Rectal Cancer Treatment and its Effect on Quality of Life - A Systematic Review

Background: Colorectal cancers (CRC) are the 4th commonest cancer in the UK, with approximately a third affecting the rectum. The management of rectal cancer is dependent on the stage and grade of the disease and may involve a combination of medical and surgical interventions such as radiotherapy, chemotherapy and surgical excision. Immunotherapy in rectal cancer management is relatively novel and could play an important role in combination therapies. This systematic review evaluated the different rectal cancer treatments and their effects on quality of life (QOL).   Methods: For this systematic review, a mixed approach using both quantitative and qualitative research was adopted, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. The databases used to search for the literature included Scopus AI, MEDLINE, EMBASE and PubMed. Eligibility criteria included articles published in the last 5 years, journals with an impact factor >3 that were peer-reviewed, available in the English language with study participants aged 18 years or older. The identified literature was then checked for duplicates using Zotero before being quality assessed, with risk of bias also quantified.   Results: Out of 657 articles identified using the defined search criteria, a total of 14 papers were included in this review. This consisted of 6 RCTs, 5 cohort studies, 1 questionnaire study, 1 phase II study and 1 cross-sectional study. The differences between the short and long-term consequences of treatment were modality dependent. For example, fatigue and nausea were more common in those who had chemotherapy, and the symptoms of radiation proctitis, such as bleeding, were more common in those who had neoadjuvant radiation therapy. The surgical preference for many patients was sphincter preservation surgery, which had benefits such as being able to return to normal bowel functioning without a stoma. However, some patients had better outcomes with a long-term stoma, including reduced rates of low anterior resection syndrome, such as faecal incontinence. The published literature had little information on the psychological impact of the physical symptoms and their effects on the well-being of patients.   Conclusions: This review highlighted the impact of rectal cancer treatments, demonstrating the breadth of information available on the physical consequences, with fatigue and bowel symptoms being prominent. There was, however, a lack of detail around the psychological impacts of rectal cancer treatments, which needs to be addressed. The addition of real-life case scenarios may be useful for informed decision-making by giving patients a better idea of likely outcomes following treatment. The need for psychological support may be implicated in the future management of rectal cancers

Cherokee High School Literary Journal Spring 2024

Poems, Stories, Essay, Art from students at Cherokee High School (North Carolina)

Tsalagi Scholars: Land, Stories, Relations

This issue of Transmotion gathers essays from members of the Tsalagi Scholars collective, which consists of citizens from the Cherokee Nation, the United Keetoowah Band of Cherokee Indians, and the Eastern Band of Cherokee Indians. It also includes the Spring 2024 issue of the student lirerary journal from Cherokee High School on the land of the Eastern Band of Cherokee Indians

Judith Butler, Who’s Afraid of Gender? (New York: Penguin Books, 2024)

Review of Judith Butler's Who's Afraid of Gender? (2024)

The widening gap: A service evaluation to map the treatment pathway of 100 consecutive patients diagnosed with breast cancer between August and July 2023 to investigate potential treatment disparities in BAME patients at A Secondary Care Breast Unit.

