Mr Dennis Gray is a 49 year old gardener. He was diagnosed as having carcinoma of the rectum after presenting to his general practitioner with bleeding on defaecation. A CT scan of the abdomen suggests that the tumour is about 3 cm in diameter and has not yet become locally invasive. There is no sign of metastatic spread. Mr Gray is scheduled for curative resection with preservation of anal function. You feel that adjuvant chemotherapy is not necessary in this case in view of the many favourable prognostic features. The senior registrar, however, wishes to maximise Mr Gray's chances of complete cure by administering an intraportal regimen of fluorouracil, 500 mg/m2, on the first day after surgery and a continuous heparin infusion for 7 days. The patient, who has three young children, is keen to follow any regimen that improves his odds of long-term survival.
You form the question: In patients with rectal cancer, would adjuvant chemotherapy improve their prognosis? and use it to search the literature. You find the following article: Swiss group for Clinical Cancer Research (SAKK). Long-term results of single course of adjuvant intraportal chemotherapy for colorectal cancer. The Lancet; 345: 349-353.
Read it and decide:
You are working in an Obstetrics and Gynaecology clinic where breast examination is a routine component of many patient assessments. You see Elizabeth Clark, a 35 year old mother of three for a routine gynaecological visit. Just as you finish carrying out a breast examination which revealed nothing unusual, you are interrupted by an urgent phone call. When you return to your patient, you inadvertently repeat the breast examination. To your surprise you detect a small palpable mass in her left breast. You are concerned about having missed the lump the first time and you decide to read up on observer variation and clinical disagreement. You come across the attached paper in your search:
Chamberlain J, Rogers P, Price JG et al. Validity of Clinical Examination and Mammography as Screening Tests for Breast Cancer. The Lancet, 1975:10261030, November 22.
Read it and decide:
Mr John Briggs is a 54 year old announcer for British Rail who presented to his general practitioner with poor urinary stream and nocturia. He was referred to a urologist who performed urodynamic studies and diagnosed severe outflow obstruction. A trans-rectal biopsy was reported as "normal prostatic tissue with no malignant cells".
Mr Brigg's neighbour had a trans-urethral resection of the prostate (TURP) three years ago and died the following month from a heart attack. Your registrar believes that TURP is more dangerous than open prostatectomy, and encourages you to perform the latter. Your senior registrar says, "In the absence of a randomised trial, how can we tell?"
Undaunted, you do a search and find the following paper: Seagroatt V. Mortality after prostatectomy: selection and surgical approach. The Lancet 1995; 346: 1521-1524.
Read it (using the book and Worksheets if you wish) and decide:
The papers have finally come out that caused all the stir about 3rd generation oral contraceptives.
You grab one of them: Jick et al: Risk of idiopathic cardiovascular death and nonfatal venous thromboembolism in women using oral contraceptives with differing progestagen components. Lancet 1995;346:1589-93.
Read it and decide:
Mr Guido Queralto, a 54 year old restaurant owner, is admitted for elective cholecystectomy. The procedure is completed uneventfully by your senior registrar, assisted by the senior house officer. As a routine measure, a nasogastric tube is inserted in theatre. On recovering consciousness, Mr Queralto attempts to pull the tube out, and appears to be in significant discomfort. The nurse attending him reassures his relatives that "the tube is essential to stop Guido being sick". That night, Guido succeeds in pulling his nasogastric tube out, and the duty house officer is called to replace it.
On the second post-operative day, Mr Queralto develops mild confusion and a fever of 38.5C. A chest X-ray shows a right upper lobe pneumonia. Your senior house officer, who has been reading up on the subject, says, "If he hadn't had that nasogastric tube put down he wouldn't have got pneumonia". The senior registrar, however, thinks he can remember a paper which showed that the overall complication rate is higher in patients treated expectantly. As the consultant, you are offered the casting vote.
A literature search reveals a single meta-analysis of selective versus routine nasogastric decompression after elective laparotomy: Cheatham ML et al. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Annals of Surgery 1995, 221, 469-78.
Read it and decide:
Mrs. Jennifer Vaughan, a 37 year old nurse, is admitted for emergency appendectomy. Post operatively, she develops a wound infection which grows Bacillus fragilis. She is treated with IV ciprofloxacin and metronidazole (a combination selected by the house officer), and recovers uneventfully after six days.
You, the surgical consultant, decide to organise a meeting of the surgical directorate to formulate a policy for minimising peri-operative sepsis. The clinical director, however, announces that "It's no good slapping everyone on an expensive cocktail of antibiotics - the department simply can't afford it". You both agree that any policy of antibiotic prophylaxis should be based on evidence of clinical effectiveness and cost-effectiveness.
You track down the attached paper: Waddell TK and Rotstein OD. Antimicrobial prophylaxis in surgery. CMAJ 1994: 151, 7: 925-931.
Read it and decide:
Mrs Judith Owen is a 59 year old cleaner who has been on the waiting list for total hip replacement for osteoarthritis. She is due to have her operation in 3 weeks' time. She is asked to supply two units of her own blood which will be frozen and stored, and used if necessary for transfusion during or after the operation. The system of collecting, storing and issuing autologous blood transfusions in this particular hospital are said to cost £120 per operation, although no-on is sure how the figures were arrived at. It is known, however, that 95 percent of autologous blood units are discarded.
You track down an economic analysis of this situation: Etchason J, Petz, L, et al. The cost effectiveness of preoperative autologous blood donations. New England Journal of Medicine 1995; 332, 11: 719-724.
Read it and decide:
Jennifer Bond is a 32 year old music teacher who got married last year and intends to start a family shortly. Her routine cervical smear is reported as "severe dysplasia; urgent colposcopy advised". A cone biopsy is performed, for which the pathologist's report states: "The specimen is a well preserved sample of cervical tissue showing microinvasive squamous cell carcinoma with maximum depth of invasion 1.8 mm; all margins are well clear of tumour tissue".
You, her gynaecologist, explain that there are five treatment choices: no further treatment (i.e. cone biopsy alone), hysterectomy, hysterectomy with pelvic lymphadenectomy, radiotherapy, or a combination of surgery and radiotherapy. Jennifer feels that preservation of fertility is crucial, but asks your advice on which option she should take. Her husband states that his wish is for "anything to be done to completely abolish the risk of the cancer spreading. If necessary we can adopt kids."
You do a literature search and come up with an odd paper that describes a decision-analytic approach: Johnson et al. Using decision analysis to calculate the optimum treatment for microinvasive cervical cancer. British Journal of Cancer 1992, 65, 717-22.
Read it and decide: