Delays in Cervical Cancer Treatment Initiation for Patients Living With or Without HIV in Botswana: An Observational Cohort Analysis (2015-2019).

PURPOSE: To assess delays in treatment initiation of chemoradiation or radiation alone for patients with advanced stage cervical cancer in Botswana. METHODS AND MATERIALS: Females with locally advanced cervical cancer (stages IB2-IVB) were prospectively enrolled in an observational cohort study from 2015 to 2019. We evaluated delays at 30, 60, 90, 120, 150, and 180 or greater days between the date of diagnosis and treatment initiation. Factors associated with overall survival were modeled with multivariable Cox proportional hazards regression (aHR). Associations between delays in cervical cancer treatment initiation were evaluated via univariable logistic regression. RESULTS: Among the 556 patients included (median age = 47.9 years), 386 (69.4%) were females living with HIV with a median CD4 count of 448.0 cells/µL (IQR, 283.0-647.5 cells/µL) at diagnosis. Most patients had stages 2 (38.1%) or 3 (34.5%) cervical cancer. Early-stage patients experienced longer delays in treatment initiation compared to late-stage patients (P = .033). Early-stage patients with delays ≥90 days and pathology diagnosis between 2016 and 2019 (aHR, 0.34; P < .001) versus <90 days had a decreased risk of mortality, and those with delays ≥90 days and pathology diagnosis before 2016 (aHR, 5.67; P = .022) versus <90 days had an increased risk of mortality. Late-stage patients with delays ≥120 days and pathology diagnosis between 2018 and 2019 (aHR, 1.98; P = .025) versus <120 days had an increased risk of mortality. Early-stage patients with pathology diagnosis between 2016 and 2019 (odds ratio, 2.32; P = .043) versus before 2016 were more likely to experience delays ≥90 days, and late-stage patients who traveled >100 km to the treatment facility (odds ratio, 2.83; P < .001) versus <100 km were more likely to experience delays ≥120 days. CONCLUSIONS: Delays in care are common in Botswana, particularly for those living farther from the treatment clinic and at advanced stages. This paper is among the first to show an association between treatment delays and worsened overall survival at advanced stages of cervical cancer, highlighting the need for interventions to help patients receive timely care in global settings.

Outcomes of neoadjuvant chemotherapy and radical hysterectomy for locally advanced cervical cancer at Kigali University Teaching Hospital, Rwanda: a retrospective descriptive study.

BACKGROUND: Half of countries in Africa lack access to radiation (RT), which is essential for standard treatment of locally advanced cervical cancers. We evaluated outcomes for patients treated with neoadjuvant chemotherapy (NACT) followed by radical hysterectomy in settings where no RT is available. METHODS: We performed a retrospective descriptive study of all patients with FIGO stage IB2-IIA2 and some exceptional stage IIB cases who received NACT and surgery at Kigali University Teaching Hospital in Rwanda. Patients were treated with NACT consisting of carboplatin and paclitaxel once every 3 weeks for 3-4 cycles before radical hysterectomy. We calculated recurrence rates and overall survival (OS) rate was determined by Kaplan-Meier estimates. RESULTS: Between May 2016 and October 2018, 57 patients underwent NACT and 43 (75.4%) were candidates for radical hysterectomy after clinical response assessment. Among the 43 patients who received NACT and surgery, the median age was 56 years, 14% were HIV positive, and FIGO stage distribution was: IB2 (32.6%), IIA1 (7.0%), IIA2 (51.2%) and IIB (9.3%). Thirty-nine (96%) patients received 3 cycles and 4 (4%) received 4 cycles of NACT. Thirty-eight (88.4%) patients underwent radical hysterectomy as planned and 5 (11.6%) had surgery aborted due to grossly metastatic disease. Two patients were lost to follow up after surgery and excluded from survival analysis. For the remaining 41 patients with median follow-up time of 34.4 months, 32 (78%) were alive with no evidence of recurrence, and 8 (20%) were alive with recurrence. One patient died of an unrelated cancer. The 3-year OS rate for the 41 patients who underwent NACT and surgery was 80.8% with a recurrence rate of 20%. CONCLUSIONS: Neoadjuvant chemotherapy with radical hysterectomy is a feasible treatment option for locally advanced cervical cancer in settings with limited access to RT. With an increase in gynecologic oncologists skilled at radical surgery, this approach may be a more widely available alternative treatment option in countries without radiation facilities.

