Transition Home Following New Fecal Ostomy Creation: A Qualitative Study.

PURPOSE: Perioperative ostomy education is essential for patients to develop skills and comfort with self-care at home with a new ostomy, but shortened hospital length of stay (LOS) reduces time for postoperative education for patients. This study explored the initial experiences and care needs of patients who have undergone creation of a new ostomy during their transition from hospital to home. DESIGN: Qualitative interpretive description using latent content analysis. SUBJECTS AND SETTING: Thirteen patients who had undergone an elective colorectal surgery involving creation of an ostomy were interviewed. Participants were 33 to 78 years of age, 54% were female, and 62% were undergoing ostomy creation for colorectal cancer operations. Eleven participants underwent temporary ileostomy creation, and 2 patients had permanent end colostomies created. METHODS: Interviews were conducted in person and audiotaped by study investigators within 4 to 6 weeks postoperatively. Audiotapes were transcribed verbatim by trained transcriptionists, and each transcript was reviewed in duplicate by study investigators. A latent content analysis method was used to determine the implied meaning in participants' experiences of having a new ostomy. RESULTS: The transition from hospital to home with a new ostomy was illustrated by 5 major themes: (1) Having an ostomy is a life-changing and bizarre experience; (2) Adjustment and adaptation occur through acceptance and self-reliance; (3) It's a hands-on thing: with the role of WOC nurse providing support in achieving independence; (4) Improved home care infrastructure is needed; and (5) Practical advice shared from experiential learning. CONCLUSION: Patients with new ostomies are motivated and able to cope with the ostomy and regain independence over a short period after surgery. Shorter LOS does not impede ostomy education so long as adequate home care and support group programs are available. Knowledge gained through this study will assist WOC nurses in managing patients' expectations and the planning and delivery of education to patients with newly created ostomies.

Incidence of delayed venous thromboembolic events in patients undergoing abdominal and pelvic surgery for cancer: a systematic review and meta-analysis.

BACKGROUND: Incidence of venous thromboembolism (VTE) following discharge for abdominal cancer surgery is uncertain. METHODS: We searched MEDLINE and Embase for studies evaluating the incidence of VTE at 3 months from surgery. Studies indicating use of post-hospital VTE prophylaxis were excluded. Two independent reviewers performed study selection, data abstraction and risk of bias. Random-effects model was used to estimate pooled incidence, and weights were estimated using inverse variance method. Statistical heterogeneity was explored via subgroup analysis. RESULTS: Of 4215 abstracts retrieved, 11 reported the incidence of VTE at 3 months. There were three randomized trials (n = 520), one prospective cohort study (n = 284) and seven retrospective cohort studies (n = 65 308). VTE incidence among prospective studies was 9.6% (95% confidence interval (CI) 2.9-16.4), while for retrospective studies was 2.2% (95% CI 1.4-3.0). Heterogeneity was high (I2 = 92% and 81%, respectively). The incidence of symptomatic VTE was 1.3% (95% CI 0.4-2.3) for prospective studies. VTE was diagnosed by screening venography in most of the prospective studies, whereas retrospective studies did not use a screening method. Subgroup analysis based on the type of organ surgery performed explained the heterogeneity. CONCLUSIONS: VTE incidence following abdominal cancer surgery varies greatly depending on the study type, with differences largely explained by the method of assessment of VTE. The fact that VTE incidence among retrospective studies was closer to the incidence of symptomatic events (non-screen detected) in the prospective studies, suggests that the screened events were mostly asymptomatic and their clinical significance is unclear.

Effect of Perioperative Nutritional Supplementation on Postoperative Complications-Systematic Review and Meta-Analysis.

