Cancer and thrombosis: Managing the risks and approaches to thromboprophylaxis

Patients with cancer are at increased risk of venous thromboembolism (VTE) compared with patients without cancer. This results from both the prothrombotic effects of the cancer itself and iatrogenic factors, such as chemotherapy, radiotherapy, indwelling central venous devices and surgery, that further increase the risk of VTE. Although cancer-associated thrombosis remains an important cause of morbidity and mortality, it is often underdiagnosed and undertreated. However, evidence is accumulating to support the use of low-molecular-weight heparins (LMWHs) in the secondary prevention of VTE in patients with cancer. Not only have LMWHs been shown to be at least as effective as coumarin derivatives in this setting, but they have a lower incidence of complications, including bleeding, and are not associated with the practical problems of warfarin therapy. Furthermore, a growing number of studies indicate that LMWHs may improve survival among patients with cancer due to a possible antitumor effect. Current evidence suggests that LMWHs should increasingly be considered for the long-term management of VTE in patients with cancer

Vertical rectus abdominis myocutaneous versus alternative flaps for perineal repair after abdominoperineal excision of the rectum in the era of laparoscopic surgery

Aims: Plastic surgical reconstruction of the perineum is often required after abdominoperineal excision of the rectum. Options for this reconstruction include a vertical rectus abdominis myocutaneous (VRAM) flap, gluteal fasciocutaneous flap, and gracilis myocutaneous flap. Although the VRAM flap is well established at most centers, less experience exists with the gluteal and gracilis flaps. In the era of laparoscopic colorectal resection, plastic surgeons are being forced to use gluteal and gracilis flaps because the VRAM flap must be tunnelled intra-abdominally requiring laparotomy. We therefore aimed to systematically review the evidence comparing VRAM, gluteal, and gracilis flaps. Methods: A comprehensive, structured literature search was conducted using Medline, Google Scholar, and Science Direct. Studies included were randomized control trials and observational studies documenting complication rates associated with the VRAM, gluteal, or gracilis flap. Results: Eleven studies meeting all inclusion and exclusion criteria were identified. When meta-analyzed, the overall rate of any perineal wound or flap complication among VRAM patients (35.8%) was significantly lower than gluteal flap (43.7%) and gracilis flap patients (52.9%) (P = 0.041). Conclusions: The VRAM flap is well established for perineal reconstruction, and this study suggests that it may be superior to the gluteal and gracilis flaps in terms perineal wound and flap complication rates. This should be taken into account when weighing up the risks and benefits of a laparoscopic approach to abdominoperineal excision of the rectum. Large studies making direct comparisons between the flap options should be conducted

Nurses\u27 Alumnae Association Bulletin - Volume 16 Number 1

Alumnae Notes ANA Biennial Convention Cancer of the Cervix, Uterus and Ovaries Committee Reports Digest of Alumnae Association Meetings Greetings from Miss Childs Greetings from the President Graduation Awards - 1950 Isotopes and the Nurse - Dr. T.P. Eberhard Marriages Necrology New Arrivals Nursing Care in Heart Disease with Pulmonary Infarction Nursing Care of a Mitral Commissurotomy Physical Advances at Jefferson - 1950 Policies of the Private Duty Nurses\u27 Registry Staff Activities, 1950-1951 Students\u27 Corner The Department of Surgical Research - Drs. Templeton and Gibbon White Haven and Barton Memorial Division

Management of Iatrogenic Urorectal Fistulae in Men with Pelvic Cancer

INTRODUCTION: Urorectal fistula (URF) is a devastating complication of pelvic cancer treatments and a surgical challenge for the reconstructive surgeon. We report a series of male patients with URF resulting from pelvic cancer treatments, specifically prostate (PCa), bladder (BCa), and rectal cancer (RCa), and explore the differences and impact on outcomes between purely surgical and non-surgical treatment modalities. METHODS: Between October 2008 and June 2015, 15 male patients, aged 59-78 years (mean 67), with URF induced by pelvic cancer treatments were identified in our institutions. Patients with a history of diverticulitis, inflammatory bowel disease, or other benign conditions were excluded. We reviewed the patients' medical records for symptoms, diagnostic tests performed, type and etiology of the fistula, type of surgical reconstruction, followup, and outcomes. RESULTS: Fourteen patients underwent surgical reconstruction. One patient developed metastatic disease before URF repair and, therefore, was excluded from this study. Mean followup (FU) was 32.7 months (14-79). All patients received diverting colostomy and temporary urinary diversion. An exclusively transperineal approach was used in nine (64.3%) patients and a combined abdominoperineal in five (35.7%). Overall successful URF closure was achieved in 12 (85.7%) patients, nine (64.3%) of whom at the first reconstructive attempt, two (14.3%) after two attempts (in our institution), and one (7.1%) after three attempts (two of which elsewhere). An interposition flap was used in seven (50%) patients. Surgical reconstruction failed ultimately in two (14.3%) patients who still have a colostomy and do not wish any further reconstruction. CONCLUSIONS: Our study has several limitations, including its retrospective nature and the heterogeneity of our small patient cohort. Nonetheless, although surgical reconstruction of URF may be extremely difficult and complex in the non-surgical/energy ablation patients, its successful reconstruction is possible in most through a transperineal, or a more aggressive abdominoperineal, approach with tissue interposition in selected patients.info:eu-repo/semantics/publishedVersio