Background: The UK has an 18% BAME (Black, Asian and Ethnic Minority) population, 4% identify as Black, Black British, Black Welsh, Caribbean or African (Diversity UK, 2023). This group makes up a small proportion of the population, yet significant disparities exist in incidence and mortality rates between ethnic communities and their White counterparts (Yedjou et al., 2019). People from BAME groups tend to have lower uptake of breast cancer (BC) screening compared to the White population (Jack et al., 2014). The United Kingdom's healthcare system, the National Health Service (NHS), is government-funded and should provide equitable care to the service users (GOV.UK, 2023). The evidence of racial and ethnic disparities highlights the need for alterations in the current provision of NHS services. This project aimed to address any racial disparity in the treatment of BC and suggests reasonable accommodations based on found modifiable variables and those stated in the literature. Methods: This study used a quantitative ex-post-facto method consisting of a service evaluation and literature review to examine the correlational factors associated with racial disparity in the outcomes of Black women (BW) with BC compared to White women with BC (WW). Non-probability sampling was used to gather 100 patients diagnosed with invasive BC between August and July 2023. Patient data regarding race, age, tumour characteristics, diagnostic imaging and initial treatment were collected. Patients’ self-reported race was used to separate patients into two groups: White and BAME. Data was collected from cancer databases at a secondary care Trust and was analysed using descriptive analytics. Results: This service evaluation found a 3-day difference in the average diagnostic interval between the two patient groups. Both groups did not reach the 31-day target set out by NHS Cancer Waiting Times (2023). Specific patient characteristics, such as age at diagnosis, were compared between the same groups. This data showed that there was a difference in the diagnostic interval depending on what type of initial treatment the patient was having; the fastest was endocrine treatment with an average 23-day wait, and the longest was systemic anti-cancer treatment (SACT) with a 41.7 day wait from diagnosis to first treatment appointment. Conclusions: This service evaluation did find a disparity between the diagnostic intervals of the White group and the BAME group. This suggested that a systematic issue or racial bias may be present in the diagnostic or treatment pathway, which could explain the results. However, this study had limitations, such as the small sample size of the BAME group. Therefore, results cannot be reliably extrapolated to settings outside this study

The Golden Thread of Woolmington - A Domestic Yarn That Should Never Have Been Spun

The case of Woolmington v The Director of Public Prosecutions [1935] 1 AC 462 is renowned for Viscount Sankey’s ‘golden thread’ ruling, that the prosecution bears the burden of proof at trial. However, what is frequently overlooked is that this judgment arises from domestic violence. In this commentary, the facts of Woolmington will be investigated, and charted using a domestic abuse risk assessment form (DARA) which is used by police to assess the potential risk to victims after an alleged domestic incident. It will be shown that there were numerous ‘red flags’ in Reginald Woolmington’s behaviour towards Violet, his wife, which indicated that she was at risk of serious physical violence from her husband. The commentary then reflects on the fact that such an important ruling is named after a domestic abuser

Intercultural barriers to communication in healthcare; is it the disparities in cultural background themselves, or internal biases and assumptions at the root of the problem?

Background: The National Health Service is one of the largest employers in the world and is currently employing the most diverse workforce in its history (Editor, 2023). This diversity reflects a broad spectrum of cultural backgrounds, values, beliefs, and most importantly, a range of languages and linguistic competencies. According to the Office for National Statistics, the 2021 census reported that in England and Wales, 1.5% (880,000) of usual residents aged three years and over could not speak English well, and 0.3%, (161,000) of the overall population could not speak English at all (Waddington, 2022). Intercultural communication within healthcare settings presents challenges when cultural disparities and personal biases conflict. This research aims to explore the root causes of intercultural communication barriers within the NHS. It seeks to determine whether these barriers stem mainly from cultural disparities, or whether internal biases and ingrained assumptions play a significant role too. Understanding the influence of cultural diversity on communication within healthcare settings is essential for developing more effective strategies and interventions to improve communication efficacy across different cultural contexts within the NHS. Methods: This study began with a review of existing literature to identify prevalent misnomers and prejudices surrounding intercultural communication in healthcare. Subsequently, the author created fictionalised ethnographic accounts to re-enact real-world scenarios of communication barriers experienced in healthcare settings. Thematic analysis was used due to its ability to help identify common themes across ethnographic accounts. Three major themes emerge: age-related communication barriers, language as a barrier, and biases in disability culture. These themes underscore the complexities of intercultural communication, revealing how assumptions and biases hinder effective patient- provider interactions. Results: Key findings from this study included 1. Assumptions and prejudices play a significant role in shaping communication dynamics, often leading to misinterpretations and misunderstandings; 2. Cultural sensitivity, awareness, and the ability to challenge one’s own biases are essential for improving communication and enhancing patient care, and 3. Effective communication in healthcare is not solely about overcoming language barriers or cultural differences but involves addressing deeper biases that pervade healthcare settings. Conclusions: In conclusion, addressing intercultural barriers in healthcare requires a holistic approach that considers both cultural and internal factors. Healthcare providers should develop critical awareness to identify and challenge the biases that hinder effective communication. By actively engaging with the diverse perspectives and experiences of patients, healthcare systems can better meet the needs of all individuals, thereby enhancing the quality of care and patient outcomes. This research highlights the importance of an inclusive healthcare system where diversity is understood and respected, and where communication barriers are actively addressed to ensure equitable and effective patient care. The conclusions drawn from this study will act as a foundation for future research and practice, emphasising the continuous need for improvement in intercultural communication within healthcare settings

What anthropometric, psychological, and lifestyle factors influence endogenous pain modulation?

