High incidence of positive peritoneal cytology in low-risk endometrial cancer treated by laparoscopically assisted vaginal hysterectomy.

OBJECTIVE: Laparoscopically assisted vaginal hysterectomy (LAVH) has evolved into an alternative form of surgical management in the treatment of low-risk endometrial cancer. The purpose of this study was to determine whether low-risk endometrial cancer patients are subject to a higher incidence of positive peritoneal cytology when treated with LAVH compared to total abdominal hysterectomy (TAH). METHODS: We retrospectively reviewed the medical records of patients with low-risk endometrial cancer (grade 1--2 endometrioid type with no evidence of extrauterine spread or grade 3 with <50% myometrial invasion (MI), no cervical or adnexal involvement, and negative lymph nodes when sampled) treated at Memorial Sloan-Kettering Cancer Center from January 1993 to September 1999. We compared 131 patients treated with LAVH to 246 controls who underwent TAH. The two groups were compared for known prognostic factors including grade, MI, vascular space involvement, and lower uterine segment extension. RESULTS: The mean age of patients who underwent LAVH (61 years) was similar to that of the controls (62 years). Fourteen (10.3%) of the patients treated with LAVH had positive peritoneal cytology compared to only 7 (2.8%) of the control population. Factors including FIGO grade, myometrial invasion, and preoperative hysteroscopy did not influence the final results. When stratifying for these factors, the odds ratios of having positive peritoneal washings in those patients treated by LAVH were 5.2, 5.2, and 3.7, respectively. CONCLUSION: Treatment of low-risk endometrial cancer by LAVH is associated with a significantly higher incidence of positive peritoneal cytology. This may be due to the retrograde dissemination of cancer cells into the peritoneal cavity during uterine manipulation. The clinical significance of these findings is yet to be determined.

Retrograde seeding of malignant cells during hysteroscopy in presumed early endometrial cancer.

OBJECTIVE: The aim of this study was to determine the effect that preoperative hysteroscopy has on the frequency of positive cytology at the time of definitive surgical management in endometrial cancer. METHODS: Charts of 222 patients with endometrial cancer were reviewed. Patients were divided according to whether (n = 64) or not (n = 158) they had hysteroscopy with saline infusion. Each group was stratified into low or high risk for positive peritoneal cytology. Logistic regression analysis was used to compare the prevalence of positive peritoneal cytology with and without hysteroscopy, before and after the stratification, adjusting for the confounding risk factors. RESULTS: After adjusting for confounding variables there was a statistical difference in the frequency of positive peritoneal cytology in those who had hysteroscopy versus those who did not (odds ratio (OR) = 2.6, 95% confidence interval (CI) = 1.02-6.63, P = 0.05). Even after stratifying patients into a low-risk group (OR = 2.12, 95% CI = 0.13-35.9, P = 0.6) and a high-risk group (OR = 3.46, 95% CI = 1.3-9.12, P = 0.01) the difference in the high-risk group was statistically significant. CONCLUSION: Hysteroscopy seems to affect the prevalence of positive peritoneal cytology, especially in those patients with high-risk cell types. Its use in patients with suspicion of endometrial cancer should be reconsidered.

Stage IVB endometrial carcinoma: the role of cytoreductive surgery and determinants of survival.

OBJECTIVE: The aim of this study was to evaluate the role of cytoreductive surgery and survival determinants in patients with Stage IVB endometrial carcinoma. METHODS: All patients with Stage IVB endometrial carcinoma diagnosed between 1/1/90 and 12/31/98 were identified from tumor registry databases. Individual patient data were collected retrospectively. Survival analyses and comparisons were performed using the Kaplan-Meier method and the log-rank test. The Cox proportional hazards model was used to identify independent variables associated with survival. RESULTS: Sixty-five patients underwent surgery as primary therapy for Stage IVB endometrial carcinoma (median survival 14.8 months). The median age of the population was 65 years (range 29-85 years); 89.2% of patients were postmenopausal, and 21.5% were nulliparous. The most common histologic subtypes were endometrioid (33.8%), serous (32.3%), and mixed (16.9%). Optimal cytoreductive surgery (residual tumor < or =1 cm in maximal diameter) was accomplished in 36 patients (55.4%), while 29 patients (44.6%) were left with >1 cm residual disease. The median survival rate of patients undergoing optimal surgery was 34.3 months, a statistically significant advantage compared to patients with >1 cm residual tumor (11.0 months, P = 0.0001). Among those with optimal surgery, patients with only microscopic residual disease survived significantly longer than patients with optimal but macroscopic residual tumor. Higher performance status, age < or = 58 years, and adjuvant chemotherapy followed by radiation therapy were also significantly associated with superior survival on univariate analysis. On multivariate analysis, residual disease (P = 0.0001), performance status (P = 0.043), and age (P = 0.023) were independent predictors of survival. CONCLUSIONS: The amount of residual disease after cytoreductive surgery, age, and performance status appear to be important determinants of survival in patients with Stage IVB endometrial carcinoma. Maximal cytoreduction should be the goal at the time of primary surgery for advanced disease. For selected patients, combined postoperative chemotherapy and radiation therapy may provide some therapeutic benefit.

