|Exam Name||:||Microsoft Project 2010. Managing Projects|
|Questions and Answers||:||52 Q & A|
|Updated On||:||December 12, 2017|
|PDF Download Mirror||:||Pass4sure 71-178 Dump|
|Get Full Version||:||Pass4sure 71-178 Full Version|
John, a team member, will be absent from the team. A new team member, Mary, will take over Johns remaining work. You need to update the project schedule to reflect the change. You also need to retain Johns actual work. What should you do?
In the Assign Resources dialog box, use the Replace feature.
In the Resource Sheet view, delete John and add Mary.
In the Multiple Task Information dialog box, change the resource assignment from John to Mary.
In the Resource Usage view, rename John to Mary.
Your project has some resources with rates that adjust over time. You need to ensure that project costs automatically adjust for these resources. What should you do?
Create cost tables to include rates that activate on effective dates.
Change the resource availability settings to establish Units for selected dates.
Create resources that include fixed Standard costs, and then apply a rate variance per project task.
Create a named resource for each Standard hourly rate.
Standard working hours are eight hours a day from Monday through Friday. You create a task of fixed units and set the duration to 2 days. You assign the task to John at 100 percent. John wants to work only 50 percent on the task. You change Johns assignment units to 50 percent for the task. Which set of values describes the specified task?
Duration shows 2 days; Work shows 0 hours
Duration shows 4 days; Work shows 16 hours
Duration shows 4 days; Work shows 8 hours
Duration shows 2 days; Work shows 8 hours
Duration shows 2 days; Work shows 16 hours
You need to replace the resource assignment for an in-progress task. You also need to retain the Work, Actual Work, Remaining Work, and Baseline data for the task. What should you do?
Use the Resource Name column drop-down list.
Use the Resource Pool feature.
Use the Team Planner feature.
Use the Level Selected feature.
A section of your project contains only a summary task along with four subtasks and a milestone. You discover that the section is located in the incorrect phase and has the incorrect Work Breakdown Structure (WBS) numbering. You need to move the section to another phase of the project. You also need to ensure that the section reflects the correct WBS numbering. What should you do?
Select the summary task and change the scheduling mode to Manually Scheduled.
Select the entire section and click Move Task.
Drag the summary task.
Modify the start and finish dates of the summary task.
You have a Project 2010 schedule that contains the following tasks: Inactive tasks Manually scheduled tasks Manually scheduled summary tasks Tasks that contain strikethrough font You want to save the schedule as a Project 2007 project. You need to ensure that no new milestones are created. What should you do?
Change all inactive tasks to active tasks.
Change all tasks that contain strikethrough font to tasks that include normal font.
Change all manually scheduled summary tasks to automatic scheduling.
Change all manually scheduled tasks to automatic scheduling.
If you haven’t scheduled your free Microsoft beta exam for test ">71-178, “Microsoft Project 2010: Managing Projects,” you still have a little time to get into the testing center and tackle that before Microsoft closes the beta program. Check your email inbox for a message from MPUG with details on registration.
Recently, an MPUG member shared this tale of his beta test-taking experience so that you’ll know what to expect when you head to the Prometric testing center…
I scheduled the exam for December 16 at 9 a.m. I arrived to the testing center at 8:30 and I was able to go in early to start the exam. When I arrived, I checked in at the front desk. The person led me into a room off the lobby where I stored all of my valuables and my computer. (Leave them at home if you’re able to.) Then I was guided to a room with 10 to 15 computers. I was given an erasable pen and an erasable type of paper for jotting notes down or doing calculations. (Both items are taken away at the end of the test.)
The proctor sat me down and activated my test, which started about 8:45. There’s an optional 15-minute practice exam in the beginning, which doesn’t count for your score but does give you practice at taking the test. It shows non-Project-related multiple choice questions where you’re supposed to select one answer, two of four answers, or the best response based on an exhibit. This latter type of question shows a pop-up exhibit, from which you answer the question. For example, you might need to order several choices as they’d actually transpire in real work.
Once you finish that practice test, you start the Project exam, and the countdown timer begins. As with the short practice test, the beta offered multiple choice and exhibit questions. Of the 75 questions in the beta, I’d say that about 75 to 80 percent were standard multiple choice.
Keep in mind, as you’re taking the beta exam that you can mark questions that you’d like to review later. This feature came in handy for the long and tedious questions. On the last screen of the exam, you’re given the opportunity to return to those questions for review.
When I finished going through the questions, I took a break. Although the countdown timer continues clicking, I stepped out of the testing room for a restroom break, returned with a slightly clearer head, and reviewed each question again — whether or not I had marked it for official review — and then clicked finish on the beta exam to submit my final answers. (I actually changed my answer on one question during that review period.)
Although in the actual exam, you’ll get your score at the end of the test, this is a beta, which means Microsoft has to analyze the results to determine what the final set of questions will be. That in turn will determine how well you did on the exam. The test shows a screen that explains that your score will be mailed to you.
After you’ve clicked Submit, Microsoft gives you the chance to go through the exam once again — though without the ability to change your answers — in order to provide feedback on any of the questions you found confusing or too obvious or too complex. I commented on one question in which I didn’t consider any of the answers very clear.
Following that, there’s a brief survey about the Prometric experience, but I opted out of taking that, because I was pretty much surveyed out by that time.
I took a little over two hours to get through the entire experience. That included the practice at the beginning, the beta test itself, the review at the end, and the Microsoft comment period.
Overall, I felt fairly confident in about 80 percent of the questions I took. In a few cases I had to choose based on the process of elimination.
To prepare for the beta test, I went over the list of objectives. Also, locally, we formed a study group to review the list. Combining our efforts this way allowed us to tap others’ knowledge in filling in gaps in our own knowledge.
Now that my beta test experience is over, I’ll admit: The night before the exam, I was panicked. But I came to realize that I had studied all that I could and that I simply had to go in and do it. After all, the beta test is free, and it’s a good chance to experience the exam, whether or not I passed it.
As for me, I’m looking forward to hearing from Microsoft. Good luck with your own test-taking experience!
Ready to Learn More?
Want to know more about this new Project 2010 exam Read MPUG’s “Microsoft Project 2010 Certification FAQ.”