Cutaneous endometriosis.

Cutaneous endometriosis is a disorder that primarily affects women of reproductive age. The disorder is most commonly associated with cyclical pain during menses, but it can be difficult to diagnose in the absence of these symptoms and requires biopsy testing for a definitive diagnosis. We report on a case of a 41-year-old patient undergoing hormonal therapy for infertility who presented with a painful firm subcutaneous nodule in the umbilicus. She was ultimately diagnosed with cutaneous endometriosis and underwent surgical excision. In this report, we discuss the differential diagnosis and comment on treatment options, including surgical excision with wide margins or treatment with hormonal agents, such as danazol or leuprolide. Finally, we discuss whether patients with cutaneous endometriosis should receive an additional evaluation for pelvic endometriosis

Utility of B-type natriuretic peptide in predicting medium-term mortality in patients undergoing major non-cardiac surgery

We assessed the ability of pre-operative B-type natriuretic peptide (BNP) levels to predict medium-term mortality in patients undergoing major noncardiac surgery. During a median 654 days follow-up 33 patients from a total cohort of 204 patients (16%) died. The optimal cut-off in this cohort, determined using a receiver operating characteristic curve, was >35pg.mL-1. This was associated with a 3.47-fold increase in the hazard of death (p=0.001) and had a sensitivity of 70% and a specificity of 68% for this outcome. These findings extend recent work demonstrating that BNP levels obtained before major noncardiac surgery can be used to predict peri-operative morbidity, and indicate that they also forecast medium-term mortality.This work was supported by a grant from TENOVUS Scotland. The Health Services Research Unit is core-funded by the Chief Scientists Office of the Scottish Executive Health Department.Peer reviewedAuthor versio

Availability and quality assessment of online nutrition information materials for pelvic cancer patients in the UK

Written information can be an essential source of support in the promotion of lifestyle changes after a cancer diagnosis. This study aimed to identify and assess the quality of available online Patient Information Materials (PIMs) in relation to diet and nutrition for pelvic cancer patients. The online sources of the National Health Service, cancer centres and charitable organisations throughout the UK were searched. Content was assessed using an evidence-based checklist, and readability with two validated formulas. Consumer feedback was sought through Patient and Public Involvement (PPI) groups. Forty PIMs were identified; four were designed specifically for pelvic cancers (bladder, bowel, prostate) and 36 were generic (relevant for all cancers). Most PIMs had a good content score, with PIMs from charities scoring higher overall than PIMs from cancer centres [32 (4) Vs 23 (11), P<0.001]. Seventy-three percent of PIMs had a readability score within acceptable levels (6th-8th grade; reading ability of 11-14 year-olds). PPI contributors found most PIMs useful and comprehensive but lacking specific information needed to meet individual needs. There is limited availability of online PIMs for cancer survivors and even fewer tailored to pelvic cancers. Most materials have comprehensive content and acceptable readability. Some PIMs may require improvemen

The comparison between presenting symptoms of ovarian cancer and other abdominal - pelvic cancers