Inability of preoperative computed tomography scans to accurately predict the extent of myometrial invasion and extracorporal spread in endometrial cancer.

OBJECTIVE: The purpose of this study was to assess the value of computed tomography (CT) scans in predicting preoperatively the depth of invasion and extrauterine spread in patients with endometrial cancer. METHODS: The records of 54 patients with endometrial cancer who underwent a preoperative CT scan and surgical treatment (36 of whom had complete surgical staging) were reviewed. Final pathological findings were compared with those of the CT scan. The ability of the CT scan to detect the depth of invasion of the tumor into the myometrium and extrauterine spread was assessed. RESULTS: The sensitivity of CT scans at predicting the depth of myometrial invasion (none, inner half, outer half) and cervical and parametrial spread was 10, 9, and 17%, respectively, and sensitivity in predicting any degree of myometrial invasion, lymph node metastasis, adnexal involvement, and the presence of malignant cells in peritoneal cytology was 61, 50, 60 and 57%, respectively. CONCLUSION: CT scan has limited usefulness in determining the depth of myometrial invasion or extent of tumor spread in patients with endometrial cancer. Its routine preoperative use is difficult to justify.

Exposure risks related to the management of three wound drainage systems.

BACKGROUND: In response to the Occupational Safety and Health Administration regulations and Centers for Disease Control and Prevention guidelines, health care employers must explore and incorporate new methods to protect staff and patients from blood-borne pathogens. An area directly affected by the new OSHA standards is the postoperative management of surgical drainage systems. This study compared three surgical wound drainage systems: a "closed" system (Tru-Close) and two currently used drainage systems (Hemovac, and Mini-Snyder) for nursing practices and risk of exposure to blood or body fluids in a simulated setting. METHODS: Fifty-eight volunteer registered nurses were asked to choose appropriate personal protection equipment and use recommended universal precautions while measuring and emptying fluid and reactivating each of the drainage systems and to complete a satisfaction questionnaire. Each postoperative wound drainage system was filled with simulated wound drainage and connected to a manikin in an empty patient room. Exposure/contamination was defined as spilling, dripping, or splashing of simulated drainage fluid anywhere in the patient's room or bathroom. RESULTS: Forty-five percent of nurses who emptied bulb evacuator systems and 40% of nurses who emptied Hemovac systems had resulting contamination to the environment or exposure to self. There were no contaminations with the Tru-Close system. Most contaminations were droplets of fluid on environmental surfaces rather than on the nurses themselves. Most nurses chose gloves for personal protection regardless of the system used. Gowns and face shields were rarely used. Most contaminations were due to emptying simulated fluid (27%) or emptying rinse water (29%) into the patient's toilet. Twenty-three percent (23%) of contaminations occurred while simulated fluid was poured into a container at the bedside. The most common object contaminated was the toilet seat (67%). The bed linen was contaminated 16% of the time. Nurse's gloves were exposed in 6% of the trials. CONCLUSIONS: As administrators and researchers explore new methods to protect patients, health care providers, and the environment from blood-borne pathogens, changes should be balanced with the impact on patient care and user satisfaction.

Reported blood exposure rates and staff nurse satisfaction with a closed surgical drainage system.

