Incidence of venous thromboembolism in patients with ovarian cancer receiving neoadjuvant chemotherapy: systematic review and meta-analysis.

OBJECTIVE: Venous thromboembolism is associated with significant patient morbidity, mortality, and can lead to delays in treatment for patients with cancer. The objectives of this study were to identify the incidence of venous thromboembolism in patients with advanced ovarian cancer receiving neoadjuvant chemotherapy, and identify risk factors for venous thromboembolism. METHODS: A systematic literature search of biomedical databases, including Ovid Medline, Web of Science, Scopus, CINAHL, and Embase was performed on December 6, 2022 and updated on December 21, 2023 for peer reviewed articles. Studies were included if they were cohort studies or randomized controlled trials that evaluated the incidence of venous thromboembolism for patients with ovarian cancer receiving neoadjuvant chemotherapy. Risk of bias assessment was performed using the Newcastle Ottawa Scale for cohort studies and the Cochrane risk of bias tool for randomized controlled trials. Random effects meta-analysis was used to pool results across studies. RESULTS: A total of 2636 studies were screened, and 11 were included in the review. Ten were retrospective cohort studies, and one was a randomized controlled trial. The incidence of venous thromboembolism in the included studies ranged from 0% to 18.9%. The pooled incidence rate of venous thromboembolism was 10% (95% confidence interval (CI) 7% to 13%). This remained significant when restricted to only studies with a low risk of bias (pooled incidence of 11%, 95% CI 9% to 14%). Body mass index of ≥30 kg/m2 was a significant risk factor for venous thromboembolism with a pooled odds ratio of 1.76 (95% CI 1.13 to 2.76) CONCLUSIONS: The results from this study demonstrated a 10% incidence of venous thromboembolism for patients with advanced ovarian cancer receiving neoadjuvant chemotherapy. This suggests that there may be a role for universal thromboprophylaxis in this population. TRIAL REGISTRATION: PROSPERO CRD42022339602.

Effect of transversus abdominis plane block on postoperative outcomes in gynecologic oncology patients managed on an Enhanced Recovery After Surgery pathway.

OBJECTIVES: To characterize the effect of transversus abdominis plane (TAP) blocks on post-operative outcomes in patients undergoing laparotomy for gynecologic malignancy. METHODS: This retrospective cohort study assessed patients undergoing laparotomy in 2016-2017 and 2020 in Alberta, Canada. The primary outcome was opioid consumption in oral morphine milligram equivalent (MME). Secondary outcomes included maximum pain scores, length of stay, and patient-controlled analgesia (PCA) use. Outcomes were compared using t-test with subgroup analysis by NSAID use. Multivariate regression modelling was performed for potential confounders. RESULTS: Data was collected on 956 patients; 828 received a TAP block, 128 did not. Opioid use in the first 24 h was lower in the TAP block group (35.9 mg MME vs 44.5 mg MME, p = 0.0294), without any increase in pain scores, this did not remain significant after regression analysis. Patients with TAP blocks had significant reduced mean length of stay (3.2 days vs. 5.0 days, p < 0.0001), and PCA use (19.9% vs. 56.25%, p < 0.0001). On subgroup analysis of patients that did not receive NSAIDs (n = 160), mean opioid use was decreased in those patients with TAP blocks compared to those without TAP blocks in the first 24 h (36.1 mg vs. 61.2 mg, p = 0.0017), and at 24 to 48 h (16.3 mg vs. 51.0 mg, p < 0.0001). CONCLUSIONS: Surgeon-administered TAP blocks were associated with decreased length of stay and post-operative opioid use in patients not receiving scheduled NSAIDs. This decrease in opioid use was not associated with any increase in average or maximum pain scores.

Cannabis use in gynecologic cancer patients in a Canadian cancer center.

