Clinician provision of oncofertility support in cancer patients of a reproductive age: A systematic review.

OBJECTIVE: The emerging discipline of oncofertility advocates for the timely provision of fertility information and referral for fertility preservation to all cancer patients of reproductive age (<45 years). A systematic review was undertaken on the clinician provision of oncofertility support to determine whether cancer patients are having their support needs adequately met by staff. METHODS: An initial search conducted in May 2016 identified 351 potentially relevant studies. The papers were divided into 2 categories: Papers on the clinician provision of oncofertility support were reviewed for this study, and papers on patient oncofertility support needs were reviewed for a separate systematic review. RESULTS: A total of 23 studies were included within the final review of this manuscript. Although many clinicians are broadly informed about the risk to their patients' fertility brought about by cancer treatment, there are many factors which hinder the appropriate discussion, referral, or service utilisation needed to provide adequate oncofertility support to patients of reproductive age. CONCLUSIONS: Oncofertility support is often not delivered to the standard of current guidelines, with many clinicians not providing the recommended care to all eligible patients, and as such many patients may lack the oncofertility support that they require. The implementation of a clear procedural process would assist clinicians in the provision of oncofertility support for cancer patients of reproductive age.

A systematic review of patient oncofertility support needs in reproductive cancer patients aged 14 to 45 years of age.

OBJECTIVE: Decline in fertility potential brought about by a cancer diagnosis or cancer treatment is one of the biggest impacts to cancer patients' long-term quality of life. As such, the current manuscript aimed to systematically review the literature on oncofertility support needs for cancer patients of a reproductive age (14-45 years of age). METHODS: A systematic review of the literature was conducted in May 2016 through the searching of electronic databases Medline, EMBASE, PSYCH Info, Web of Science and SCOPUS, alongside the screening of relevant reference lists. An initial search identified 351 potentially relevant studies. The papers were divided into 2 categories; papers on patient oncofertility support needs were reviewed for this systematic review, and papers on clinician provision of oncofertility support were reviewed for a separate systematic review. RESULTS: A total of 30 studies were included within the final review. Support needs were categorised as information, service, clinician-patient interactions, psychological, and family. A number of studies indicated that cancer patients place great important on their oncofertility care and have unmet support needs. Patients were satisfied and felt supported when additional care was taken to ensure fertility information and service needs were met. CONCLUSIONS: Patients desire for clinicians to support their concerns through the provision of adequate information, access to oncofertility services, taking time to discuss oncofertility treatment and concerns, specialised psychological support, and responsiveness to individual needs.

Culture Clash? Investigating constructions of sexual and reproductive health from the perspective of 1.5 generation migrants in Australia using Q methodology.

BACKGROUND: In Australia, those who migrate as children or adolescents (1.5 generation migrants) may have entered a new cultural environment at a crucial time in their psychosexual development. These migrants may have to contend with constructions of sexual and reproductive health from at least two cultures which may be at conflict on the matter. This study was designed to investigate the role of culture in constructions of sexual and reproductive health and health care seeking behaviour from the perspective of 1.5 generation migrants. METHODS: Forty-two adults from various ethno-cultural backgrounds took part in this Q methodological study. Online, participants rank-ordered forty-two statements about constructions of sexual and reproductive health and health seeking behaviours based on the level to which they agreed or disagreed with them. Participants then answered a series of questions about the extent to which their ethnic/cultural affiliations influenced their identity. A by-person factor analysis was then conducted, with factors extracted using the centroid technique and a varimax rotation. RESULTS: A seven-factor solution provided the best conceptual fit for constructions of sexual and reproductive health and help-seeking. Factor A compared progressive and traditional sexual and reproductive health values. Factor B highlighted migrants' experiences through two cultural lenses. Factor C explored migrant understandings of sexual and reproductive health in the context of culture. Factor D explained the role of culture in migrants' intimate relationships, beliefs about migrant sexual and reproductive health and engagement of health care services. Factor E described the impact of culture on sexual and reproductive health related behaviour. Factor F presented the messages migrant youth are given about sexual and reproductive health. Lastly, Factor G compared constructions of sexual and reproductive health across cultures. CONCLUSIONS: This study has demonstrated that when the cultural norms of migrants' country of origin are maintained it has a significant influence on how 1.5 generation migrants construct, experience and understand various aspects of sexual and reproductive health. Policy makers, health care professionals and resettlement service providers are advised to engage with migrant parents and youth in exploring, discussing, reframing and reconstructing SRH in an Australian context.

Let's talk about gay sex: gay and bisexual men's sexual communication with healthcare professionals after prostate cancer.