To learn about the Project 2010 certification, read MPUG’s “How to Get Certified in Microsoft Project 2010.”
Article by ArticleForge
MS Project 2010 training in Atlanta, GA. Curriculum approved as preparation for Exam ">71-178: Microsoft Project 2010, Managing Projects. Full preparation for the certification exam involves taking MS Project 2010 Basic and MS Project 2010 Advanced.
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Superior vena cava (SVC) syndrome is caused by obstruction of the flow of venous blood from the upper body into the right atrium. In 95% of the cases, the obstruction is due to an underlying malignant disease, usually advanced-stage lung cancer. Obstruction of the SVC causes congestion and edema of the face and upper thorax [1, 2]. Other symptoms are often associated with the disorder such as dyspnea, dysphagia, cognitive dysfunction, and severe headache. These symptoms result from cerebral venous hypertension that can arise due to blockage of the venous blood flow return.
The traditional treatment for SVC syndrome has been radiation therapy (RT), chemotherapy, or both . Bypass surgery, despite having been used in some centers until recently, is not justified because SVC syndrome is not a terminal disease [4, 5].
Initial technical success using RT and chemotherapy to manage SVC syndrome rarely exceeds 90%. It is common to observe 46% efficacy for RT in non-small cell lung carcinoma (NSCLC) and 62-80% for chemotherapy in patients with small cell lung carcinoma (SCLC) [6, 7]. The use of chemotherapy and RT in combination is controversial and is currently under revision because of the many side effects and the low response rates (mean survival at 2 years = 5%) .
Placement of endovascular stents to manage SVC syndrome and inferior vena cava syndrome has been used over the past 15 years as an additional tool for the palliative treatment of these patients [8-14]. To date, most of the patient series described in the literature consider the use of stents to be a coadjuvant treatment with RT or chemotherapy if there had been little or no response to RT or chemotherapy or if the clinical syndrome recurred after conventional treatment.
Earlier this decade, however, some investigators suggested that stents may be used as the first-line therapeutic measure in all patients with SVC syndrome because stenting does not interfere with subsequent antitumor treatments. Also, the stent provides urgent relief of symptoms [15-17], the response is immediate and spectacular, and symptoms are alleviated within 24-72 hours after placement. Further, if chemotherapy, RT, or both are the first-choice treatment of symptom relief, the protracted waiting time of 3-4 weeks to assess treatment effectiveness is eliminated.
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Fig. 1A —68-year-old man with small cell carcinoma and severe stenosis of superior vena cava (SVC) with marked development of collateral veins. Patient had one Wallstent endoprosthesis (Boston Scientific) implanted in right innominate vein and SVC. Superior venacavogram shows stenosis of SVC and collateral network of veins that have developed in neck and via hemiazygos vein.
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Fig. 1B —68-year-old man with small cell carcinoma and severe stenosis of superior vena cava (SVC) with marked development of collateral veins. Patient had one Wallstent endoprosthesis (Boston Scientific) implanted in right innominate vein and SVC. Image shows placement of Wallstent (diameter, 16 mm; length, 6 cm). Scale: mm.
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Fig. 1C —68-year-old man with small cell carcinoma and severe stenosis of superior vena cava (SVC) with marked development of collateral veins. Patient had one Wallstent endoprosthesis (Boston Scientific) implanted in right innominate vein and SVC. Image shows use of angioplasty balloon to help achieve greater initial expansion of stent. Scale: mm.
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Fig. 1D —68-year-old man with small cell carcinoma and severe stenosis of superior vena cava (SVC) with marked development of collateral veins. Patient had one Wallstent endoprosthesis (Boston Scientific) implanted in right innominate vein and SVC. Final superior venacavogram obtained after right unilateral stent placement shows collateral venous network is no longer present and good angiographic results.
We report our 15-year experience with the Wallstent endoprosthesis (Boston Scientific) in the palliative management of SVC syndrome of malignant origin. The database was prospective and undertaken jointly with the oncology departments at our institution and two other hospitals that work closely with our referral center unit. The objective of the database is to make stent placement available as an alternative to chemotherapy, RT, or surgery as the initial approach for the palliative relief of symptoms caused by SVC syndrome.
All procedures used in the study were in accord with good clinical practice and were approved by our hospital's clinical review board.
Between January 1993 and June 2008, 208 stents were implanted for the treatment of 149 cancer patients with SVC syndrome. The study group included 137 men and 12 women, all of whom had a clinical diagnosis of SVC syndrome confirmed by phlebocavography; the median age was 65 years (range, 44-84 years). The causes of SVC syndrome were mainly lung cancer: SCLC, also known as “oat cell carcinoma,” in 49 patients and NSCLC (epidermoid lung carcinoma or adenocarcinoma) in 78 patients. Mediastinal adenopathy resulted from different tumors in 19 other patients: sarcoma of the uterus in one, breast cancer in eight, esophageal carcinoma in one, larynx carcinoma in two, cervical carcinoma in four, renal carcinoma in two, and carcinoma of the penis in one. There was one case of mesothelioma and two cases of double tumor (laryngeal and NSCLC) presenting together. The degree to which large thoracic veins were involved was highly variable; according to the classification of Stanford et al. , types I, II, III, and IV were noted in 14, 60, 41, and 34 cases, respectively.
Stent Placement Technique
The Wallstent insertion technique is well established and well described in the literature. We highlight only the slight modifications to the technique that we have introduced. We used a 9-French introducer (Super Arrow-Flex set, Arrow International) for the vein selected for the route of stent insertion. A hydrophilic 0.035-inch guidewire (Radiofocus, Terumo) was inserted and passed through the stenosis. We then used a 5-French catheter (Multipurpose catheter, AngioDynamics) followed by an Amplatz-type rigid guide (Amplatz-Super stiff, Boston Scientific) for the final placement of the Wallstent. No antibiotics were administered. Heparin was administered IV during the procedure as a single bolus of between 3,000 and 5,000 IU. After the deployment of the stent, the angiographic end point of success was when the vessel stenosis was resolved; this change was accompanied, in most cases, by an evident decrease in the collateral venous network (Figs. 1A, 1B, 1C, and 1D).