Introduction: Diagnostic delays of ovarian cancer, has been attributed to the lack of a reliable and cost-effective screening test and presumption that ovarian cancer is  symptomatic in the early stages. To investigate presenting symptoms of ovarian cancer and compare with symptoms of other abdominal-pelvic cancersMethods: We reviewed the medical records of all women with abdominal-pelvic cancers between March, 2003 and March, 2005 in Shiraz medical centers to compare, presenting symptoms of ovarian cancer and other abdominal-pelvic cancers.Results: Of 168 women with a diagnosis of abdominal-pelvic cancers, ovarian cancer was diagnosed for 22 women. (Stage I: 0, Stage II: 2, Stage III: 10, Stage IV: 7 and 3 patientswithout staging.) The mean age of patients with ovarian cancer was 51/6.The sensation of abdominal mass was more common in women with ovarian cancer than other abdominalpelvic cancers (P=0.00l). Constipation was documented in the patients with colon cancer more than women with ovarian cancer (P=0.012), whereas urinary symptoms were more common in patients with ovarian cancer (P=0.004).Although the women with bladder cancer complained from urinary problems more than who had ovarian cancer (P=0.00l), but defecation problems and abdominal pain were more detected in patients with ovarian cancer (p=0.05). Conclusion: The most common cases of ovarian cancer present in the end stage that usually have poor prognosis. It can be associated to both patient and healthcare factors. This cancer is associated with many symptoms, but few symptoms are related to reproductive system. Sensation of abdominal mass, abdominal pain and urinary and defecation problems are the symptoms that can be associated with this cancer.Key words: Presenting Symptoms, Ovarian Cancer, and Abdominal-Pelvic Cancers

Symptom burden and health-related quality of life in cancer survivors undergoing hyperbaric oxygen therapy for pelvic late radiation tissue injuries : A mixed-methods study