Burn and Trauma Burden and Screening for Interpersonal Violence During the COVID-19 Pandemic.

INTRODUCTION: Nationwide shelter-in-place (SIP) orders during the pandemic have had long-lasting effects, including increased rates of domestic violence and interpersonal violence. Screening for violence varies by institution, which tool is used, and when. Given increases in burn and trauma admissions over the course of the pandemic, we sought to examine trends at our institution during this time period to better guide care and anticipate system-level effects. METHODS: We performed a retrospective cohort study of pediatric burn and adult burn and trauma patients at our level 1 trauma/burn center between March-May 2019 and March-May 2020. Home safety screening was performed by nursing staff using a 1-part screening questionnaire. Patients presenting before March 15, 2020, were defined as "pre-SIP; " between March 16-May 19, 2020, were "during SIP; " and those after May 19, 2020, were designated as "post-SIP." Descriptive and chi-square statistics were used. Demographic, injury patterns, and screening information were collected. RESULTS: Blunt trauma comprised 60% of injuries, followed by burns (30%) then penetrating injury (7%). Over the entire time period analyzed, 1822 patients had documented home safety screening; ∼2% of patients screened reported a safety concern pre-SIP, compared to 3% of patients during SIP. There were higher rates of burns and penetrating injury during SIP compared to other periods (P ≤ 0.0001). Home safety screening rates were 94%-95% pre- and during SIP, but dropped to 85% post-SIP (P < 0.0001). Home safety concerns were reported almost 2% of the time pre-SIP and 3% during SIP (P = 0.016). CONCLUSIONS: We noted an increase in trauma and burns during and after SIP orders, consistent with the experiences of other institutions. Implementation of a nurse-driven screening process demonstrated high compliance with appropriate referrals. The burden of burn and traumatic injury remains significant, highlighting a need for continued psychosocial screening and the provision of psychosocial support resources in the acute trauma setting.

Body image and Black African women: A comparative study of Kenya and Nigeria.

Very few cross-national studies on body image focus on Black African women. In this study, a comparative analytical approach and sociocultural theory framework was utilized in examining measures of body image among 209 Kenyan and Nigerian women aged 18-69 (M = 34.4, SD = 7.81). We examined both weight-related and non-weight-related aspects of appearance, including hair texture, skin tone, and other racialized features. The regional samples were compared on scores of internalized Eurocentric beauty ideals, skin color satisfaction, objectified body consciousness, racialized body image satisfaction, and other demographic metrics. Kenyan and Nigerian women showed differences across multiple body image measures. Nigerian women showed thinner body ideals compared to Kenyan women and also endorsed higher skin color satisfaction, racialized body dissatisfaction, and internalized Eurocentric beauty idealization. Kenyan women showed higher levels of objectified body consciousness. An indirect effect of nationality was observed with internalized Eurocentric beauty ideals mediating differences in racialized body dissatisfaction and objectified body shame. Attention to regional variation in appearance satisfaction may deepen understandings of the particular sociocultural influences impacting body image among populations of Black African women.

Optimizing Respiratory Therapy Resources by De-Implementing Low-Value Care.