Only 14 cases required balloon dilatation (Powerflex, Cordis) before stent placement and 43 cases required dilatation after stent placement when the initially placed stent did not achieve a widening of > 50% of the vessel's original diameter.
Wallstents were used in all cases and varied in length (3-8 cm) and diameter (10-16 mm). The most commonly used Wallstent was 6 cm × 14-16 mm (nominal length and diameter, respectively). For 75 prostheses, the easy system method of release was used and the uni system was used for the other 71 stents. Three prostheses initially designed for biliary use (shorter with a narrower bore) were inserted to treat complications that arose in two patients.
In 102 cases, only one stent was necessary to resolve SVC syndrome, whereas 36 patients needed two stents, 10 needed three stents, and one patient needed four.
Of the 208 stents inserted in our series of patients, 182 were first-time placements and the remaining 26 (nine immediate and 25 in follow-up) were second coaxial stents inserted to treat unexpected complications.
All patients had an obstruction of > 75% of the vessel's lumen; a significant network of collateral veins was present in 135 of the 149 patients (91%). To ensure proper measurement and evaluation of the degree and extent of the stenosis as well as of the response after implantation, digital subtraction equipment with associated measurement software was installed (Digitron 3D, Siemens Healthcare) for use in most but not all cases. Because this system was automated and computerized, routine pressure readings were not considered necessary.
Each patient gave informed consent before the procedure. In all cases the procedures were performed with the patient under local anesthesia without any sedatives. Blood pressure, ECG, and oxygen saturation were continuously monitored. Double venous access was achieved using the basilic vein for both phlebocavography and stent insertion. Access via the common femoral vein was needed in two cases. We were unable to recanalize the SVC in the course of the manipulations via the basilic vein at the level of the elbow flexure; instead, the femoral vein was used quite successfully using the “through-and-through” technique. This commonly used technique involves using a guidewire that confers a degree of external rigidity to the vein to enable the stent, or the balloon in angioplasty, to be introduced and to proceed through and beyond the stenosis. In the first few cases (n = 12) between 1993 and 1994, the stents were placed bilaterally in the right and left brachiocephalic veins and involving the SVC. From 1995 onward, single stents were placed in the SVC and right innominate vein or the SVC and left innominate vein irrespective of whether the contra lateral venous axis was affected.
Table 1 summarizes the locations of stenoses, clinical data of the patients with respect to the number of stents and stent positioning, the cause of SVC syndrome, whether additional coadjuvant therapies were used, and the effectiveness of treatment in terms of patient survival.
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TABLE 1 : Characteristics of 149 Cancer Patients With Superior Vena Cava (SVC) Syndrome
Of the 43 patients who received treatment before stenting, 24 had received chemotherapy, four, mediastinal RT; nine, chemotherapy and RT; and six, surgery for treatment of the neoplasia but not for SVC syndrome. The remaining 106 patients had not received any antitumor treatment to alleviate SVC syndrome before stenting.
After the endovascular stenting procedure, all patients received their scheduled treatment of chemotherapy or RT or of palliative care alone for symptom relief.
Follow-Up and Evaluation of Symptom Response
Patients underwent follow-up in the medical oncology department of our hospital, the members of which were not involved in stent placement, thereby ensuring objectivity of assessment. Pulmonary insufficiency and severe cardiac or coagulation abnormalities were considered the only contraindications.
All but six of the patients received anticoagulant treatment. Immediately after the procedure, the patients were placed on a continuous infusion of heparin at full dosage for 1 week. Over the next 4-6 months, they received oral anticoagulant agents in the form of coumarin derivatives at weight-adjusted doses to keep the international normalized ratio above 2; here, we refer to this treatment as the “classical treatment.” For patient safety and comfort this regimen was changed after the 15th patient to a modern oral antiaggregant treatment, which we describe here as the “current treatment,” with dipyridamole in place of the coumarin-type oral anticoagulants. Only five patients were maintained in this second phase with the older “classical” oral anticoagulant therapy schedule because of concomitant pathologies and the advisability of continuing with coumarin. They had been on coumarin-type anticoagulants for protracted periods because of cardiac valve replacement.
Over the first 48- to 72-hour period after stent implantation, simple anteroposterior and lateral radiographs of the thorax were obtained to ensure that the prosthesis was correctly positioned and had fully expanded. Another radiography examination was performed for the same purpose on the seventh day after implantation. Usually phlebocavography was not necessary during follow-up, but it was performed if signs and symptoms of SVC syndrome recurrence were detected because of possible reobstruction.
Vena cava patency was evaluated by monitoring symptom response. Five signs and symptoms were assessed: dyspnea; cervicofacial edema and edema of the upper limbs; superficial-subcutaneous collateral venous network; jugular engorgement; and headache. Because most of these symptoms except jugular engorgement are either subjective (dyspnea and headache) or nonquantifiable or objectively measurable signs (edema and collateral venous network), a simple scale or points score was devised to measure response: 0, no response; 1, partial response (incomplete disappearance of the sign or symptom); or 2, complete response (disappearance of the sign or symptom).
Not all of the patients had all five signs and symptoms. Some had only four or even three; the most variable were dyspnea and headache. However, evaluation of response to stenting was scored as the number of original symptoms that resolved after the procedure—for example, five of the original five symptoms present, four of four, and so on.
Response was assessed at intervals of 1, 2, 12, and 24 hours and up to 2-7 days after the procedure. During the first 7 days after stent placement, medications such as diuretics or corticosteroids were neither required nor administered as prophylaxis; thus, the patients' observed responses could not have been influenced by those drugs.
Description of the data were with means, SDs, ranges, and percentages. The Kaplan-Meier method and log-rank test were used to calculate and compare survival curves of groups as a function of the values of the following variables: patient sex, patient age, stenosis location, main complications such as thrombosis and obstruction, anticoagulant therapy, treatment before and after stenting, tumor type, other complications such as occlusion of the stent caused by tumor growth to cover the stent's mesh, complications immediately after stenting such as stent shortening or partial migration, number of stents per patient, type of Wallstent, and type of angiography for SVC syndrome classification according to Stanford et al. . A probability value of p < 0.05 was considered significant. Further, the association between survival and each of these variables was studied using the adjusted multivariate model of proportional risks (Cox's regression) to calculate the adjusted hazard ratio and 95% CI.
