by model A was 5.4 months (95% CI, 3.8–7.0), and 5.2 months by model B (95% CI, 4.7–5.6).
Conclusions:
We present the first aggregate estimates of OS and PFS for RM-NPC patients receiving first and second-line or higher treatment settings, which could inform the design of future clinical trials in this disease setting.
Journal Article
Depression and anxiety in dry eye disease: a systematic review and meta-analysis
Aim
To evaluate the association of dry eye disease (DED) with depression and anxiety.
Patients and methods
We conducted a systematic review and meta-analysis of studies that reported the prevalence, incidence and/or severity grading of depression and/or anxiety in DED patients and healthy controls. We searched MEDLINE, EMBASE, PsycINFO, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform for relevant studies.
Results
Twenty-two eligible studies consisted of 2 980 026 patients were analyzed. DED was associated with an increased prevalence of depression (summary odds ratio (OR)=2.92, 95% CI: 2.13–4.01,
P
<0.00001) and anxiety (OR=2.80, 95% CI: 2.61–3.02,
P
<0.00001). The depression score (standardized mean difference (SMD)=0.81, 95% CI: 0.48–1.15,
P
<0.00001) and anxiety score (SMD=0.37, 95% CI: 0.10–0.64,
P
=0.007) were higher in DED patients than in controls. Subgroup analyses revealed that the prevalence and severity of depression are greatest in primary Sjogren’s syndrome patients. No study reported the incidence.
Conclusion
Depression and anxiety are more prevalent in DED patients than in controls. Among patients with DED, those suffering from primary Sjogren's syndrome have higher prevalence and severity of depression.
Journal Article