BACKGROUND: Our institution was experiencing a respiratory therapy staffing crisis during the COVID-19 pandemic, in part due to excessive workload. We identified an opportunity to reduce burden by limiting use of 3% hypertonic saline and/or N-acetylcysteine nebulizer therapies (3%HTS/NAC). METHODS: Leveraging the science of de-implementation, we established a policy empowering respiratory therapists to discontinue 3%HTS/NAC not meeting the American Association for Respiratory Care (AARC) Clinical Practice Guideline: Effectiveness of Pharmacologic Airway Clearance Therapies in Hospitalized Patients. After a 3-month period of educating physicians and advanced practice practitioners the policy went to into effect. Outcomes measured included monthly number of treatments, orders, and full-time employees associated with administering nebulized 3%HTS/NAC. RESULTS: Post policy activation, the monthly mean 3%HTS/NAC treatments were significantly reduced to 547.5 ± 284.3 from 3,565.2 ± 596.4 (P < .001) as were the associated monthly mean of full-time employees, 0.8 ± 0.41 from 5.1 ± 0.86 (P < .001). The monthly mean 3%HTS/NAC orders also fell to 93.8 ± 31.5 from 370.0 ± 46.9 (P < .001). Monthly mean non-3%HTS/NAC treatments remained stable; post policy was 3,089.4 ± 611.4 and baseline 3,279.6 ± 695.0 (P = 1.0). CONCLUSIONS: Implementing a policy that empowers respiratory therapists to promote adherence to AARC Clinical Guidelines reduced low-value therapies, costs, and staffing needs.

Stage and outcomes of invasive cervical cancer patients in Botswana: A prospective cohort study from 2013 to 2020.

Objective: To present the stage distribution, patterns of care, and outcomes of patients from Botswana with invasive cervical cancer, living with or without HIV. Methods: Between 2013 and 2020, women with cervical cancer were prospectively enrolled in an observational cohort study. Results: A total of 1,043 patients were enrolled; 69% were women living with HIV. The median age of the cohort was 47 years (interquartile range [IQR] 40-58 years), with women living with HIV presenting at a younger age compared to women without HIV (44 versus 61 years, p < 0.001). Among women living with HIV, the median CD4 count at the time of cancer diagnosis was 429.5 cells/µL (IQR 240-619.5 cells/µL), 13% had a detectable viral load, and 95% were on antiretroviral therapy. In regard to treatment, 6% (n = 58) underwent surgery, 33% (n = 341) received radiation therapy, 51% (n = 531) received chemoradiation, and 7% (n = 76) did not receive treatment. Stage distribution in the cohort was as follows: I 17% (n = 173), II 37% (n = 388), III 35% (n = 368), and IV 8% (n = 88). For all patients, 2-year OS was 67%. In multivariable Cox regression, worse OS was associated with stage: II (HR 1.91, p = 0.007), III (HR 3.99, p < 0.001), and IV (HR 5.06, p < 0.001) compared to stage I. Improved OS was associated with hemoglobin > 10 g/dL (HR 0.51, p < 0.001) compared to Hb ≤ 10 g/dL. Conclusions: Among women in Botswana with cervical cancer, most patients presented with stage II or III disease warranting radiation therapy or chemoradiation. While two-thirds of cervical cancer patients were women living with HIV, HIV did not impact OS.

Effect of implementing an enhanced recovery protocol for pediatric colorectal surgery on complication rate, length of stay, and opioid use in children.

Introduction In the past two decades, Enhanced Recovery After Surgery (ERAS) pathways for adults have improved efficiency of care and decreased length of stay (LOS) without increasing postoperative complications. The effects of enhanced recovery pathways for children are less well known. In this retrospective cohort study, we evaluated the effects of an enhanced recovery protocol (ERP) implementation in children undergoing colorectal surgery. Methods We introduced a colorectal ERP in 2017. Children and young adults (ages 2-22 years) were divided into pre-intervention (2014-2016) and post-intervention groups (2017-2019) for analysis. We abstracted data, including demographics, primary surgery, LOS, postoperative pain scores, and postoperative complications. Results A total of 432 patients were included. Of those,148 (34%) were pre-ERP implementation and 284 (66%) were post-ERP implementation. Post-ERP patients experienced significantly shorter LOS (5.7 vs. 8.3 days, p<0.01); required less intraoperative local anesthetic (9.5% vs. 38.5%, p<0.01) because 55% of patients received an epidural and 18% received an abdominal plane block; and used less postoperative opioid (62.5% vs. 98.7%, p<0.01) than did pre-ERAS patients. After protocol implementation, average pain scores were lower on postoperative day 1 (3.6 vs. 4.5, p<0.05) and across the hospitalization (3.0 vs. 4.0, p<0.01). Conclusion Enhanced recovery pathways decrease LOS, opioid use, and postoperative pain scores for children undergoing colorectal surgery and should be considered for this patient population.