BACKGROUND: Perioperative carbohydrate loading, increased protein intake, and immunonutrition may decrease postoperative complications. Studies on the topic have led to controversial results. METHODS: We searched Medline, EMBASE, and CENTRAL up to August 2018 for randomized trials comparing the effect of perioperative nutritional supplements (intervention) versus control on postoperative complications in patients undergoing gastrointestinal cancer surgery. Secondary outcomes included infectious complications and length of hospital stay (LOS). Random effects model was used to estimate the pooled risk ratio (RR) of treatment effects. Pooled mean difference (MD) was used to compare LOS. Heterogeneity was assessed using I2. Sources of heterogeneity were explored through subgroup analysis by nutritional supplementation protocol, type of surgery, and type of nutritional supplement. Risk of bias and quality of the evidence were assessed. RESULTS: Of 3951 articles, we identified 56 trials (n = 6370). Perioperative nutrition was associated with a lower risk of postoperative complications (RR 0.74, 95% confidence interval (CI) 0.69-0.80); postoperative infections (RR 0.71, 95% CI 0.64-0.79, n = 4582); and postoperative non-infectious complications (RR 0.79, 95% CI 0.71-0.87, n = 4883). There were no significant heterogeneity outcomes analyzed (I2 = 14%, 1%, and 7%, respectively). LOS was shorter for the intervention group, MD - 1.58 days; 95% CI - 1.83 to - 1.32; I2 = 89%). Subgroup analysis did not identify sources of heterogeneity. The quality of evidence for postoperative complications was high and for LOS was moderate. CONCLUSION: Perioperative nutritional optimization decreases the risk of postoperative infectious and non-infectious complications. It also decreases LOS in patients undergoing gastrointestinal cancer surgery, but these findings should be taken with caution given the high heterogeneity.

Adjuvant Chemotherapy With or Without Biologics Including Antiangiogenics and Monoclonal Antibodies Targeting EGFR and EpCAM in Colorectal Cancer: A Systematic Review and Meta-analysis.

BACKGROUND: Adjuvant therapy for early-stage colorectal cancer improves survival. Biologic agents have shown promise as adjuncts to chemotherapy in metastatic colon cancer, but the effect on earlier stage cancer remains unclear. MATERIALS AND METHODS: We conducted a systematic review and meta-analysis of the additive effect of biologic agents to adjuvant chemotherapy on survival in colorectal cancer (all comers and subpopulations defined by microsatellite instability, BRAF and KRAS status, and stage). Only randomized controlled trials published between 2002 and 2017 in MEDLINE, EMBASE, and CENTRAL were included. The control arm: chemotherapy alone, the intervention arm: chemotherapy with biologic agents. OUTCOMES: overall survival (OS) and disease-free survival. RESULTS: Six trials including 10,754 patients were included. OS (hazard ratio [HR] 2.55, 95% confidence interval [CI] 2.15-3.03) and disease-free survival (HR 2.54, 95% CI 2.25-2.87) were significantly worse in the intervention arm. High heterogeneity was explained by subgroup analysis of different biologic agents (bevacizumab versus others); however, results still showed harm in the intervention arm across subgroups. Bevacizumab was associated with improved OS in patients with microsatellite instability (HR 0.58, 95% CI 0.36-0.92); this was the only indication of benefit for a biomarker-defined subpopulation. Analyses by tumor stage failed to demonstrate advantage with use of a biologic agent; however, it explained heterogeneity. CONCLUSIONS: The addition of biologic agents to adjuvant chemotherapy in the treatment of high-risk stage II and III colorectal cancer is associated with worse survival outcomes. The only subgroup of patients that may benefit from the addition of bevacizumab to adjuvant chemotherapy is those with microsatellite unstable tumors.

Does the Addition of Biologic Agents to Chemotherapy in Patients with Unresectable Colorectal Cancer Metastases Result in a Higher Proportion of Patients Undergoing Resection? A Systematic Review and Meta-analysis.

BACKGROUND: Surgical resection provides the best opportunity for cure for metastatic colorectal cancer. Whether addition of a biologic agent to chemotherapy improves the rate of conversion from unresectable to resectable disease remains uncertain. We carried out a systematic review of the literature and meta-analysis to define the impact of biologic agents on resection. METHODS: We searched Medline, Embase, CENTRAL, and PubMed for randomized controlled trials published up until April 2017 comparing chemotherapy and biologics (intervention) vs. chemotherapy alone (control) in treatment-naïve patients with unresectable metastatic colorectal cancer. Study selection, data abstraction, risk of bias, and quality of evidence assessment were performed in duplicate. Random-effects meta-analysis was used to estimate the pooled odds ratio (OR) for resection rate and corresponding confidence interval (CI). RESULTS: Nine studies, including a total of 4345 patients, were analyzed. Seven studies assessed epithelial growth factor receptor (EGFR)-directed monoclonal antibodies, and two used antiangiogenic agents. The addition of a biologic agent to chemotherapy was associated with higher resection rate (OR 1.47, 95% CI 1.07-2.02; resection rate 8.4 vs. 6.1%). Subgroup analysis based on mechanism of action of drugs showed benefit for resection rate only with EGFR-directed agents (OR 1.70, 95% CI 1.10-2.64). Heterogeneity among studies was low (I 2  = 34%). CONCLUSIONS: The addition of biologic agents to systemic chemotherapy in patients with initially unresectable metastatic colorectal cancer improved resection rate. The optimal biologic agent for this outcome cannot yet be determined.