The proportionality-of-hazards assumption was checked using diagnostic plots based on Schoenfeld residuals plots against time for each covariable and using the comparisons of survival curves versus time between the groups formed as a function of the values of the covariables. In the final model, we retrieved all the variables with statistically significant coefficients and those that were not significant whose removal from the model provoked a clinically relevant change in the coefficients of the variables that were significant. Analyses were performed with SPSS software (version 11.0, SPSS) for Microsoft Windows.
Stent placement was successful in all patients. Clinical success was evident in 123 patients who showed partial disappearance of symptoms within 24 hours of the procedure and complete disappearance within 72 hours. Partial response (i.e., persistence of one or more signs or symptoms) was seen in 22 patients and no resolution of signs and symptoms caused by SVC syndrome in only four patients; however, even in the latter group of patients, at least one symptom improved.
After the procedure, 87 patients continued to receive scheduled antitumor treatment: 44 received chemotherapy; 11, mediastinal RT; and 32, RT and chemotherapy. The most used chemotherapy regimes were cisplatin plus etoposide and regimes based on anthracyclines. The radiation dose ranged between 4,000 and 5,000 Gy. The remaining 62 patients received only support or maintenance for symptom relief.
All patients were regularly monitored. After the intervention, the survival time averaged 6 months (range, 2 days-43 months) and all patients had improvement in at least one of their symptoms before stenting. Of the study group patients, 134 died as a result of the natural history of the neoplasia, whereas eight were alive as of June 2008, still with their neoplasia but with clinical resolution of their SVC syndrome symptoms as a result of continued patency of the stents or, possibly, as a result of spontaneous increase in collateral blood flow. Seven patients were lost to follow-up.
Of the patients who died, three still had clinical evidence of SVC syndrome at the time of death, which was probably due to obstruction of the stent. However, obstruction was not confirmed by radiologic imaging because of the patient's status before death.
The patients who were still alive as of June 2008 (n = 8) represent a median survival time of 10.6 months (range, 15 days-36 months). Of the seven patients lost to follow-up, all had a good response to stenting up to the time of loss to follow-up (three in the third month and four in the sixth month after the procedure) and were without clinical evidence of SVC syndrome recurrence.
Symptom response was evaluated by clinical and nursing staff of the medical oncology department. The main findings were complete response in almost 80% and partial response in approximately 15% of patients with respect to jugular engorgement and collateral circulation within the first 72 hours after stenting. Headache resolved completely in 70% of patients and partially in 30% within the first 24-48 hours after stent placement. Cervicofacial edema and edema of the upper limbs, which affected 100% of the patients, were the symptoms that responded best to the procedure. In all patients, those symptoms disappeared within 48-72 hours after implantation of the prosthesis. Dyspnea was the symptom that was most resistant and resolved completely in only 45% of patients, whereas partial remission was achieved in 60% of the patients.
During follow-up of the 149 patients (Figs. 2A, and 2B), only 20 obstructions of the endoprostheses (16 complete or partial stent occlusions and four episodes of stent thrombosis) were detected. These data yield a primary patency of 86.6%. The stent in one patient partially migrated to the right atrium but did not result in any clinical consequences. In four patients, the stent was positioned poorly during placement, one with an excessive angle, and there were four episodes of shortening of the prosthesis, two of which occurred in the same patient. In another patient, the initial expansion of the stent was inadequate and did not resolve until 2 months later.
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Fig. 2A —65-year-old man with non-small cell lung carcinoma already treated on previous occasions (4 and 2 months earlier) with stents to resolve superior vena cava (SVC) syndrome. SVC syndrome recurred, probably from malfunction of prostheses. Scale: xxx. Superior venacavogram before de novo endovascular treatment show complete blockage of previous stents with incipient development of collateral venous network from azygos vein.
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Fig. 2B —65-year-old man with non-small cell lung carcinoma already treated on previous occasions (4 and 2 months earlier) with stents to resolve superior vena cava (SVC) syndrome. SVC syndrome recurred, probably from malfunction of prostheses. Scale: xxx. Venacavogram obtained after placement of third vascular endoprosthesis shows Wallstent endoprosthesis (Boston Scientific) (diameter, 14 mm; length, 6 cm) implanted coaxially. Note immediate restoration of venous inflow and decrease in venous network.
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Fig. 3A —66-year-old man with occlusion of superior vena cava (SVC) due to non-small cell lung carcinoma. Although SVC occlusion was initially managed successfully for 6 months with stent placement, patient was readmitted because of reappearance of SVC syndrome. Superior venacavogram shows stenosis of vena cava due to partial obstruction of stent resulting from invasion by tumor (circle). Arrows indicate considerable collateral circulation.
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Fig. 3B —66-year-old man with occlusion of superior vena cava (SVC) due to non-small cell lung carcinoma. Although SVC occlusion was initially managed successfully for 6 months with stent placement, patient was readmitted because of reappearance of SVC syndrome. Image shows balloon angioplasty to reopen obstructed area.
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Fig. 3C —66-year-old man with occlusion of superior vena cava (SVC) due to non-small cell lung carcinoma. Although SVC occlusion was initially managed successfully for 6 months with stent placement, patient was readmitted because of reappearance of SVC syndrome. Image shows second coaxial Wallstent alongside first prosthesis. Scale: mm.
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Fig. 3D —66-year-old man with occlusion of superior vena cava (SVC) due to non-small cell lung carcinoma. Although SVC occlusion was initially managed successfully for 6 months with stent placement, patient was readmitted because of reappearance of SVC syndrome. Venacavogram after placement of second Wallstent. Note vessel reopening and resolution of vena cava stenosis.