Risk Behavioral Contexts in Adolescence of Obese Adults.

PURPOSE: Previous research suggests that poor nutrition, physical activity, sleep, and social/emotional climate are associated with weight gain. However, few empirical studies have examined how these factors relate to each other in adolescents who are later obese. Are these factors uniformly present, or do some co-occur or occur independently? This study seeks to identify subgroups of obese individuals at ages 24-32 years who exhibited unique, co-occurring behavioral and emotional contexts for obesity at ages 14-17 years. METHODS: To identify subgroups of behavioral and contextual profiles in adolescence, the study applies latent class analysis to a sample of individuals who were obese in the fourth wave of the National Longitudinal Study of Adolescent to Adult Health (Add Health, N = 1,889). The study then explored covariates (e.g., gender, race) of class membership. RESULTS: Considerable heterogeneity exists in risk profiles of adolescents obese as adults. For example, 21.1 percent of the sample is in a class with no differentiating risk factors, whereas two classes containing 22.1 percent of the sample exhibit high levels of depression, and nearly all the emotional factors are considered. Although some covariates are predictive of class membership, clear patterns are difficult to discern. However, poor physical health is clearly predictive of membership in the classes exhibiting a high risk of depression. DISCUSSION: Clinicians should be aware that at younger ages, people who are ultimately obese display a range of factors linked to obesity. Although some exhibit behaviors such as high screen time and processed food consumption, others exhibit mainly poor social/emotional climate.

Gluten-induced Neurocognitive Impairment: Results of a Nationwide Study.

GOALS: This study aimed to understand the neurocognitive symptoms associated with gluten exposure in individuals with self-reported celiac disease (CD) and nonceliac gluten sensitivity (NCGS). BACKGROUND: While gluten-induced neurocognitive impairment (GINI; eg, "celiac fog" or "brain fog") is commonly described by individuals with CD and NCGS, there are little data regarding the prevalence and symptoms associated with these experiences. STUDY: A 9-question online survey was accessed by 1396 individuals (1143 with CD; 253 with NCGS). Forced choice and free-response questions were asked of participants to obtain a description of neurocognitive symptoms experienced after gluten ingestion. Free-response answers were coded using a coding structure developed based on the Health-Related Quality of Life Instrument. RESULTS: The majority of survey participants (89% of CD and 95% of NCGS) reported having GINI symptoms. When describing symptoms, the most common word descriptors for both groups were difficulty concentrating, forgetfulness, and grogginess. Timing of symptoms, including onset and symptom peak, were similar across the 2 groups. Coding of free responses found the most common references were to cognitive, physical, psychological, and overall quality of life impacts. CONCLUSIONS: This survey suggests that GINI is common and may be severe in both individuals with CD and NCGS. Cognitive impairment and decline in physical functioning may be similar to that occurring in other illnesses, such as lupus. Clinical follow-up with both individuals with CD and NCGS should include assessment of GINI symptoms. Further research is warranted, including the development of a patient-reported outcome measure including neurocognitive effects of gluten exposure.

What Does He Think? Male Knowledge and Attitudes Regarding Long-Acting Reversible Contraception.

STUDY OBJECTIVE: Contraceptive counseling, especially regarding long-acting reversible contraception (LARC), has generally been directed at women. However, male partners and peers may influence contraceptive decision making. As there were no published studies examining male perceptions of LARC in the United States, this study investigated male knowledge and attitudes regarding LARC. DESIGN: An anonymous electronic cross-sectional survey collecting qualitative and quantitative data was administered from May to September 2018. SETTING: Participants were recruited via university e-mail listservs and in-person at a campus student organization fair at the University of Illinois at Chicago in Chicago (UIC), Illinois. PARTICIPANTS: University students identifying as male and 18-24 years of age. INTERVENTIONS: None. MAIN OUTCOMES MEASURED: Knowledge of LARC, perceptions of LARC, interest in learning about LARC. RESULTS: Participants (n = 97) were predominantly heterosexual (83.5%) men. Of those who were sexually active (63.9%), 98.4% reported female partners trying to avoid pregnancy. The most commonly used methods of contraception were oral contraceptive pills (48.4%) and/or condoms (80.6%). The majority (76.3%) of participants had not heard of LARC. Absence of prior LARC use by a partner was associated with knowledge deficits about LARC (odds ratio = 0.26, 95% confidence interval = 0.70-1.00); however, this association was not seen with other contraceptive methods. Participants familiar with LARC were generally neutral to very supportive of LARC (87.0%). Additionally, 80.4% of participants were interested in learning more about LARC. CONCLUSION: Males 18-24 years of age had limited knowledge of LARC, with an interest in learning more about LARC. This information could shape interventions to bridge knowledge gaps, ultimately helping women to make supported contraceptive choices.