Kurativ strålebehandling for kreft kan føre til alvorlige vevsstråleskader (LRTI). Det finnes imidlertid begrenset kunnskap om bekkenkreft-overleveres LRTI symptomer, psykisk belastning og helse-relatert livskvalitet (HRQOL). Hyperbar oksygenbehandling (HBOT) er en adjuvant, men lite studert, behandling for LRTI symptomer. Derfor var det overordnede formålet med denne studien å få økt forståelse av symptombyrde og HRQOL hos kreft-overlevere som gjennomgår HBOT for stråleskader i bekkenet. Pasienter som ble inkludert i studien ble rekruttert fra kreft-overlevere med bekken LRTI henvist til Norsk Nasjonal Enhet for Planlagt Hyperbar Oksygenbehandling. Her ble deltakerne behandlet med HBOT i enmannstrykkammer, og pustet rent oksygen ved et trykk på 2.4 atmosfære absolutt i 90 minutter en gang daglig i seks uker. En mixed-metode med et forklarende sekvensielt forskningsdesign ble benyttet. Data ble samlet inn sekvensielt ved hjelp av selvrapporterte spørreskjemaer på baseline (T1), ved avslutning HBOT (T2) og ved seks måneders oppfølging (T3), og dybdeintervju ved avslutning HBOT. Gjennom en kvantitativ tilnærming og tverrsnittsdesign studerte vi i Artikkel 1 symptombyrde, psykisk belastning og HRQOL hos kreft-overlevere med etablerte bekken LRTI symptomer sammenlignet med normpopulasjoner, og sammenhengen mellom disse faktorene før oppstart av HBOT. Totalt 107 deltakere (gjennomsnittsalder 64 år, 53% menn) ble inkludert. Sammenlignet med normpopulasjonen rapporterte deltakerne mer urinsymptomer (gjennomsnitt 68.7 vs. 89.5; p=.00; d=1.4) og tarmsymptomer (gjennomsnitt 62.5 vs. 92.4; p=.00; d=2.7), økt psykisk belastning (gjennomsnitt 13.4 vs. 10.3; p=.00; d=0.6), og generelt dårligere HRQOL (gjennomsnitt 54.9 vs. 71.2; p=.00; d=0.7). Høyere symptombyrde og høyere nivå av psykiske plager var assosiert med lavere HRQOL (r2=46%), men psykiske plager modererte ikke symptomenes påvirkning på HRQOL. Gjennom en kvalitativ metode og et fenomenologisk-hermeneutisk forskningsdesign, undersøkte vi i Artikkel 2 hvordan kreft-overlevere med bekken LRTI erfarte å gjennomgå HBOT. Data ble samlet inn via dybdeintervjuer med 20 deltakere. Intervjuene ble tatt opp på lydbånd, ordrett transkribert og analysert ved bruk av Systematisk Tekstkondensering. Fire hovedtemaer fra analysen synliggjorde informantenes erfaringer: 1) ‘Tilnærming til en ukjent verden’. Dette temaet belyste at tross informasjon i forkant av behandlingen, var informantene bekymret, men svært motiverte for HBOT, 2) ‘Fra å føle seg bekymret til å bli kjent’. Dette temaet utdypet HBOT som en prosess der en kombinasjon av relevant informasjon, klare rutiner, personsentrert omsorg var viktige faktorer for aksept og mestring av behandlingen, 3) ‘Et langvarig behandlingsforløp’. Dette temaet belyste at fraværet fra hjemmet og sosiale relasjoner var akseptable ettersom møte med medpasienter tillot et unikt fellesskap å utvikle seg, og 4) ‘Behandlingsforløpet gikk bedre enn forventet’. Dette temaet viste at de fleste deltakerne kun opplevde mindre, forbigående og svært tolerable bivirkninger av HBOT, hvorved majoriteten beskrev initial symptomlindring underveis i behandlingen. Gjennom en kvantitativ tilnærming og et før – og etter forskningsdesign, studerte vi i Artikkel 3 utviklingen av, og assossiasjonene mellom, symptomer på bekken LRTI og HRQOL etter HBOT ved slutten av behandlingen (T2), og ved seks måneders oppfølging (T3). Nittifem deltakere (gjennomsnittsalder 65 år, 52.6 % menn) ble inkludert. Resultatene indikerte at bekken LRTI symptomer, HRQOL symptom skala, søvn, diare, smerte, fatigue, generell HRQOL og alle funksjonsskalaer var signifikant forbedret seks måneder etter behandling (P-område =0.00-0.04). Endringer var til stede allerede ved slutten av behandlingen og opprettholdt eller ytterligere forbedret ved 6 måneders oppfølging. Det ble kun funnet en svak, men signifikant korrelasjon mellom endringer i symptomer og overordnet HRQOL ble funnet (Pearson r-område 0.20-0.27). I tillegg til resultatene fra de tre artiklene, bidrar sammenstillingen av de kvantitative og de kvalitative resultatene til en økt, omfattende og nyansert kunnskap og forståelse for deltakernes situasjon ved oppstart av behandlingen, behandlingsprosessen, deltakernes situasjon ved avslutning og seks-måneders oppfølging etter HBOT. De sammenslåtte resultatene fra før oppstart av HBOT indikerte stor symptombyrde, psykiske belastning, svekket HRQOL, som påvirket alle områder av livet. HBOT representerte en ukjent, men håpefull behandlingsmodalitet. De kvalitative funnene som beskriver selve behandlingsprosessen, viste at det var vanskelig for informantene å absorbere HBOT informasjonen. Deltakerne tilpasset seg imidlertid raskt til HBOT prosedyrene. Her var sykepleiernes oppfølging og omsorg avgjørende. Det langvarige HBOT forløpet, borte fra dagliglivet ble til en viss grad oppveid av støtte fra medpasienter. Ved behandlingsslutt viste de sammenslåtte resultatene forbedrede bekken LRTI symptomer, og de fleste HRQOL dimensjoner, samt at deltakerne erfarte minimale bivirkninger av HBOT. Ved seks måneders oppfølging indikerer de kvantitative resultatene ytterligere forbedrede LRTI symptomer og HRQOL. Så vidt vi vet er dette den første mixed-metode studien som studerer hele prosessen med symptombyrde, og HRQOL hos kreft-overlevere med stråleskader i bekkenet som gjennomgår HBOT. Kunnskapen fra denne avhandlingen viser behov for økt kunnskap og utdanning av helsepersonell knyttet til stråleskader i bekkenområdet, betydningen av systematisk kartlegging av symptomer på stråleskader og HRQOL etter stråling i bekkenområdet, god symptomlindring og opplæring av kreftoverleverne i adekvat symptombehandling og mestring. Videre gir resultatene fra denne studien sterke føringer for at kreftoverlevere med stråleskader i bekkenområdet og redusert HRQOL kan ha stor nytte av HBOT. Spesielt kan redusert symptombyrde og forbedret HRQOL med økt rolle – og sosial funksjon ha stor betydning for disse kreftoverleverne hverdagsliv. Selv om resultatene fra denne studien ikke kan generaliseres, bidrar den til viktig kunnskap på et lite utforsket område og en viktig basis både for klinisk praksis og videre forskning.Curative