Although sexual changes after prostate cancer (PCa) have specific meanings and consequences for gay and bisexual (GB) men, little is known about how GB men navigate sexual well-being support. We surveyed 124 GB men with PCa and 21 male partners, and interviewed a sub-sample of 46 GB men and 7 male partners, to examine GB men's experiences of sexual communication with healthcare professionals (HCPs) since the onset of PCa. GB men perceived a number of deficits in HCPs communication: medical support dominated sexual and psychological support; heterosexuality of GB patients was often assumed; sexual orientation disclosure was problematic; and GB men perceived rejection or lack of interest and knowledge from a majority of HCPs with regard to gay sexuality and the impact of PCa on GB men. Facilitators of communication were acknowledgement of sexual orientation and exploration of the impact of PCa on GB men. In order to target improved support for GB men with PCa, it is concluded that HCPs need to address issues of hetero-centricism within PCa care by improving facilitation of sexual orientation disclosure, recognising that GB men with PCa might have specific sexual and relational needs, and increasing knowledge and comfort discussing gay sexuality and gay sexual practices.

Talking about fertility in the context of cancer: health care professional perspectives.

Health care professionals (HCPs) play a key role in providing information and counselling about the implications of cancer for fertility, however, many patients do not receive such information. The aim of this study was to examine the perspectives and practices of Australian HCPs in relation to discussing fertility with cancer patients. A mixed-methods design, comprising of an online survey of 263 HCPs [41.4% nurses; 25.5% doctors; 31% allied health care professionals (AHP)] and qualitative interviews with 49 HCPs, was utilised. HCPs reported that fertility is an important concern for patients and their partners; however, only 50% of doctors and nurses, and 24% of AHPs reported that they always addressed this issue. The primary barriers to discussing fertility were poor patient prognosis; patient gender or age; time constraints; and absence of appropriate resources and materials. Only a minority of HCPs (29%) had undergone training in discussing fertility with cancer patients. The majority wanted further training or education: including nurses (81.8%), AHPs (80.6%) and doctors (55.4%). HCPs agreed that a number of resources would assist them to raise fertility with their patients, including a list of appropriate referral sources, fact sheets, information booklets, a fertility consultation checklist and on-line resources.

Talking about sex with health professionals: the experience of people with cancer and their partners.

Changes to sexuality can be one of the most difficult aspects of life following cancer. This study examines the experience of discussing sexuality post cancer with health care professionals (HCPs), from the perspective of women and men with cancer (PWC), and their partners (PPWC), across a range of cancer types. A total of 657 PWC (535 women, 122 men) and 148 PPWC (87 women, 61 men) completed a survey containing closed and open-ended items, analysed by analysis of variance and thematic analysis. Discussions about sexuality with a HCP were more likely to be reported by men (68%) compared to women PWC (43%), and by women (47%) compared to men PPWC (28%), as well as by those with a sexual or reproductive cancer. Men PWC and women PPWC were most likely to want to discuss sexuality with a HCP, with men PWC and PPWC reporting highest levels of satisfaction with such discussions. Open-ended responses revealed dissatisfaction with the unwillingness of HCPs to discuss sexuality, unhappiness with the nature of such discussion, and positive accounts of discussions about sexuality with HCPs. These findings lend support to the notion that people with cancer and their partners may have unmet sexual information and support needs.

Loss, uncertainty, or acceptance: subjective experience of changes to fertility after breast cancer.

This qualitative study examines the subjective experience of infertility in a large sample of Australian women with breast cancer. Participants were 1830 women, average age 54, who responded to an email invitation to complete an online survey on sexual well-being and fertility concerns after breast cancer. 24.6% (n = 452) reported that cancer had affected their fertility; 21.3% (n = 391) did not know their fertility status. In thematic analysis of open-ended responses provided by 381 women about changes to fertility status, reactions to infertility, and experiences of information and interventions to assist fertility, five themes were identified: 'Negative responses to infertility and early menopause'; 'Sexual changes associated with menopause and infertility'; 'Uncertainty and anxiety about fertility status'; 'Information and fertility preservation'; 'Acceptance of the end of fertility'. These findings confirm previous reports that infertility and premature menopause are a significant cause of anxiety for many women with breast cancer. However, some women closer to natural menopause, or who had completed their families, reported acceptance of changed fertility status. Accounts of deficits in information provision and fertility counselling suggest an urgent need for accessible and comprehensive information about fertility and cancer to be developed and evaluated, as well as education and training of health professionals in addressing fertility concerns following cancer.

Vocationally oriented cognitive behavioural training for the very long-term unemployed.