All complications except two were resolved by a second intervention (primary assisted patency = 93.3%). The cases of partial obstruction due to thrombosis (n = 2) were resolved by thrombolysis and balloon dilatation. In another two patients, the thrombosis was massive and poor clinical status precluded new repeat interventions; both patients died over the next few days with florid SVC syndrome. Regarding the 16 cases of invasion of the stent or mesh by the tumor, 12 were complete and four were partial. All resolved with placement of a second coaxial prosthesis (Figs. 3A, 3B, 3C, and 3D). The six cases in which the stents were shortened or poorly positioned were also easily relieved with coaxial prostheses. Table 2 summarizes these data.
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TABLE 2 : Summary of Outcomes
Figures 4A, 4B, 4C, 4D, and 4E summarizes the overall survival of the patients and the censored pattern. The median survival was 6 months after stenting (range, 2 days-43 months) during which the patients remained symptom-free. The natural history of the neoplasia was responsible for the deaths of 134 patients, whereas eight were alive with patent stents as of June 2008, albeit with their disease.
The median survival was 7, 5, and 4 months, respectively, in patients with SCLC, NSCLC, and metastatic adenopathies (overall, p = 0.0436). Subgroup comparisons indicated significant differences only between the patients with adenopathies and those with NSCLC (p = 0.0076). In the patients with bilateral innominate venous stenosis (Figs. 5A, 5B, 5C, and 5D) or stenosis in both venous axes, the median survival was 3.1 months, whereas in the patients with unilateral involvement, the median survival reached 6 months (p = 0.0001).
The type of treatment administered before stenting was also a factor that significantly affected survival: The median survival was 2 months in patients who had undergone RT or surgery before stenting, 4 months in patients who had undergone chemotherapy before stenting, 5 months in those who had received chemotherapy and RT before stenting, and 6 months in those who did not receive any treatment before stenting. The log-rank test was significant (p = 0.0045), and the differences centered on the group who did not undergo treatment before stenting compared with the group who underwent chemotherapy (p = 0.0271) and on the group who did not undergo treatment compared with those who underwent surgery (p = 0.0008).
Treatment after stenting also significantly influenced survival. The median survival was 4 months for the patients who did not receive treatment after stenting or who underwent only RT after stent placement compared with 6 months for those who underwent chemotherapy and 7 months for those who underwent chemotherapy and RT. The overall difference in the survival curves was statistically significant (p = 0.0002).
In the 2 × 2 comparisons, statistical significance was reached between patients who did not receive treatment after stenting and those who underwent chemotherapy alone after stenting (p = 0.042) and those who underwent chemotherapy and RT after stenting (p = 0.0002). Statistical significance was also reached between patients who underwent RT alone after stenting and those who received chemotherapy alone after stenting (p = 0.0199) and those who underwent RT and chemotherapy after stenting (p = 0.0006). In patients in whom the stent became thrombosed, survival was shortened to a median of 2 months compared with the group without thrombosis (p = 0.0331).
In the univariate analysis, no significant differences in survival were observed from the rest of the variables studied including patient sex; patient age; type of antithrombotic treatment; complications, such as occlusions of the stent due to tumor growth across the stent mesh; immediate complications, such as stent shortening or partial migration; number of stents used per patient; type of Wallstent; and type of angiography used to determine the Stanford classification of SVC syndrome.
In the multivariate analysis using the adjusted model of proportional risk (Cox's regression), the analysis of the Schoenfeld residuals plot versus time for each of the covariables and an examination of the cumulative survival curves led to the conclusion that the assumption of proportional hazards was not sustainable in the case of the covariate “type of tumor” (Table 3); as a consequence, tumor type was used as a stratification factor, and a set of pooled coefficients was computed for the other covariates. Table 3 also contains the hazard ratios and 95% CIs of the variables that, with the indicated criteria in the Subjects and Methods section, were finally included in the model. As can be seen, the significant prejudicial effect was conserved with respect to survival time as was observed in the univariate analysis with respect to bilateral localization of the stenosis, stent thrombosis, and chemotherapy and surgery before stenting (in both cases compared with the no-previous-treatment group).
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TABLE 3 : Variables to Survival Based on Cox's Regression Analysis
Treatment after stenting with RT and chemotherapy increased survival significantly relative to the group who did not receive treatment after stenting, as indicated by the Kaplan-Meier analysis. Statistically significant effects that were not detected by Kaplan-Meier analysis were also observed, such as the case of previous RT with an increase in the risk compared with no previous therapy and, in the case of males, a greater risk than the females. The effect of chemotherapy after stenting that was detected in the univariate analysis did not appear in the Cox model analysis. Similarly, the effects of patient age and the presence of stent obstruction continued being nonsignificant. Other factors not retained in the final model were immediate complications such as shortenings type, partial migration, number of stents per patient, type of Wallstent, and type of angiography used to determine the Stanford type classification of SVC syndrome.
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Fig. 4C —Kaplan-Meier curves. Survival of patients who underwent coadjuvant therapies after stenting. RT = radiation therapy.
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Fig. 4D —Kaplan-Meier curves. Survival according to tumor type. NSCLC = non-small cell lung carcinoma, SCLC = small cell lung carcinoma.
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Fig. 4E —Kaplan-Meier curves. Survival of patients who underwent coadjuvant therapies before stenting. RT = radiation therapy.
Vena cava syndrome generally occurs because the vein is being compressed by adjacent tumor masses. It is less frequent for a tumor to invade the vena cava, although this can occur at advanced stages of the disease . Vena cava syndrome is a highly stressful additional complication for patients whose life expectancy is already severely curtailed.
Lung cancer is the most frequent cause of vena cava syndrome and is responsible for more than 70% of the cases. RT and chemotherapy are the standard forms of treatment, and the combination of the two recently was proposed. Symptom improvement of 75-90% has been observed by some investigators, whereas others have obtained results that are less hopeful (46% success with RT for NSCLC and 62-80% success with chemotherapy for SCLC) [6, 7]. Conventional therapies take between 2 and 4 weeks to begin to show any degree of effectiveness [3, 7, 15]. Further, vena cava syndrome recurs in 20-50% of patients, and at that stage of disease, only symptom treatment is possible.