Background: The endogenous pain modulatory system in humans inhibits the sensation of pain throughout the body. Conditioned Pain Modulation (CPM) is an experimental technique used to measure the capabilities of this system in an individual. It is unknown which factors are most predictive of an individual’s ability to modulate pain endogenously, and which type of factors are most significant. Thus, this research aimed to discover the relationship between anthropometric, psychological and lifestyle factors and CPM in healthy adults. Methods: Twenty-six adults (12 males, 14 females) attended two lab visits; their age, height, weight, BMI, and fat mass percentage presented as mean ± SD were 23 ± 3 years, 172 ± 8 cm, 68± 11 kg, 23.15 ± 3.98, and 24% ± 10.5% respectively. To measure CPM, participants first underwent test stimulus (on index finger of right hand) by pressing an algometer and reaching 0.5 out of 10 on the Cook Pain Intensity Scale. This was followed by the conditioning stimulus (above antecubital fossa of left arm) where a pressure cuff was inflated gradually to 7 out of 10 on the scale. Following this, the test stimulus was tested again. The outcome variable was the degree of change in pressure pain threshold before and after the conditioning stimulus. Psychological variables measured include positive and negative affect, pain expectation and confidence, and pain quality. Subjective and objective measures of physical activity were taken. Stepwise regression analysis was performed to identify which variables can form a regression model which can predict participants’ CPM. Significance testing was used to identify the variables that are significant independent predictors of CPM. Results: The regression model included five variables which predicted 62.1% of the variance in CPM (R2 = 0.621, Adjusted R2 = 0.526, ΔR2 = 0.087) with a p < .001. These variables were negative affect at the present moment, pain expectation, objective walking data (hr/day), subjective vigorous physical activity (day/week) and walking data (day/week). The first three variables were negatively correlated with CPM, while the latter were positively correlated. Negative affect and pain expectation combined explained the most variance (31.6%) before the lifestyle factors. Significance testing revealed only the first three variables were significant independent predictors of CPM (p <.05), whereas the subjective physical activity measures were not (p >.05). Conclusions: This study provides evidence for the importance of psychological and lifestyle factors in the efficacy of the endogenous pain modulatory system, highlighting psychological factors as more significant. Objective walking data is negatively correlated with CPM, while self-reported vigorous physical activity and walking help contribute to the accurate prediction of CPM but are not directly correlated with the efficacy of endogenous pain modulation significantly. The discovery of these five variables as key in predetermining CPM, and the endogenous analgesic system by extension, sets up key targets for promoting emotional well-being and physical activity as effective pain management strategies. The findings should lead future research to identify what interventions can improve these five variables the most effectively and improve endogenous pain inhibition

The risk factors of perinatal mental illness in forced migrant women: a systematic review.