BACKGROUND: The very long-term unemployed (i.e. those unemployed for more than 2 years) face serious mental health problems and social difficulties in regaining employment. AIMS: To assess the effectiveness of a pilot vocationally oriented cognitive behaviour therapy (CBT) programme on mental health and vocational outcomes among a group of very long-term unemployed. METHODS: A pre-test-post-test design with follow-up assessment at 12 weeks was used to assess the effects of CBT group training on mental health, self-esteem, optimism and attitudes to work. Participants were recruited through employment agencies in Sydney, Australia. RESULTS: Twelve weeks following CBT training, the 21 participants reported increased optimism and attitudes to work, and more than half of them had participated in some kind of paid employment. CONCLUSIONS: While this study is small and non-generalizable, the findings suggest the value of vocationally oriented CBT approaches in assisting the very long-term unemployed to get back into the workforce.

Gender differences in cancer carer psychological distress: an analysis of moderators and mediators.

Women cancer carers report higher rates of distress than men; however, there is little understanding of the mechanisms underlying these gender differences. The aim of this study was to examine the potential mediating roles of burden of care, unmet needs, self-silencing, self-efficacy and optimism, and the potential moderating influence of social support, cancer stage, patient gender, time spent caring and other responsibilities, on gender differences in carer distress. Of 329 informal cancer carers (245 women, 119 men), women reported significantly more anxiety, burden of care and unmet needs than men. In the mediation analysis, gender differences in anxiety were fully explained by both the independent contribution and combination of: Disrupted Schedule, Health Problems and Emotional and Spiritual Unmet Needs. Women cared for both men and women patients, across a broad range of relationships, whereas men predominantly cared for their female partner. There was no gender difference in number of hours spent caring or in companionship, amount of support received, and additional responsibilities for children, housework or studies, and none of these factors acted as moderators of gender differences in anxiety. It is concluded that women's gendered role is associated with unmet needs and burden of care, resulting in greater anxiety.

Sexuality after breast cancer: a review.

It is widely recognised that women's sexuality can be particularly complex after breast cancer, with sexual changes often becoming the most problematic aspect of a woman's life. The impact of such changes can last for many years after successful treatment, and can be associated with serious physical and emotional side-effects. The objective of this paper is to review research on breast cancer and sexuality from the years 1998 to 2010. Research has documented a range of physical changes to a woman's sexuality following breast cancer, including disturbances to sexual functioning, as well as disruptions to sexual arousal, lubrication, orgasm, sexual desire, and sexual pleasure, resulting from chemotherapy, chemically induced menopause, tamoxifen, and breast cancer surgery. Women's intrapsychic experience of changes to sexuality includes a fear of loss of fertility, negative body image, feelings of sexual unattractiveness, loss of femininity, depression and anxiety, as well as alterations to a sense of sexual self. The discursive construction of femininity and sexuality shapes the way women construct and experience their illness and their body - leading many women to try to appear 'normal' to others post-breast surgery. Finally, the quality of a woman's partnered relationship consistently predicts sexual health post-breast cancer - reinforcing the importance of recognising the intersubjective nature of issues surrounding breast cancer and sexuality. It is concluded that analyses of sexuality in the context of breast cancer cannot conceptualise the physical body separately from women's intrapsychic negotiation, her social and relational context, and the discursive constructions of sexuality and femininity: a material-discursive-intrapsychic interaction.

Healthcare-associated hepatitis C virus transmission among patients in an abdominal organ transplant center.

BACKGROUND: De novo hepatitis C virus (HCV) infection among transplant patients is rarely recognized but can have severe consequences. We investigated the scope, source, and mode of HCV transmission within a transplant center after incident HCV infection was identified in 2 patients who had liver transplantation in late 2006. METHODS: Patients were interviewed, and transplant logs, medical records, and staff practices were reviewed to identify opportunities for HCV transmission. Infection via receipt of blood or organs was evaluated. Molecular epidemiology was used to determine the relatedness between persons with incident and chronic HCV infection. RESULTS: HCV from infected blood or organ donors was ruled out. Among the 308 patients who underwent transplant in 2006, no additional incident HCV infections were identified. Eighty-five (28%) had pre-transplant chronic HCV infection; 13 were considered possible HCV source patients based upon shared days on the inpatient unit, nursing assignment, or invasive procedures in common with incident HCV case-patients. Viral isolates from 1 HCV source patient and 1 incident case-patient were found to be highly related by quasispecies analysis, confirming patient-to-patient HCV transmission. Possible modes of transmission identified were the improper use of multidose vials, sharing of blood-contaminated glucometers, and touch contamination. CONCLUSION: Sporadic transmission or endemic levels of HCV transmission might be overlooked in a setting with high HCV prevalence, such as liver transplant units, where multiple, repeated opportunities for patient-to-patient HCV transmission can occur. Surveillance through pre- and post-transplant screening is necessary to identify incident HCV infection in this setting. Constant, meticulous attention must be paid to maintaining aseptic technique and good infection control practices to eliminate HCV transmission opportunities.