Objective: The primary objective of this study was to estimate the prevalence of cannabis use in patients with gynecologic malignancies and to describe patterns of cannabis use. Secondary objectives included identifying sources of cannabis information used by patients. Methods: This is a single institution cross sectional survey conducted in Calgary, Alberta. Patients with a current or prior gynecologic cancer diagnosis were considered for inclusion. Planned analysis included descriptive statistics of patient demographics, and the patterns of cannabis use were described using frequencies and proportions. Results: Forty-six patients participated in the survey. The most common disease sites were ovarian cancer and uterine cancer, with the majority of patients receiving chemotherapy as part of their treatment (n = 35). Seventeen participants were current cannabis users (37%). The most common symptoms participants used cannabis for were pain (9/17), anxiety (9/17), and insomnia (9/17).Most patients using cannabis did not have a prescription and obtained their cannabis from a recreational dispensary (11/17). Many participants using cannabis had not talked to their doctor about cannabis (9/17). Instead, the most common sources of information about cannabis were cannabis retailers (20/46), and friends/family (20/46). Over 50% of patients would be interested in discussing cannabis if their physician broached the subject (26/46). Conclusions: The results from this survey indicate that patients would like to talk to their oncologist about cannabis. Further research is needed to inform physician training and direct patient education to ensure that patients have access to unbiased, evidence-based information to make decisions about cannabis use.

Examining ACCURE's Nurse Navigation Through an Antiracist Lens: Transparency and Accountability in Cancer Care.

There are persistent disparities in the delivery of cancer treatment, with Black patients receiving fewer of the recommended cancer treatment cycles than their White counterparts on average. To enhance racial equity in cancer care, innovative methods that apply antiracist principles to health promotion interventions are needed. The parent study for the current analysis, the Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) intervention, was a system-change intervention that successfully eliminated the Black-White disparity in cancer treatment completion among patients with early-stage breast and lung cancer. The intervention included specially trained nurse navigators who leveraged real-time data to follow-up with patients during their treatment journeys. Community and academic research partners conducted thematic analysis on all clinical notes (n = 3,251) written by ACCURE navigators after each contact with patients in the specialized navigation arm (n = 162). Analysis was informed by transparency and accountability, principles adapted from the antiracist resource Undoing Racism and determined as barriers to treatment completion through prior research that informed ACCURE. We identified six themes in the navigator notes that demonstrated enhanced accountability of the care system to patient needs. Underlying these themes was a process of enhanced data transparency that allowed navigators to provide tailored patient support. Themes include (1) patient-centered advocacy, (2) addressing system barriers to care, (3) connection to resources, (4) re-engaging patients after lapsed treatment, (5) addressing symptoms and side effects, and (6) emotional support. Future interventions should incorporate transparency and accountability mechanisms and examine the impact on racial equity in cancer care.

Structural competency in pre-health and health professional learning: A scoping review.

Structural competency training provides guidance to healthcare providers on recognizing and addressing structural factors leading to health inequities. To inform the evidence-based progression of structural competency curriculum development, this study was designed to map the current state of the literature on structural competency training with pre-health students, healthcare professional students, and/or healthcare professionals. We performed a scoping review and identified peer-reviewed, primary research articles assessing structural competency training interventions. The category of learners, timing of the structural competency training, types of teaching and learning activities used, instruments used to measure training outcomes, and evaluation criteria were examined. Eleven (n = 11) articles met inclusion criteria, addressing all training levels, and largely focused on medical education. Active learning strategies and researcher-developed instruments to measure training outcomes were most used. Evaluation criteria largely focused on trainees' affective reactions, utility assessments, and direct measure of the trainee learning. We suggest designing interprofessional structural competency education with an emphasis on active learning strategies and standardized training curricula. Evaluation instruments integrated at different points in the health professional learning trajectory are important for evidence-based progression in curriculum development focused on achieving structural competency.

Perspectives of Indigenous medical students on a postgraduate Indigenous admissions pathway.