Five-year overall survival following chemoradiation therapy for locally advanced cervical carcinoma in women living with and without HIV infection in Botswana.

PURPOSE: To compare updated prospective 5-year survival outcomes of cervical cancer patients living with and without human immunodeficiency virus (HIV) infection who initiated curative chemoradiation therapy (CRT) in a resource-limited setting. METHODS & MATERIALS: Women in Botswana with locally advanced cervical cancer were enrolled in a prospective, observational, cohort study from July 2013 through January 2015. Survival outcomes were analyzed after 5 years of follow-up. RESULTS: This cohort included 143 women initiating curative CRT. Sixty-seven percent (n = 96) of cohort were women living with HIV (WLWH), all of whom were receiving antiretroviral therapy (ART) at the time of treatment initiation and boasted a median CD4 count of 481 cells/µL (IQR, 351-579 µL). The 5-year overall survival (OS) rates were 56.8% (95% CI, 40.0-70.5%) for patients without HIV infection and 55.1% (95% CI, 44.2-64.7%) for WLWH (p = 0.732). Factors associated with superior 5-year OS on multivariate analyses included baseline hemoglobin > 10 g/dL (hazard ratio (HR) 0.90, 95% CI, 0.83-0.98, p = 0.015), lower stage at diagnosis (stage I and II vs. III and IV) (HR 1.39, 95% CI 1.09-1.76, p = 0.007), and higher EQD2 (HR 0.98, 95% CI 0.97-0.99, p = 0.001). CONCLUSIONS: Five-year OS was not impacted by HIV status in this population of WLWH with well-managed infection who initiated curative treatment for cervical cancer in Botswana. Regardless of HIV status, hemoglobin levels and stage at diagnosis were associated with survival. These findings suggest that treatment for cervical cancer in WLWH with well-controlled infection need not be altered solely due to HIV status.

Rapid Implementation of Telehealth Services During the COVID-19 Pandemic.

Telehealth is an important tool utilized to provide remote clinical care and has increased in prevalence during the coronavirus disease of 2019 (COVID-19) pandemic. It allows providers to conduct safe, timely, and high-quality ambulatory care for patients without increasing risk of disease exposure for both parties. Major organizations including the Centers for Disease Control and Prevention and American College of Obstetrics and Gynecology have released recommendations encouraging the use of telehealth systems for patient care. In obstetrics and gynecology, practice of telehealth has not been commonplace and no practical procedural guidelines have been published. The authors have created such guidelines for use of telehealth in a moderate-risk academic generalist practice in response to the COVID-19 pandemic. This document highlights the process to determine which obstetrics and gynecology patients are candidates for telehealth, the frequency of follow-up, and the technical aspects of designing and delivering a de novo telehealth system. The guidelines were vital in providing structure amid a sudden transition in an academic setting while ensuring patient and provider safety.

Translation, Adaptation, and Assessment of the Communication Assessment Tool in Tigray, Northern Ethiopia.