Background: Perinatal mental illness is a common complication of pregnancy and the post-partum period, with anxiety and depression being the most common disorders. Despite efforts to improve identifying women at risk, forced migrant women are often missed out leading to a higher prevalence of perinatal mental illness in this vulnerable group. This qualitative systematic review aimed to comprehensively review the literature on the risk factors for perinatal mental illness in forced migrant women to further understand their increased vulnerability. Methods: A comprehensive literature search was conducted on PubMed, CINAHL and PsycINFO (OVID), using keywords such as ‘perinatal’, ‘’antenatal’, ‘postnatal’, ‘migrant’, ‘refugee’, ‘asylum seeker’, ‘depression, ‘and ‘anxiety’ to identify studies published between 2013 and 2023. Following screening and critical appraisal, 21 papers were included in the systematic review. The papers selected then underwent thematic analysis. Results: Five themes emerged which identified pertinent risk factors for perinatal mental illness in forced migrant women. These were a: lack of social support, trauma and adverse events, poor emotional wellbeing, socioeconomic inequalities, and barriers to healthcare access. Forced migrant women were experiencing social isolation, stigma, marginalisation, and relationship distress which contributed to a poor social network. They were also exposed to traumatic experiences including violence which increased their level of fear during and after arrival to the host country. Consequently, this caused poor emotional wellbeing increasing the risk of suicide. Moreover, socioeconomic inequalities were significant in forced migrant women with low educational attainment, economic insecurity, and poor living conditions contributing to further marginalisation. In addition, communication challenges including poor language proficiency, produced barriers to healthcare access. All these risk factors were found to exacerbate perinatal mental illness and cause long term impacts both medically and socially. Conclusion: The risk factors identified were found to contribute to worsening perinatal mental illness with higher levels of anxiety and depression symptoms present in forced migrant women. However, the effects also included chronic health issues such as post- traumatic stress disorder, leading to maladaptive coping mechanisms such as smoking and substance misuse. The risk factors identified also contributed to wider societal impacts including unemployment, poor living conditions and increased violence, all of which promoted the socioeconomic inequalities already present. This led to continued marginalisation and poverty within forced migrant women. Although risk factors were established, further research is required to disentangle the complexity and understand the interplay of these factors to improving screening and provide effective interventions for forced migrant women. &nbsp

How can fracture risk be minimised in people living with HIV in the United Kingdom? A systematic review.

Background: The extended life expectancy of people living with human immunodeficiency virus (PLWH), has increased the risk of age-related non-communicable comorbidities, such as osteopenia, osteoporosis, and fragility fractures (FFs). The risk arises from the virus itself, antiretroviral therapy (ART) and traditional risk factors of low bone mineral density (BMD) which may be more widespread in this population. BMD loss in PLWH begins a decade earlier than the general population, therefore earlier assessment and intervention is warranted. There is a lack of national consensus on the approach to prevent FFs and optimise bone health in PLWH within the UK. This systematic review evaluated the evidence for interventions to minimise fracture risk in PLWH through bone health assessment, risk stratification, osteoprophylaxis and osteotherapy. Methods: MEDLINE, EMBASE and Cochrane library were searched in English language. Eligibility criteria included PLWH over the age of 16 with no geographical restrictions. Studies were included if they fulfilled one or more of the predefined themes: assessment and screening, osteoprophylaxis or osteotherapeutic interventions. Pre-existing guidelines from reputable professional bodies were also included. One reviewer was involved in data extraction, synthesis, quality assessment and analysis. Data was narratively synthesised. Results: Out of 6233 studies identified, 56 studies and 6 guidelines were included in this review. 4 studies fulfilled criteria for the ‘assessment and screening’ theme, 30 fulfilled ‘bone prophylaxis’ objectives and 22 studies evaluated ‘treatment.’ 41565 PLWH were included, of whom were primarily Caucasian males. The fracture risk assessment tool (FRAX) underestimated fracture risk in PLWH. Predictive accuracy increased when HIV was included as a secondary risk factor for osteoporosis, or by the addition of BMD evaluation by Dual-energy X-ray absorptiometry (DXA). Various interventions, such as testosterone replacement, vitamin D supplementation and switching to bone-protective ART regimens were effective in attenuating BMD loss in PLWH. In terms of osteotherapeutic interventions, multimodal exercise programmes, bisphosphonates, and denosumab were beneficial in improving BMD. Conclusions: This review recommends that all PLWH should have lifestyle interventions initiated and considerations around ART prescribed at the point HIV diagnosis or at ART initiation. After identification of PLWH high risk of FF using FRAX (with HIV added as a secondary cause of osteoporosis) or in all PLWH ³50, BMD evaluation by DXA is indicated, and considerations of osteotherapy with regular review is advised. Further studies should be conducted considering the effects of osteoprophylaxis and osteotherapies on FF incidence in PLWH