Objective: The objective of this study is to assess the perceptions of Indigenous medical students on postgraduate admissions through an Indigenous admissions pathway (IAP), and to determine what factors may influence Indigenous medical students' choice of residency training program. Methods: We distributed a survey to self-identified Indigenous students at settler Canadian medical schools. The survey questioned the students' acceptability of an IAP, and what factors would influence application through an IAP. Analysis included descriptive statistics and thematic analysis of open-ended questions. Results: Thirty-six participants responded to the survey. Location and proximity to family or support system were the most important factors in choosing a residency program. Participants identified mentorship from Indigenous physicians and community involvement as being important features of a residency program that has an IAP. Eighty-one percent of participants felt the availability of an IAP would influence their choice of residency program. Fear of judgement or stigma, concern about entrance requirements, and program logistics were identified as barriers to applying to residency through an IAP. All participants believed that an IAP would have a positive influence on the healthcare system more broadly. Conclusions: An IAP appears to be an acceptable residency application format to Indigenous students but cannot exist in isolation. It is important for programs to consider the needs and safety of Indigenous trainees within residency programs.

Objectif: L'objectif de cette étude était d'avoir le point de vue des étudiants en médecine autochtones sur une éventuelle voie d'admission aux études postdoctorales réservée aux candidats autochtones et de relever les facteurs qui influenceraient leur choix de programme de résidence. Méthodes: Nous avons fait parvenir un questionnaire aux étudiants inscrits dans les facultés de médecine canadiennes qui se définissent comme Autochtones. L'enquête portait sur l'acceptabilité par les étudiants d'un programme d'admission pour candidats autochtones (PACA) et sur les facteurs qui influenceraient leur choix de poser leur candidature dans le cadre d'un PACA. Les données ont été évaluées par des méthodes statistiques descriptives et par une analyse thématique des questions ouvertes. Résultats: Trente-six participants ont répondu à l'enquête. Le lieu et la proximité de la famille ou du réseau de soutien ressortent comme les facteurs les plus importants dans le choix d'un programme de résidence. Les répondants attachent également de l'importance à l'existence d'un mentorat de la part de médecins autochtones et à une participation de la communauté dans le cadre d'un programme de résidence doté d'un PACA. Quatre-vingt-un pour cent des participants ont estimé que l'existence d'un PACA influencerait leur choix de programme de résidence. La crainte d'être jugé ou stigmatisé, et une inquiétude par rapport aux conditions d'admission et la logistique du programme ont été identifiées comme des obstacles à la présentation d'une demande de résidence dans le cadre d'un PACA. Les participants sont unanimes quant à l'influence positive d'un tel programme sur le système de soins de santé en général. Conclusions: Les étudiants autochtones trouvent la formule d'une voie d'admission à la résidence réservée aux candidats autochtones acceptable, à condition qu'elle ne soit pas un élément isolé et qu'on tienne compte des besoins et de la sécurité des étudiants dans le cadre des programmes de résidence eux-mêmes.

Lessons Learned: The Varied Responses of Massachusetts' Local Health Departments During the COVID-19 Pandemic.

CONTEXT: Massachusetts' decentralized public health model holds tightly to its founding principle of home rule and a board of health system established in 1799. Consequently, Massachusetts has more local health departments (n = 351) than any other state. During COVID-19, each health department, steeped in centuries of independence, launched its own response to the pandemic. OBJECTIVES: To analyze local public health resources and responses to COVID-19. DESIGN: Semistructured interviews and a survey gathered quantitative and qualitative information about communities' responses and resources before and during the pandemic. Municipality demographics (American Community Survey) served as a proxy for community health literacy. We tracked the frequency and content of local board of health meetings using minutes and agendas; we rated the quality of COVID-19 communications on town Web sites. SETTING: The first 6 months of the COVID-19 pandemic in Massachusetts: March-August 2020. PARTICIPANTS: Health directors and agents in 10 south-central Massachusetts municipalities, identified as the point of contact by the Academic Public Health Corps. MAIN OUTCOME MEASURES: We measured municipality resources using self-reported budgets, staffing levels, and demographic-based estimates of community health literacy. We identified COVID-19 responses through communities' self-reported efforts, information on town Web sites, and meeting minutes and agendas. RESULTS: Municipalities excelled in communicating with residents, local businesses, and neighboring towns but lacked the staffing and funding for an efficient and coordinated response. On average, municipal budgets ranged from $5 to $16 per capita, and COVID-19 consumed 75% of health department staff time. All respondents noted extreme workload increases. While municipal Web sites received high scores for Accurate Information, other categories (Navigability; Timeliness; Information Present) were less than 50%. CONCLUSIONS: Increased support for regionalization and sustained public health funding would improve local health responses during complex emergencies in states with local public health administration.