BACKGROUND: Ethiopia has experienced tremendous growth in medical education beginning in the early 2000s. Research shows a need for emphasis on empathy and compassionate care in this setting. In the United States, the Communication Assessment Tool (CAT) is a widely used, validated survey measuring provider-patient interactions. OBJECTIVE: The goal of this study was to translate, culturally adapt, and pilot the CAT to allow it to be used with trainees and patients in Ethiopia. METHODS: Bilingual experts translated the CAT into Tigrigna, the primary language of the Tigray region in northern Ethiopia, followed by focus group discussions, back translation, and review by the original author of the CAT. The translated tool was administered to the patients of resident physicians in 6 specialties at Ayder Referral Hospital between December 2016 and February 2017. RESULTS: Our translation of the CAT into Tigrigna had semantic, idiomatic, and experiential equivalence. Of 1024 patients recruited, 1002 (98%) completed interviews using the CAT. Mean score was 3.09; 3% of all scores were excellent and 54% were good. Cronbach's alpha score for the full survey was 0.942, demonstrating high reliability. CONCLUSIONS: The translated CAT in Tigrigna can be used to assess communication skills in Ethiopian residents. Both mean score and percentage of excellent scores were considerably lower than scores in other countries, suggesting that there may be opportunities for improvement in residents' communication skills.

Screening and treating hospitalized trauma survivors for posttraumatic stress disorder and depression.

Traumatic injury affects over 2.6 million U.S. adults annually and elevates risk for a number of negative health consequences. This includes substantial psychological harm, the most prominent being posttraumatic stress disorder (PTSD), with approximately 21% of traumatic injury survivors developing the disorder within the first year after injury. Posttraumatic stress disorder is associated with deficits in physical recovery, social functioning, and quality of life. Depression is diagnosed in approximately 6% in the year after injury and is also a predictor of poor quality of life. The American College of Surgeons Committee on Trauma suggests screening for and treatment of PTSD and depression, reflecting a growing awareness of the critical need to address patients' mental health needs after trauma. While some trauma centers have implemented screening and treatment or referral for treatment programs, the majority are evaluating how to best address this recommendation, and no standard approach for screening and treatment currently exists. Further, guidelines are not yet available with respect to resources that may be used to effectively screen and treat these disorders in trauma survivors, as well as who is going to bear the costs. The purpose of this review is: (1) to evaluate the current state of the literature regarding evidence-based screens for PTSD and depression in the hospitalized trauma patient and (2) summarize the literature to date regarding the treatments that have empirical support in treating PTSD and depression acutely after injury. This review also includes structural and funding information regarding existing postinjury mental health programs. Screening of injured patients and timely intervention to prevent or treat PTSD and depression could substantially improve health outcomes and improve quality of life for this high-risk population. LEVEL OF EVIDENCE: Review, level IV.

The Pathogenesis and Clinical Management of Cutaneous Melanoma: An Evidence-Based Review.

Cutaneous malignant melanoma (CM) is the leading cause of skin cancer-related mortality and accounts for approximately 1,250 deaths in Canada each year. It is also one of few cancers continuing to display rates of increasing incidence throughout the world. The past decade has brought significant growth in our understanding of the pathogenesis and clinical management of CM. This evidence-based review synthesizes that knowledge, beginning with a review of the epidemiology and etiology of the disease followed by a broad review of the roles of diagnostic imaging in its management. Special attention is given to the role of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography-computed tomography (PET/CT) in supporting assessment at primary presentation of disease, follow-up to surgical and nonsurgical treatment, and for the surveillance of high-risk asymptomatic patients. After a brief review of current treatment options, this article concludes with a demonstration of how and when uncertainty exists at the point of care systematic review processes may be used to resolve clinical questions. Learning Objectives: By the end of this Continuing Medical Education article, participants will be able to 1. Describe the epidemiology and etiology of cutaneous melanoma, 2. Describe broadly the role of diagnostic imaging in the clinical management of cutaneous melanoma, 3. Describe the specific roles and limitations of 18F-FDG PET/CT in the clinical management of cutaneous melanoma, 4. Describe broadly the best practice in the treatment of cutaneous melanoma, 5. Define the value of systematic review for synthesizing knowledge pertaining to a specific clinical question, and 6. Discuss the utility of 18F FDG PET/CT in the management of early-stage (AJCC 0-IIc) cutaneous melanoma. This is a CME article and provides the equivalent of 2 hours of continuing education that may be applied to your professional development credit system. A 12-question multiple choice quiz follows this reading. Please note that no formalized credit (Category A) is available from CAMRT.