Some investigators propose more aggressive RT (8 Gy three times a week for 3 weeks) and have achieved responses of up to 90% . However, one needs to account for the many complications of high-dose RT. These complications include tumor necrosis with concomitant fever and bleeding and perforation of the SVC. Other debilitating effects include nausea, vomiting, anorexia, skin irritation, and esophagitis. These negative effects on the quality of life for a patient whose life expectancy is only on the order of approximately 6 months may be considered unacceptable and counterproductive. Also, RT can induce fibrotic changes that further constrict the vessels. A secondary effect of radiation fibrosis is that collaterals do not develop in this scarred tissue . This is not surprising because RT cannot easily discriminate between tumor and adjacent normal tissue .
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Fig. 5A —57-year-old man with type IV obstruction (Stanford classification) of superior vena cava (SVC) caused by metastatic adenopathies from laryngeal carcinoma. Despite patient's preterminal clinical status (patient died 1.5 months after these images were obtained) and with difficult approach because SVC could be visualized only with difficulty, there was intent to open one of brachiocephalic trunk veins. Procedure was successful, and although aperture of stent was small, symptoms were effectively alleviated. Scale in C and D is mm.
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Fig. 5B —57-year-old man with type IV obstruction (Stanford classification) of superior vena cava (SVC) caused by metastatic adenopathies from laryngeal carcinoma. Despite patient's preterminal clinical status (patient died 1.5 months after these images were obtained) and with difficult approach because SVC could be visualized only with difficulty, there was intent to open one of brachiocephalic trunk veins. Procedure was successful, and although aperture of stent was small, symptoms were effectively alleviated. Scale in C and D is mm.
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Fig. 5C —57-year-old man with type IV obstruction (Stanford classification) of superior vena cava (SVC) caused by metastatic adenopathies from laryngeal carcinoma. Despite patient's preterminal clinical status (patient died 1.5 months after these images were obtained) and with difficult approach because SVC could be visualized only with difficulty, there was intent to open one of brachiocephalic trunk veins. Procedure was successful, and although aperture of stent was small, symptoms were effectively alleviated. Scale in C and D is mm.
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Fig. 5D —57-year-old man with type IV obstruction (Stanford classification) of superior vena cava (SVC) caused by metastatic adenopathies from laryngeal carcinoma. Despite patient's preterminal clinical status (patient died 1.5 months after these images were obtained) and with difficult approach because SVC could be visualized only with difficulty, there was intent to open one of brachiocephalic trunk veins. Procedure was successful, and although aperture of stent was small, symptoms were effectively alleviated. Scale in C and D is mm.
The deployment of endovascular stents emerged during the early 1990s as a promising new therapy [22-29]. Although there do not appear to be doubts regarding the benefits that these endovascular prostheses offer patients in terms of symptom relief, debate continues as to whether the stent should be used as the initial treatment of choice—that is, before implementing RT or chemotherapy. Also being debated is if a stent is an option only when obstruction recurs or if it can be used subsequent to the failure of RT and chemotherapy. There are two opposing views, each acquiring more adherents. Beginning earlier this decade, several authors of case series advocated stents as the initial treatment of SVC syndrome [16, 17, 30, 31]. Systematic reviews of the results of the different therapeutic options of SVC syndrome related to lung cancer have reported a higher effectiveness for stenting compared with chemotherapy, RT, or steroid treatment . However, the classic views of other investigators persist [33, 34]. The recommendations are for initial insertion of stents for symptomatic SVC syndrome in NSCLC, but stent insertion is not recommended initially in symptomatic SVC syndrome caused by other malignancies such as SCLC and metastatic adenopathies of other tumors. More restrictively , stenting has been used only to alleviate urgent symptoms and in more anecdotal cases such as mesothelioma.
Over a period of 15 years, we implanted 208 stents in 149 cancer patients. Our results in terms of technical and clinical success are encouraging. Immediate and late complications were minimal and were easily resolved with repeat stenting (primary stent patency = 86.6%, primary assisted patency = 93.3%). These outcomes are similar to those of other published series. Patient survival after stenting is currently approximately 6 months, as observed in other published studies [15-17, 30-36]. Curiously, median life expectancy among patients with obstruction of the SVC is approximately 6 months, but estimates vary widely depending on the underlying malignant condition and this figure does not appear to differ significantly from survival among patients with the same tumor type and disease stage but who do not have obstruction of the SVC .
The innovative approach of our study was to collect and analyze the results of an extended series of patients with malignant SVC syndrome who had a stent inserted independent of whether they had received prior treatment and who had completed long-term follow-up in which other factors that could have had a confounding effect on the outcomes (e.g., the use of a stent as the first-choice therapeutic tool) were collected.
Deployment of a stent as the first step neither influenced the decision of the oncologist to continue with the scheduled coadjuvant therapies (chemotherapy, RT, or chemotherapy and RT) nor affected the survival rate. Other factors such as bilateral involvement of the innominate veins and the SVC, male sex, certain tumor types, and having undergone surgery, chemotherapy, or RT before stenting do appear to negatively impact survival, whereas RT and chemotherapy treatment after stenting decreases the mortality hazard and is the only factor that had a significant positive effect on survival in our study. However, these findings could be associated more with the advanced stage of the disease and, thus, the poorer prognosis than with the stent treatment per se.
The innovative approach of stenting de novo appeared for the first time in an article in 1997 by Nicholson et al. . Those investigators compared the results obtained in 76 SVC syndrome patients treated with stents (with or without associated RT) versus those in 25 retrospective cases treated only with RT. They concluded that stenting provided faster relief of symptoms and resulted in significantly greater improvement in the SVC obstruction score than RT (p < 0.001).
The option of conducting randomized prospective comparative studies is very limited. To our knowledge, only two small retrospective studies [15, 35] in which the use of endovascular stents was compared with RT have been reported. We agree with Dyet et al.  and Irving et al.  who concluded that this procedure incurs a very marginal increase in the overall cost of management of these cancer patients.
With respect to other technical issues, we believe (and our view is supported by many other authors) that it is necessary to open only one venous axis to insert the stent for SVC syndrome to be completely reversed. As we proposed since the third year of our commitment to the use of stents in 1992, we observed that inserting stents bilaterally is not necessary. We are in complete agreement with Dinkel et al.  and with others [15, 16, 31] that unilateral placement is preferable in patients with SVC syndrome because it was as clinically effective as bilateral placement while offering lower cost, easier placement, and low rates of complications and recurrence.