LACE-conditioned autologous stem cell transplantation for relapsed or refractory Hodgkin's lymphoma: treatment outcome and risk factor analysis in 67 patients from a single centre.

High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is a recognized treatment option for patients with relapsed Hodgkin's lymphoma. We have analysed 67 patients who underwent ASCT after LACE (lomustine (CCNU), cytarabine (Ara-C), cyclophosphamide, etoposide) conditioning for relapsed (n=61) or primary refractory (n=6) Hodgkin's lymphoma. The 100-day treatment-related mortality was 3%. With a median follow-up of 67 months (range 3.3-161.0) the probabilities of overall survival (OS) and progression-free survival (PFS) at 5 years were 68 and 64%, respectively. Probabilities for OS and PFS at 5 years for patients with chemosensitive relapse (n=40) were 81 and 78% versus 50 and 35%, respectively, for patients (n=27) with chemoresistant relapse (P=0.012 for OS, P=0.002 for PFS). In multivariate analysis mixed cellularity classical or lymphocyte-depleted classical histology subtype and haemoglobin level of 10 g/dl or less at the time of ASCT were identified as risk factors for worse OS, whereas stage III or IV disease at diagnosis and disease status at ASCT other than complete or partial remission predicted inferior PFS. LACE followed by ASCT is an effective treatment for the majority of patients with chemosensitive relapsed Hodgkin's lymphoma and a proportion of chemorefractory patients also benefit.

[Interdisciplinary guidelines on diagnosis and treatment for extracerebral amyloidoses--published by the German Society of Amyloid Diseases (www.amyloid.de)]. / Interdisziplinäre Leitlinien zur Diagnostik und Therapie der extrazerebralen Amyloidosen--Herausgegeben von der Deutschen Gesellschaft für Amyloid-Krankheiten e.V (www.amyloid.de).

Within the past 10 years, a new range of knowledge has been achieved in the field of amyloidosis, especially with regard to pathogenesis, diagnosis and therapy. Amyloidosis leads to variable and distinct symptoms and is caused by different underlying conditions. Some amyloidoses are acquired secondary to a chronic condition; others are caused by genetic mutations. Amyloid and amyloidosis occur more frequently than they are perceived. Among the frequent localized forms are the cerebral amyloidosis linked to Alzheimer disease (AD) and the pancreatic amyloidosis linked to diabetes mellitus. Among the most frequent systemic (extracerebral) forms is AL amyloidosis, which often has a poor prognosis and if untreated can rapidly lead to death. Systemic amyloidosis that happen at infancy are mainly AA amyloidosis that can progress to death already at early or at middle adulthood. Amyloidosis can be treated but therapeutic success significantly depends upon early diagnosis and proper classification of the amyloid type. It is mandatory that differential diagnosis demonstrate the presence of amyloid and clearly identify the type of the disease. Development of methods and techniques have contributed to improvements in the diagnosis and treatment. Early diagnosis and proper classification of amyloid is decisive for therapeutic options and upon them depend quality of life and mortality. The therapeutic spectrum is various and includes organ transplantation, chemotherapy, and anti-inflammatory strategies. Gene therapy and biological active substances have to be considered in the near future.

Long-term outcome of high-dose melphalan and autologous stem cell transplantation for AL amyloidosis.

Light chain (AL) amyloidosis is the result of a clonal plasma cell expansion, in which amyloidogenic monoclonal light chains deposit in various tissues resulting in organ dysfunction and organ failure. The median survival of patients with AL amyloidosis without therapy is 10-14 months. Several phase II studies report haematological and clinical remission in up to 50% of patients after high-dose melphalan and autologous stem cell transplantation. We analysed retrospectively the long-term outcome of 19 patients treated in this way between August/1996 and December/2001. We observed a relatively high treatment-related mortality of 26%, but 12 patients (63%) were high-risk candidates. Eight patients (42%) surviving longer than 100 days achieved haematological remission and long-term survival, whereas 6 (32%) obtained no clear benefit from high-dose therapy. However, 62% of patients survived beyond 2 years and the median survival from transplant was 48 months (range 0-104 months).

Predictive factors for survival in myeloma patients who undergo autologous stem cell transplantation: a single-centre experience in 211 patients.