MedFTs' Role in the Recruitment and Retention of a Diverse Physician Population: A Conceptual Model.

Recruitment and retention of a diverse physician population across stages of medical education is essential for the success of the healthcare system. MedFTs have a unique role to play in advocacy and intervention related to the recruitment and retention of these physicians at all stages of their education and career. As MedFTs expand their influence in healthcare systems, they must ground into their fundamental theories, like systems theory and the Four World View, all while advancing in their professional competencies to attune their skills and those whom they are entrusted in training. The conceptual model, MedFTs' Role in the Recruitment and Retention of a Diverse Physician Population, provides a framework for MedFTs to use their influence to enact change related to diversity and equity in the healthcare system. In addition, the model provides avenues for intervention and advocacy on the part of the MedFT related to each of the four worlds and their specific role(s) in the health care.

Linking Technology to Address the Social and Medical Determinants of Health for Safe Medicines Use.

OBJECTIVES: Both social and medical factors can negatively affect health outcomes, especially in vulnerable populations. To address these 2 types of factors in a postdischarge population, 2 nonprofit organizations collaborated to combine their novel decision support programs and address the question: Could combined programs have greater potential for improved health outcomes? METHODS: HomeMeds, a social health program in which trained social services staff make home visits to vulnerable clients, was combined with MedSafety Scan, a medical health, clinical decision support tool. Data captured in the home visits were entered into the HomeMeds and MedSafety Scan programs to detect those patients at the greatest risk of adverse health outcomes because of medications. RESULTS: Patients (n = 108; mean age, 77 years; multiple comorbidities and LACE+ (length of stay, acuity, comorbidities, emergency department visits [hospital index]; score >29) received a postdischarge home visit by trained social services staff. The number of drugs reported as being taken was 10.4 ± 5.1 (range, 1-26), which was less than prescribed at discharge in 62% of patients (range, 1-8). Both programs detected a serious risk of medication-induced harm, mostly from different causes such as drug-drug interactions or for use not recommended in the elderly. CONCLUSIONS: Combined analysis of data from 2 novel decision support programs yielded complementary findings that together address both medical and social determinants of health. These have the potential to reduce medication-induced harm, costly rehospitalization, and/or emergency department visits and support the further evaluation of this combined approach in other vulnerable populations such as the seriously mentally ill, frail, those confined to home, opioid dependent, or otherwise impaired.

Expanding the Reach of an Evidence-Based, System-Level, Racial Equity Intervention: Translating ACCURE to the Maternal Healthcare and Education Systems.

The abundance of literature documenting the impact of racism on health disparities requires additional theoretical, statistical, and conceptual contributions to illustrate how anti-racist interventions can be an important strategy to reduce racial inequities and improve population health. Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) was an NIH-funded intervention that utilized an antiracism lens and community-based participatory research (CBPR) approaches to address Black-White disparities in cancer treatment completion. ACCURE emphasized change at the institutional level of healthcare systems through two primary principles of antiracism organizing: transparency and accountability. ACCURE was successful in eliminating the treatment completion disparity and improved completion rates for breast and lung cancer for all participants in the study. The structural nature of the ACCURE intervention creates an opportunity for applications in other health outcomes, as well as within educational institutions that represent social determinants of health. We are focusing on the maternal healthcare and K-12 education systems in particular because of the dire racial inequities faced by pregnant people and school-aged children. In this article, we hypothesize cross-systems translation of a system-level intervention exploring how key characteristics of ACCURE can be implemented in different institutions. Using core elements of ACCURE (i.e., community partners, milestone tracker, navigator, champion, and racial equity training), we present a framework that extends ACCURE's approach to the maternal healthcare and K-12 school systems. This framework provides practical, evidence-based antiracism strategies that can be applied and evaluated in other systems to address widespread structural inequities.