Anticoagulation therapy is often prescribed for patients with SVC syndrome after stenting, although its effectiveness has never been clearly proven. The stent is highly thrombogenic in the first month until neoendothelium covers the endovascular surfaces. We believe that anticoagulation therapy is mandatory especially during the period immediately after stent placement. We and other investigators [16, 37, 38] use only oral antiplatelet therapy (aspirin, ticlopidine, or similar) for maintenance after complete heparinization for the first 3 or 4 days after stent placement. Our results indicated that this more modern therapy does not significantly differ from the classical therapy we had used in 15 of our early patients. The question of the appropriate antithrombotic preventive strategy remains to be resolved as well.
In conclusion, our experience over more than 15 years has shown the effectiveness of vascular stenting in the management of SVC syndrome in cancer patients. Palliation of symptoms, together with more general improvement of quality of life, is the major goal in the overall management of lung cancer patients experiencing a highly stressful additional complication such as SVC syndrome. The syndrome requires effective fast-acting treatment, and percutaneous implantation of vascular endoprostheses is fully justified in patients with a terminal illness irrespective of their life expectancy because of the rapid disappearance of clinical symptoms. The Wallstent endoprosthesis can be rapidly and safely introduced and, above all, does not interfere in any way with subsequent scheduled neoadjuvant oncology treatment. We believe that stenting should be considered the first treatment option for patients with this clinical condition.
Article by ArticleForge
We start out determined. We vow to save more for retirement, eat less, and bike to work. But we eventually succumb to the allure of burgers and fries. We never get around to enrolling in that 401(k). And we hop in the car to get to the office on time.
Habit, convenience, and temptation often hamper the most conscientious goals. But behavioral science is showing that those same forces can be rerouted to make fitness and thrift more rewarding than indolence and waste. Amid concerns about rampant obesity, climate change, and aging Baby Boomers with scant retirement savings, psychological scientists are teaming with economists, business leaders, and policymakers to compel people to take better care of themselves, their communities, and the environment.
“We’re helping people to do what they want to do, but never get around to starting — or don’t maintain if they do,” said APS Fellow Richard Suzman during a forum on psychological science and behavioral economics held in May in Washington, DC. Suzman is director for the Behavioral and Social Research Program at the National Institute on Aging (NIA), which co-sponsored the event with APS and the White House (see related story on page 21).
Pioneering this marriage of behavioral science and policymaking is the United Kingdom’s Behavioural Insights Team (BIT) that British Prime Minister David Cameron set up in 2010. Also known as the “nudge” unit, the BIT has found a variety of techniques to cue people to act in their own self-interest, and thus lessen the burden that bad habits place on society. Under the leadership of experimental psychologist and policy expert David Halpern, a former Cambridge University social psychology lecturer, the BIT has conducted a variety of trials to promote good citizenship and healthy behavior, and many of those trials are now being expanded across the UK. The group found, for example, that sending a personalized text message to people owing court fines results in a 33 percent response rate, compared with a mere 5 percent compliance rate when standard letters are sent. In another trial, the nudge unit documented that job seekers participating in a newly designed program — one that included such features as reduced paperwork and specific job-hunting commitments — were 15 to 20 percent more likely than control subjects to roll off government benefits 13 weeks after signing on.
Based on the BIT team’s early successes (its work has boosted income tax collections by £200 million), policymakers and business leaders in the United States and other countries are anxious to adopt similar models.
The “nudge” unit borrows its nickname, and its mission, from University of Chicago economist Richard Thaler’s “nudge” theory — the idea that positive reinforcement and indirect suggestions better influence behavior than do laws and edicts. Also factoring into these strategies is much of the legendary work of Princeton University professor and APS William James Fellow Daniel Kahneman and late APS William James Fellow Amos Tversky, who showed how a human tendency toward status-quo bias and loss aversion lead to irrational decision-making.
Behavioral science is also demonstrating how those same traits can be turned around for the common good.
Hitting the Default Button
Researchers have learned that options and services too often falter because they’re designed to depend on people taking some kind of action. Studies show that relying on inaction yields better results.
Organ donation is one of the most-cited examples. In the United States, 85 percent of Americans say they approve of organ donation, but only 28 percent give their consent to be donors by signing a donor card. The difference means that far more Americans die awaiting transplants.
But APS Fellow Eric J. Johnson, a professor at Columbia University Business School, and Daniel Goldstein, an advisor to BIT and now a principal researcher at Microsoft Research, found in a 2003 study that in many European countries, individuals are automatically organ donors unless they opt not to be — organ donation is the default choice. In most of these countries, fewer than 1 percent of citizens opt out. In an article published in Science in 2003, Johnson and Goldstein theorized that, among other things, opting out in those countries was simply too much of a hassle for most people, since it involved “filling out forms, making phone calls, and sending mail.”
Harvard economics professor David Laibson, whose research focuses on the psychology of savings and investment, has found that defaults counter workers’ tendencies to delay enrollment in employer-provided retirement plans. The problem with those savings benefits, he says, is that people are beset with present bias, which leads them to avoid thinking about their future. As a consequence, only about half of US employees save sufficient sums for retirement, he says, largely because on average they wait two years to enroll in a 401(k) program. But in one of his studies, he showed that when newly hired workers have to act to “opt out” rather than “opt in” to those savings plans, participation jumped to 85 percent in a year. These findings have sparked the Obama administration to call for employers to enroll workers automatically in retirement plans.
What Are the Neighbors Doing?
Behavioral scientists have found that one of the most effective tools for spurring behavior change is consensus messaging, which taps into people’s tendency to follow social norms and rules.
For example, a study by psychological researchers Noah J. Goldstein (University of California, Los Angeles), Robert B. Cialdini (Arizona State University), and Vladas Griskevicius (University of Minnesota) compared the effectiveness of different types of messages in getting hotel guests to reuse their towels rather than send them to the laundry. Messages framed in terms of social norms — “the majority of guests in this room reuse their towels” — were more effective than messages simply emphasizing the environmental benefits of reuse.