radiotherapy for cancer may lead to severe late radiation tissue injuries (LRTI). However, limited knowledge exists about pelvic cancer survivors’ LRTI symptoms, distress and health-related quality of life (HRQOL). Hyperbaric oxygen therapy (HBOT) is an adjuvant therapy for LRTI, but has only been studied to a limited extent. The overall purpose of this thesis was therefore to provide an increased understanding of the symptom burden and HRQOL of cancer survivors undergoing HBOT for pelvic LRTI. Patients enrolled in the study were recruited from cancer survivors with pelvic LRTI assigned to the Norwegian National Unit for Planned Hyperbaric Oxygen Treatment. Here, participants received HBOT in a mono-place pressure chamber, breathing pure oxygen at a pressure of 2.4 atmosphere absolute for 90 minutes once a day for six weeks. A mixed-methods approach with an explanatory sequential research design was adopted, whereby data was collected sequentially through self-reported questionnaires at baseline (T1), on completion (T2) and six months after HBOT (T3), and in-depth interviews were performed on completion of HBOT. Taking a quantitative approach with a descriptive cross-sectional research design, Paper 1 studied the symptom burden, distress and HRQOL in survivors with established pelvic LRTI compared to norm populations, and the relation between these factors at baseline. Here, 107 participants (mean age 64, 53% men) were included. Compared to norms, participants reported more urinary (mean 68.7 vs. 89.5; p=.00; d=1.4) and bowel symptoms (mean 62.5 vs. 92.4; p=.00; d=2.7), increased psychological distress (mean 13.4 vs. 10.3; p=.00; d=0.6), and overall poorer HRQOL (mean 54.9 vs. 71.2; p=.00; d=0.7). A higher symptom burden and higher levels of psychological distress were associated with lower HRQOL (r2=46%), but psychological distress did not moderate the influence of symptoms on HRQOL. Taking a qualitative approach with a phenomenological-hermeneutical research design, Paper 2 explored how cancer survivors with pelvic LRTI experienced undergoing HBOT. Data was collected via in-depth interviews with 20 participants. The interviews were audiotaped, verbatim transcribed and analysed using Systematic Text Condensation. Four main themes emerged from the analyses to describe the participants’ experience of HBOT: 1) ‘Approaching an unknown world’. This theme illuminated that, despite information prior to the treatment, informants were worried about, but highly motivated for HBOT; 2) ‘From feeling worried to becoming familiar’. This theme elaborated on HBOT as a process whereby a combination of relevant information, clear routines and person-centred care were important acceptance and coping factors during HBOT; 3) ‘A long lasting treatment course’. This theme showed that absence from home and social relations were acceptable, since meeting peer patients allowed a unique community to develop; and 4) ‘The treatment course went better than expected’. This theme elaborated on how most participants only experienced minor, temporary and highly tolerable side-effects of HBOT, where most participants described initial symptom relief during the treatment course. Taking a quantitative approach with a pre-test – post-test research design, Paper 3 studied the development of, and the associations between, symptoms of LRTI and HRQOL, with six-months follow-up after HBOT. Ninety-five participants (mean age 65 years, 52.6% men) were included. Pelvic LRTI, overall HRQOL, and all function scales and the HRQOL symptom scales of sleep, diarrhoea, pain and fatigue improved significantly six months after treatment (P-range =0.00-0.04). Changes were already present on the completion of HBOT and were maintained or further improved up to follow-up at T3. Only a weak significant correlation between changes in symptoms and overall HRQOL was found (Pearson r-range 0.20-0.27). In addition to the results from the three papers, the merging of the quantitative and qualitative results provides increased, comprehensive and nuanced understanding and knowledge of the participants’ situation at baseline and in the HBOT process, and the participants’ situation on completion of HBOT and at six-month follow-up. Here, the merged findings at baseline show that all areas of the participants’ lives were highly impaired, documented as a severe LTRI symptom burden, psychological distress and impaired HRQOL, whereby HBOT was expressed as a hopeful treatment opportunity. The qualitative data describing the HBOT process indicates that it was difficult for the participants to absorb the HBOT information provided before treatment. However, the participants adjusted quickly to the HBOT procedures, whereby the nurses’ follow-up and care were crucial. The long-lasting HBOT course away from daily life was to a certain degree outweighed by peer support. On completion of HBOT, the merged results indicated an improved symptom burden and improved HRQOL, and limited side-effects. At six-month follow-up, the quantitative results showed a further improvement from the end of HBOT in pelvic LRTI, and overall HRQOL. However, the participants still had pelvic LRTI and impaired HRQOL at follow-up. To the best of our knowledge this is the first mixed-methods study which studies the entire process of pelvic LRTI and HRQOL of cancer survivors with pelvic LRTI undergoing HBOT. The knowledge gained from this thesis illustrates the need for increased competence and education of healthcare professionals about pelvic LRTI, the importance of systematic assessment of pelvic LRTI symptoms and HRQOL after radiation, proper symptom management, and educating survivors in adequate symptom management and coping skills. Furthermore, the results provide strong evidence that cancer survivors with pelvic LRTI and impaired HRQOL may benefit from undergoing HBOT. In particular, reduced symptom severity and improved social and role function may influence daily living positively. Even if the results from this study cannot be generalised, the results do provide important knowledge in a field that has only been studied to a limited extent, and an important basis for clinical practice and further research. Doktorgradsavhandlin