Venous Thromboembolism in Patients Receiving Neoadjuvant Chemotherapy for Advanced Ovarian Cancer and Impact on Survival.

OBJECTIVE: To determine the incidence of venous thromboembolism (VTE) in patients with ovarian cancer receiving neoadjuvant chemotherapy (NACT), identify risk factors for VTE, and assess the effect of VTE on treatment trajectory and overall survival. METHODS: This is a retrospective cohort study of patients diagnosed with ovarian, fallopian tube, or primary peritoneal cancer treated with NACT between 2013 to 2016 in Alberta, Canada. The primary outcome was incidence of VTE during NACT. Secondary outcomes were risk factors for VTE and overall survival. Data related to patient demographics, cancer treatment, and incidence of VTE were collected. Statistical analyses included Kaplan-Meier estimates and univariate and multivariate Cox regression analysis. RESULTS: A total of 284 patients were included in this study. Average age at diagnosis was 63.8 years. The incidence of VTE during NACT was 13.3%. Patients with VTE were less likely to undergo interval debulking surgery (58.3%) than patients without VTE (78.6%). Kaplan-Meier estimates demonstrated a decrease in overall survival in patients who had VTE during NACT (15.0 mo; 95% CI 14.5-16.5) compared with patients who did not (26.8 mo; 95% CI 22.8-30.9) (P < 0.0001). Multivariate analysis identified albumin <35 g/L, BMI >30 kg/m2, and non-serous histology as risk factors for VTE. CONCLUSION: The risk of VTE in this cohort was 13.3%, which was associated with decreased overall survival. These findings suggest that thromboprophylaxis may have a role in this patient population.

Forced and Coerced Sterilization of Indigenous Peoples: Considerations for Health Care Providers.

Forced and coerced sterilization refers to the provision of permanent contraception without true informed consent. In Canada, this topic is particularly relevant to Indigenous Peoples because of this country's history of racialized eugenics programs. In this commentary, we briefly review the history of forced and coerced sterilization in Canada, describe the clinical considerations for health care providers who work with Indigenous patients in this context, and outline calls to action for health care providers and organizations to support the provision of culturally appropriate reproductive health care to Indigenous people.

Development of a medical education podcast in obstetrics and gynecology.

Podcasts are used in medical education to supplement conventional teaching methods such as lectures and reading. We identified a lack of Canadian medical education podcasts covering obstetrics and gynecology (Ob/Gyn) content and created a podcast specific for Canadian medical students and residents. The podcast called "OB-G in YEG" is freely available and currently has fourteen episodes that cover common topics in Ob/Gyn. We describe the process for creating a high-quality medical education resource that is widely accessible to learners that readers may be able to replicate in their own discipline.

Les baladodiffusions sont utilisées dans l'éducation médicale en complément aux méthodes d'enseignement traditionnelles comme les cours magistraux et la lecture de textes. Ayant constaté un manque de baladodiffusions d'enseignement dans les domaines de l'obstétrique et de la gynécologie (OB/GY) au Canada, nous avons créé une telle émission destinée aux étudiants et aux résidents en médecine de ce pays. La baladodiffusion, intitulée « OB-G in YEG ¼, est disponible gratuitement et elle comporte actuellement onze épisodes sur des sujets d'intérêt général touchant à l'obstétrique et à la gynécologie. Nous décrivons le processus de création d'une ressource d'enseignement médical de qualité, qui est largement accessible aux apprenants et que les lecteurs seraient peut-être en mesure de reproduire dans leur propre discipline.

Epithelioid trophoblastic tumor presenting as a Caesarean scar defect: A case report.

BACKGROUND: Epithelioid trophoblastic tumor is a rare form of gestational trophoblastic neoplasia. We present the first known case of this rare malignancy presenting as a Caesarean scar defect. CASE: A patient with 3 prior Caesarean sections presented with vaginal bleeding 2 months following management of retained products of conception. Her hCG was negative. She underwent surgical repair of a Caesarean scar defect, and pathology was consistent with epithelioid trophoblastic tumor. CONCLUSION: This case highlights the possibility of malignancy presenting to the general gynecologist as a Caesarean scar defect. The diagnosis of gestational trophoblastic neoplasia should always be considered in the differential diagnosis of a patient with postpartum vaginal bleeding. Limited evidence on fertility conserving treatment of epithelioid trophoblastic tumors does not seem favorable.