Retrospective Cohort Study of Venous Thromboembolism Rates in Ambulatory Cancer Patients: Association With Khorana Score and Other Risk Factors.

BACKGROUND: Guidelines do not recommend that cancer outpatients receive thromboprophylaxis unless at high venous thromboembolism (VTE) risk, with the Khorana score suggested for risk stratification. This study investigated VTE incidence in outpatients with pancreatic, endometrial, colorectal, ovarian and cervical cancer, the role of Khorana score in risk assessment and potential risk factors. METHODS: Data were retrospectively collected 1 year after cancer diagnosis. VTE associated with inpatient admissions was excluded. RESULTS: Seven hundred forty-six patients were included. VTE rates varied: 26.8% pancreatic; 5.7% endometrial; 9.8% colorectal; 10.2% ovarian; and 0.0% cervical cancer. Excluding VTE at diagnosis, potentially preventable VTE rates were 16.5% in pancreatic, 3.8% in endometrial, 9.8% in colorectal and 8.7% in ovarian cancer. Khorana score was associated with VTE in endometrial cancer only (high-risk: 16.7% vs. low-risk: 1.5%; P < 0.001). VTE rates for patients with central venous catheters (CVCs) were 22.6-34.8% in pancreatic, endometrial, colorectal and ovarian cancers. VTE was associated with CVCs in endometrial, colorectal and ovarian; chemotherapy and Hb < 100 g/L in pancreatic; surgery in endometrial and ovarian; and body mass index > 35 in ovarian cancers following adjusted analysis (P < 0.05). CONCLUSIONS: VTE is a significant burden in pancreatic, endometrial, colorectal and ovarian cancers. Khorana score was not predictive in most cancers. The major VTE-associated variable was CVC. Our data suggest a role for clinical trials of thromboprophylaxis in targeted cancer outpatients.

Process measures facilitate maturation of pediatric enhanced recovery protocols.

BACKGROUND/PURPOSE: The role of process measures used to predict quality in pediatric colorectal surgery enhanced recovery protocols has not been described. The purpose of this study was to demonstrate the feasibility of abstracting and monitoring process measures over protocol improvement iteration. METHODS: Patients enrolled in the Pediatric Colorectal Enhanced Recovery After Surgery pathway at our institution were grouped by stage of implementation. We used a quality improvement database to compare multistage enhanced recovery process measures and 30-day patient outcomes. RESULTS: We identified 58 surgical patients with 28(48%) cases enrolled in the pathway. There was increased use of regional anesthesia techniques in pathway patients (83% versus 20%, p < 0.001). All preoperative process measures clinically improved between early and full implementation. Improvements included a dramatic increase in formal preoperative education (56% versus 0%, p = 0.004) and administration of preoperative medication (p = 0.025). Overall, 12 (21%) patients experienced postoperative complications, which were similarly distributed between implementation groups. Readmissions were highest during the early implementation phase (40%, p = 0.029). Children in the late implementation group experienced fewer complications, which clinically correlated with process measure adherence. CONCLUSIONS: Process measures complement outcome measures in assessing quality and effectiveness of a pediatric colorectal recovery protocol. Adherence to processes may reduce complications. LEVEL OF EVIDENCE: Treatment study, Level III.

Universal screening for intimate partner and sexual violence in trauma patients-What about the men? An Eastern Association for the Surgery of Trauma Multicenter Trial.