High-dose therapy with autologous stem cell therapy (ASCT) has become the treatment of choice for eligible patients with myeloma. We analysed retrospectively the prognostic influence of pre-transplant characteristics and transplant modalities on response and survival in 211 myeloma patients who were transplanted in our centre between 1994 and 2004. All patients received peripheral blood stem cell support after conditioning with melphalan alone (183 patients), or melphalan and total blood irradiation (28 patients). We evaluated the influence of age, type of multiple myeloma, status prior and post ASCT, previous treatment regimens, time of ASCT from diagnosis, year of autograft, dose of re-infused CD34(+) cells, plasma cell infiltration and beta2-microglobulin at diagnosis on overall survival (OS) and event-free survival (EFS) to define patients with better prognosis. Median OS and EFS from transplantation were 50.9 and 20.1 months, respectively. Median OS from diagnosis was 68.8 months. Transplant-related mortality was 1.4%. Lower beta2-microglobulin levels, achievement of complete remission (CR) post transplant and lower plasma cell infiltration at diagnosis and transplant correlated with longer EFS and OS, whereas CR at transplant and low international prognostic index at transplant correlated with better EFS. Higher CD34(+) cell dose correlated with improved OS. We conclude that ASCT is safe and effective and the outcome is independent of age, time from diagnosis, previous treatment and conditioning regimen.

Candidemia in pediatric outpatients receiving home total parenteral nutrition.

This is a cohort study of pediatric outpatients receiving total parenteral nutrition (TPN) and follow-up care in a Tennessee hospital between January and June 1999. The study was conducted following an increase in the incidence of candidemia. Of 13 children receiving home TPN, five had candidemia; three were due to Candida parapsilosis. Case patients were more likely to have an underlying hematologic disease (P = 0.02) as well as previous history of fungemia (P = 0.02). Two case patients had successive candidemia episodes 3 months apart; karyotypes and RAPD profiles of each patient's successive C. parapsilosis isolates were similar. Candida spp. were frequently detected in hand cultures from cohort members (four of 10) and family member caregivers (nine of 11); C parapsilosis was isolated from five caregivers. Our findings underscore the challenges of maintaining stringent infection control practices in the home health care setting and suggest the need for more intensive follow-up and coordination of home TPN therapy among pediatric patients.

Viral hepatitis transmission in ambulatory health care settings.

In the United States, transmission of viral hepatitis from health care-related exposures is uncommon and primarily recognized in the context of outbreaks. Transmission is typically associated with unsafe injection practices, as exemplified by several recent outbreaks that occurred in ambulatory health care settings. To prevent transmission of bloodborne pathogens, health care workers must adhere to standard precautions and follow fundamental infection-control principles, including safe injection practices and appropriate aseptic techniques. These principles and practices need to be made explicit in institutional policies and reinforced through in-service education for all personnel involved in direct patient care, including those in ambulatory care settings. The effectiveness of these measures should be monitored as part of the oversight process. In addition, prompt reporting of suspected health care-related cases coupled with appropriate investigation and improved monitoring of surveillance data are needed to accurately characterize and prevent health care-related transmission of viral hepatitis.

Evaluation of innovative surveillance for drug-resistant Streptococcus pneumoniae.

To monitor disease incidence and antibiotic resistance, effective, practical surveillance strategies are needed at the local level for drug-resistant Streptococcus pneumoniae (DRSP). Knox County, Tennessee, participates in three forms of DRSP surveillance: an active system sponsored by the Centers for Disease Control and Prevention (CDC; Atlanta, Georgia); a novel county-sponsored system; and conventional state-mandated reporting. Ascertainment of invasive S. pneumoniae infection cases by each system in 1998 was evaluated, and completeness of reporting, antibiotic resistance patterns, costs, and other attributes were compared. The county-sponsored system collects patient identifiers and drug susceptibility data directly from hospital laboratories, whereas the CDC-sponsored system performs medical chart abstractions and reference laboratory susceptibility testing. Similar numbers of invasive S. pneumoniae cases were detected by the county-sponsored (n = 127) and CDC-sponsored (n = 123) systems; these systems held >75% of all cases in common, and each system achieved >85% sensitivity. Conventional reporting contained 88% and 76% of the DRSP cases identified by the county- and CDC-sponsored systems, respectively, but did not capture infections produced by susceptible isolates. Both the county- and CDC-sponsored systems indicated that large proportions of isolates were resistant to penicillin and extended-spectrum cephalosporins. The county-sponsored DRSP surveillance system was inexpensive, simple to execute, and relevant to local needs.