Cialdini, an APS Fellow, has also documented the effectiveness of this persuasion approach as applied to home energy use. In one study, Cialdini’s research team (led by Jessica Nolan and APS Fellow Wesley Schultz at California State University San Marcos) went door to door in a San Diego suburb, placing hangers on doorknobs with messages about energy conservation. For some homes, the signs urged the homeowner to save energy to protect the environment; another said to conserve to benefit future generations; a third pointed to the cost savings that would result; and the last stated that most of the homeowner’s neighbors were taking steps to save energy every day.
At the end of the month, Cialdini and his team returned to the homes to read the meters, and compared them to homes that received no messages at all. Among all those dwellings, the only hanger that made a difference was the one that cited neighbors’ behavior. Homeowners who received any other type of message were no more likely to change their energy usage than control subjects.
“People are looking at those around them, like them, in their particular environment, in their particular context, to decide what to do,” Cialdini explains.
Cialdini’s work served as the inspiration for the launch in 2007 of a Virginia-based software company, Opower, which has partnered with more than 75 utilities to incorporate neighbor comparisons into gas and electric bills. According to its website, Opower in 2012 helped consumers save more than $75 million and cut carbon dioxide emissions by 1 billion pounds.
Scientists have also documented this social norm appeal as a potential way to boost voter participation in elections. In two randomized field experiments, Yale University political scientist Alan S. Gerber and psychological scientist Todd Rogers, at Harvard’s Kennedy School, tested two get-out-the-vote scripts in the days prior to the November 2005 general election in New Jersey and the June 2006 primary election in California. One script suggested that voter turnout was expected to be high, while the other forecast the turnout to be low. The call recipients were then asked if they planned to vote. The results showed that the scripts forecasting high voter turnout motivated infrequent or occasional voters to participate in the upcoming elections.
To Your Health
Another concern among US government leaders centers on how people take care of their health. APS Fellow Laura Carstensen of Stanford University studies message framing to promote healthy behavior across the adult life span. She and doctoral student Nanna Notthoff are testing an intervention comparing groups of elderly people who received information about the positive effects of walking with those who were told about the risks of inactivity. Early results have shown that those who were told about the benefits of walking walked more than those who received negative messages about the consequences of inactivity, and that difference is sustained or increased over 30 days.
Influence at Work, a training and consultancy company that Cialdini founded, worked with the United Kingdom’s National Health Service (NHS) in a set of studies aimed at reducing the number of patients who fail to show up for medical appointments. They did this by simply making patients more involved in the appointment-making process, such as asking the patient to write down the details of the appointment themselves rather than simply receiving an appointment card. This reduced the number of wasted appointments by 18 percent. And when the practices participating in the study advertised the number of people who attend their appointments on time, no-shows fell by more than 30 percent.
Behavioral scientists and economists are also identifying the best ways to combat rising levels of overweight and obesity brought on by the rampant availability of cheap, unhealthy, processed foods. Studies have shown that laws requiring calorie postings in restaurant chains is yielding no observable reduction in people’s calorie consumption.
Dan Ariely, professor of psychology and behavioral economics at Duke University, joined a multidisciplinary team in three field experiments that tested an alternative approach: having servers ask customers if they want to downsize portions of three starchy dishes at a Chinese fast-food restaurant. The researchers found that 14 percent to 33 percent of customers accepted the downsizing offer, whether or not they received a discount for the smaller portion, and on average were served 200 fewer calories.
APS Fellow George Loewenstein, a professor of economics and psychology at Carnegie Mellon University, has worked closely with University of Pennsylvania Professor of Medicine Kevin Volpp in research on health incentives. The pair have found that dieters lose more weight when they’re offered cash incentives. In a study published in the Journal of the American Medical Association, the scientists placed adult dieters into three groups — all given the goal of losing 16 pounds in about four months. Participants in one group entered a daily lottery and won money if they hit their weight-loss targets, while those in a second group invested their own money but lost it if they fell short of their goals. A third group received no financial incentive.
Both groups offered the incentives achieved a mean weight loss of more than 13 pounds, with about half the participants reaching the full 16-pound weight-loss goal. The mean weight loss for the control group was just four pounds. While both incentive groups gained some weight back over the next seven months, they fell short of their original weights.
The application of the nudge theory is not without its critics. Many deride it as manipulative and paternalistic. Cornell University political scientist Suzanne Mettler, author of the 2011 book The Submerged How Invisible Government Policies Undermine American Democracy, argues that governmental nudge policies treat citizens as consumers who need choices arranged for them, which clashes with many tenets of democracy. And a report from the British House of Lords’ Science and Technology Subcommittee questioned the effectiveness of “nudge” policies, concluding they alone will not change behavior enough to surmount the scale of such problems as obesity or joblessness.
But while Halpern himself concedes that the long-term effect of the policy changes sparked by BIT’s research remain unknown, in many cases those questions are irrelevant. Nudge-induced behavior changes, such as workers being automatically enrolled in retirement plans, are designed to endure, he suggests.
In other words, doing what’s good for us, and for society, eventually becomes the habit.
References and Further Reading
Gerber, A. S., Rogers, T. (2009). Descriptive social norms and motivation to vote: Everybody’s voting and so should you. Journal of Politics, 71, 178–191.
Goldstein, N. J., Cialdini, R. B., & Griskevicius, V. (2008). A room with a viewpoint: Using social norms to motivate environmental conservation in hotels. Journal of Consumer Research, 35, 472–482.
Johnson, E. J., & Goldstein, D. (2003). Do defaults save lives? Science, 302, 1338–1339.
Nolan, J. M., Schultz, P. W., Cialdini, R. B., Goldstein, N. J., & Griskevicius, V. (2008). Normative social influence is underdetected. Personality and Social Psychology Bulletin, 34, 913–923.
Schwartz, J., Riis, J., Elbel, B., Ariely, D. (2012), Inviting consumers to downsize fast-food portions significantly reduces calorie consumption. Health Affairs, 31, 2399–2407.
Volpp, K. G., John, L. K., Troxel, A. B., Norton, L, Fassenber, J., Loewenstein, G (2008). Financial incentive-based approaches for weight loss: A randomized trial. Journal of the American Medical Association, 300, 2631–2637.