BACKGROUND: A recent Eastern Association for the Surgery of Trauma-supported multicenter trial demonstrated a similar rate of intimate partner and sexual violence (IPSV) between male and female trauma patients, regardless of mechanism. Our objective was to perform a subgroup analysis of our affected male cohort because this remains an understudied group in the trauma literature. METHODS: We conducted a recent Eastern Association for the Surgery of Trauma-supported, cross-sectional, multicenter trial over one year (March 2015 to April 2016) involving four Level I trauma centers throughout the United States. We performed universal screening of adult trauma patients using the validated Hurt, Insult, Threaten, Scream and sexual violence screening surveys. Risk factors for male patients were identified. χ Test compared categorical variables with significance at p values less than 0.05. Parametric data are presented as mean ± standard deviation. RESULTS: A total of 2,034 trauma patients were screened, of which 1,281 (63%) were men. Of this cohort, 119 (9.3%) men screened positive for intimate partner violence, 14.1% for IPSV, and 6.5% for sexual violence. On categorical analysis of the Hurt, Insult, Threaten, Scream screen, the proportion of men that were physically hurt was 4.8% compared to 4.3% for women (p = 0.896). A total of 4.8% of men screened positive for both IPSV. The total proportion of men who presented with any history of intimate partner violence, sexual violence, or both (IPSV) was 15.8%. More men affected by penetrating trauma screened positive for IPSV (p < 0.00001). The IPSV positivity in men was associated with mental illness, substance abuse, and trauma recidivism. CONCLUSION: One of every 20 men that present to trauma centers is a survivor of both IPSV, with one of every six men experiencing some form of violence. Men are at similar risk for physical abuse as women when this intimate partner violence occurs. The IPSV is associated with penetrating trauma in men. Support programs for this population may potentially impact associated mental illness, substance abuse, trauma recidivism, and even societal-level violence. LEVEL OF EVIDENCE: Epidemiological study, level II.

Striatal norepinephrine efflux in l-DOPA-induced dyskinesia.

l-DOPA remains the primary treatment for Parkinson's disease (PD). Unfortunately, its therapeutic benefits are compromised by the development of abnormal involuntary movements (AIMs) known as l-DOPA-induced dyskinesia (LID). The norepinephrine (NE) system originating in the locus coeruleus is profoundly affected in PD and known to influence dopamine (DA) signaling. However, the effect of noradrenergic loss on l-DOPA-induced striatal monoamine efflux and Parkinsonian motor behavior remains controversial and is frequently overlooked in traditional animal models of LID. Thus, the current study sought to determine whether degeneration of the DA and/or NE system(s) altered l-DOPA-induced striatal monoamine efflux in hemiparkinsonian rats with additional NE loss induced by the potent NE-toxin α DA beta hydroxylase (DBH)-saporin. Sham-, DA-, NE-, and dual DA + NE-lesioned rats were treated with l-DOPA (6 mg/kg, s.c.) for 2 weeks. Thereafter, l-DOPA-mediated striatal monoamine efflux was measured with in vivo microdialysis, and concurrent AIMs testing occurred to determine responsiveness to l-DOPA. Noradrenergic lesions exacerbated parkinsonian motor deficits but did not significantly alter LID expression or corresponding l-DOPA-induced striatal monoamine efflux. Interestingly, l-DOPA-induced striatal NE efflux rather than DA efflux, corresponded more closely with dyskinesia severity. Moreover, marked reductions in striatal NE tissue concentration did not appear to impact l-DOPA-induced striatal NE efflux. The current study implicates l-DOPA-induced striatal NE as an important factor in LID expression and demonstrates the importance of developing treatment strategies that co-modulate the NE and DA systems.

Review of the enhanced recovery pathway for children: perioperative anesthetic considerations.

PURPOSE: Enhanced recovery after surgery (ERAS) pathways have been used for two decades to improve perioperative recovery in adults. Nevertheless, little is known about their effectiveness in children. The purpose of this review was to consider pediatric ERAS pathways, review the literature concerned with their potential benefit, and compare them with adult ERAS pathways. SOURCE: A PubMed literature search was performed for articles that included the terms enhanced recovery and/or fast track in the pediatric perioperative period. Pediatric patients included those from the neonatal period through teenagers and/or youths. PRINCIPAL FINDINGS: The literature search revealed a paucity of articles about pediatric ERAS. This lack of academic investigation is likely due in part to the delayed acceptance of ERAS in the pediatric surgical arena. Several pediatric studies examined individual components of adult-based ERAS pathways, but the overall study of a comprehensive multidisciplinary ERAS protocol in pediatric patients is lacking. CONCLUSION: Although adult ERAS pathways have been successful at reducing patient morbidity, the translation, creation, and utility of instituting pediatric ERAS pathways have yet to be realized.