'It's like you don't have a roadmap really': using an antiracism framework to analyze patients' encounters in the cancer system.

Background: Cancer patients can experience healthcare system-related challenges during the course of their treatment. Yet, little is known about how these challenges might affect the quality and completion of cancer treatment for all patients, and particularly for patients of color. Accountability for Cancer Care through Undoing Racism and Equity is a multi-component, community-based participatory research intervention to reduce Black-White cancer care disparities. This formative work aimed to understand patients' cancer center experiences, explore racial differences in experiences, and inform systems-level interventions.Methods: Twenty-seven breast and lung cancer patients at two cancer centers participated in focus groups, grouped by race and cancer type. Participants were asked about what they found empowering and disempowering regarding their cancer care experiences. The community-guided analysis used a racial equity approach to identify racial differences in care experiences.Results: For Black and White patients, fear, uncertainty, and incomplete knowledge were disempowering; trust in providers and a sense of control were empowering. Although participants denied differential treatment due to race, analysis revealed implicit Black-White differences in care.Conclusions: Most of the challenges participants faced were related to lack of transparency, such that improvements in communication, particularly two-way communication could greatly improve patients' interaction with the system. Pathways for accountability can also be built into a system that allows patients to find solutions for their problems with the system itself. Participants' insights suggest the need for patient-centered, systems-level interventions to improve care experiences and reduce disparities.

Retained Shotgun Pellets in the Vulva: Case Report.

BACKGROUND: Vulvar trauma is relatively uncommon and typically occurs in accidental or sports-related injuries. There is limited literature for management of penetrating trauma to the vulva. CASE: A 38-year-old G9, P9 woman presented to the gynaecology service for assessment of vulvar injury after a gunshot wound to the right lateral thigh. She underwent initial stabilization and operative management by the Trauma and Plastic Surgery services for predominantly soft-tissue injuries. Multiple gunshot pellets were found embedded in the right labia majora and medial thigh. On assessment, surgical removal was deemed necessary on the basis of symptoms and potential for functional impairment. CONCLUSION: We present the first reported case on the management of vulvar injury secondary to penetrating trauma. The principles of non-obstetrical vulvar trauma management are discussed.

The Other Side of Through: Young Breast Cancer Survivors' Spectrum of Sexual and Reproductive Health Needs.

The long-term reproductive health impact of cancer treatments is a concern for premenopausal women with a history of breast cancer. This study examined the unmet sexual and reproductive health needs of breast cancer survivors, as well as concordances and discordances in needs by childbearing status and race. We interviewed 17 women diagnosed with breast cancer between the ages of 18 and 45 years and living in North Carolina. To analyze these data, we used the Sort and Sift, Think and Shift© method, a multidimensional qualitative analysis approach. We learned that breast cancer survivors (a) received limited reproductive health information, (b) desired realistic expectations of conceiving postcancer, (c) struggled with adjusting to their altered physical appearance, and (d) had menopause symptoms that led to sexual health and quality of life issues. Breast cancer survivors are in need of and desire more education and resources to address their sexual and reproductive health concerns.

Racial Differences in the Influence of Health Care System Factors on Informal Support for Cancer Care Among Black and White Breast and Lung Cancer Survivors.

This retrospective, secondary qualitative analysis investigates whether health system factors influence social support among Black and white breast and lung cancer survivors and racial differences in support. These data come from race- and cancer-stratified focus groups (n = 6) and interviews (n = 2) to inform a randomized controlled trial utilizing antiracism and community-based participatory research approaches. Findings indicate social support was helpful for overcoming treatment-related challenges, including symptom management and patient-provider communication; racial differences in support needs and provision were noted. Resources within individual support networks reflect broader sociostructural factors. Reliance on family/friends to fill gaps in cancer care may exacerbate racial disparities.