The effectiveness of interventions to treat obesity in survivors of childhood brain tumors: a systematic review protocol.

BACKGROUND: Pediatric brain tumors are the most common solid tumors in children. Advances in understanding the hallmarks of cancer biology and novel therapies have led to an increasing number of survivors of childhood brain tumors (SCBT). However, these survivors are at an increased risk of obesity and cardiometabolic disorders that affect their quality of life and lifespan. It is important to define effective strategies to treat and prevent obesity in this population. This systematic review aims to investigate the effectiveness of lifestyle interventions, pharmacotherapy, and bariatric surgery on treating obesity in SCBT. METHODS: Searches will be conducted in PubMed, MEDLINE, EMBASE, PsycINFO, SPORTDiscus, CINAHL, Cochrane Database of Systematic Review, Cochrane Central Register of Controlled Trials (CENTRAL), and Database of Abstracts of Reviews of Effect (DARE). In addition, ClinicalTrials.gov and ProQuest Dissertations and Theses A&I will be searched to identify relevant gray literature. The reference lists of eligible articles will be searched for additional studies. All screening, quality assessment, and data abstraction will be done independently by two reviewers. We will perform meta-analysis if there are sufficient studies. DISCUSSION: This review will summarize evidence for the effectiveness of interventions used to reduce obesity risk in SCBT. This has significant implications for SCBT, as it can identify gaps in knowledge and provide insights into the development of new interventions to manage obesity in survivors, which may improve their outcomes. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015025909.

Design, implementation, and evaluation of a pediatric and adolescent type 2 diabetes management program at a tertiary pediatric center.

Global rates of type 2 diabetes in children and adolescents have increased significantly over the past three decades. Type 2 diabetes is a relatively new disease in this age group, and there is a dearth of information about how to structure treatment programs to manage its comorbidities and complications. In this paper, we describe the design and implementation of a personalized multidisciplinary, family-centered, pediatric and adolescent type 2 diabetes program at a tertiary pediatric center in Hamilton, Ontario, Canada. We report the process of designing and implementing such a program, and show that this multidisciplinary program led to improvement in glycated hemoglobin (n=17, 8% at baseline versus 6.4% at 1 year, 95% confidence interval (0.1-0.28), P-value <0.0001) and stabilized body mass index, with lowered C-peptide and no change in fitness or metabolic biomarkers of lipid metabolism and liver function. As type 2 diabetes becomes more prevalent in youth, the need for programs that successfully address the complex nature of this disease is central to its management and to mitigate its long-term adverse outcomes.

Recruitment feasibility to a cohort study of endocrine and metabolic health among survivors of childhood brain tumours: a report from the Canadian study of Determinants of Endometabolic Health in ChIlDrEn (CanDECIDE).

OBJECTIVES: The aim of this study was to test the feasibility of recruitment and performance of study procedures of the Canadian Study of Determinants of Endometabolic Health in ChIlDrEn (CanDECIDE) study, which was designed to assess the determinants of endocrine and metabolic health in survivors of childhood brain tumours. SETTING: A single paediatric tertiary care centre in Hamilton, Ontario, Canada. PARTICIPANTS: We included boys and girls, aged 5 years and older, who were lean (body mass index (BMI) below 85th centile for age and gender) or overweight/obese (BMI 85th centile or above for age and gender). We excluded children on steroids or immunosuppressant therapy, smokers and those who had an active infection for the 2 weeks prior to participation. OUTCOMES: Feasibility targets included recruitment rate of at least 50%, the consenting of 80% of participants to provide biological samples, 90% questionnaire completion rate and the ability to process biological samples from at least 80% of participants. RESULTS: We approached 210 potential participants, and of the 112 (53%) who agreed to participate, 30 (26.8%) completed the study visit over 7 months. All participants agreed to fast, provide biological samples and complete the questionnaires. Sample collection was successful in 97% (29/30) of participants and laboratory procedures were feasible in 100% of collected samples. We also tested resources required for the conduct of the full study including personnel, space, laboratory equipment and procedures and determined that they are all feasible. CONCLUSIONS: Recruitment and consenting of patients for the CanDECIDE study may be feasible. However, we are considering prolonging recruitment duration and collaboration with other centres to meet recruitment targets due to lower than expected recruitment rate. Completion of questionnaires and implementation of sample processing protocols are feasible.