BACKGROUND: The purposes of this investigation were (1) to describe performance characteristics, incidence of exposure, and staff satisfaction with a closed drainage system, the Kendall Tru-Close, and (2) to compare performance, incidence of exposure, and satisfaction between the closed drainage system and a currently used surgical drainage system (the Hemovac). METHODS: Subjects were 40 adult male and female patients who had undergone selective orthopedic joint surgery. Twenty patients received the Hemovac drainage system, and 20 patients received the Tru-Close drainage system. Data collection instruments included a patient demographic data form, a daily assessment form, a nurses' bedside survey (self-report), and a satisfaction questionnaire. RESULTS: There were significantly fewer exposures with the closed drainage system when compared with the Hemovac system. An odds ratio of 5.09 indicated that the odds of exposure to fluids with the Hemovac system were five times greater than for the closed system. Nursing satisfaction scores were higher for the Tru-Close system than the Hemovac system for items that related to protection from exposure to self or environment. However, overall nursing satisfaction with the new device was mixed. CONCLUSIONS: Although nurses liked the increased protection from exposure afforded by the Tru-Close drainage system, other patient management issues emerged related to the increased weight of the reservoir bag.

Laminar air flow versus reverse isolation: nurses' assessments of moods, behaviors, and activity levels in patients receiving bone marrow transplants.

PURPOSE/OBJECTIVES: To compare nursing assessments of moods, behaviors, and activity levels of patients receiving bone marrow transplants (BMTs) according to type of isolation environment. DESIGN: Retrospective, descriptive. SETTING: University BMT unit. SAMPLE: Records of 22 patients receiving BMT treated over a two-year period-12 were treated in laminar air flow (LAF) rooms and 10 in reverse isolation. METHODS: Using a retrospective chart review, daily nursing assessments of patients' moods, behaviors, and activity levels were collected and compared based on type of isolation. MAIN RESEARCH VARIABLES: Type of isolation and patient's behavior, mood, and activity level. FINDINGS: Patients assigned to LAF had significantly higher anxiety levels at admission than those assigned to reverse isolation. CONCLUSIONS: Admission to LAF isolation appeared to be more anxiety-provoking than admission to reverse isolation; however, this finding needs to be replicated in a study with a prospective design using standardized psychosocial assessment. Findings are consistent with the evidence that patients view isolation as a temporary inconvenience rather than a major stressor. IMPLICATIONS FOR NURSING PRACTICE: Future research is needed. Preparing patients for isolation can include tours, educational materials, and explanations of procedures and events. Physical contact, even through gloves, can impart warmth and caring in the isolation environment.

Critical hemorrhage during pregnancy.

The major causes of obstetric hemorrhage are described, and guidelines for nursing assessment and interventions presented. Complications associated with life-threatening blood loss during pregnancy are identified as well as physiologic changes unique to pregnancy that impact on nursing care.

Relationships between oral mucositis and treatment variables in bone marrow transplant patients.

The pattern of oral mucositis and related treatment variables was studied in 20 bone marrow transplant patients. Patients received either total body irradiation (TBI) or busulfan in combination with cyclophosphamide and etoposide as pretransplant conditioning. Daily oral assessment scores were analyzed. Mucosal changes began approximately 2 days before transplant and peaked approximately 8 days after transplant. There was a trend for patients receiving TBI to have slightly higher oral scores during the first week posttransplant than patients receiving busulfan. The TBI patients averaged almost twice the number of days of continuous intravenous morphine infusion for oral pain and 6 additional days of total parenteral nutrition when compared with patients receiving busulfan. Subjects who died during aplasia manifested mucositis that gradually worsened and did not return to baseline. Differences in oral status based on type of transplant, either autologous or allogeneic, were not shown in this study.

A new clinical educator role: bridging the education-practice gap.

A new clinical educator role implemented at Georgetown University Hospital is described in this article. Nurses in this role assume dual responsibilities for nursing staff development and clinical supervision of baccalaureate nursing students. These clinical educators have joint appointments in the Department of Nursing and the School of Nursing. This role helps to bridge the education-practice gap and encourages a more efficient use of nursing resources.

Planning a baccalaureate clinical practicum abroad.

Clinical practicum abroad can offer a wealth of unique professional and personal experiences for nursing students. Most of the resources and expertise necessary to develop an international programme may already exist within the nursing school. Below, some pointers on how to plan a study-abroad programme, based on the successful experience of the School of Nursing at Georgetown University.

A three-tiered team model for undergraduate preceptor programs.

At the Georgetown University School of Nursing, a three-tiered team model is used to ensure the effectiveness of the undergraduate preceptor program. Using the three-tiered model, clinical teaching activities are shared among preceptors, clinical instructors, and the course coordinator. This strategy allows the assignment of more complex patients and groups of patients in a closely supervised learning environment. Through evaluations of the program, students have indicated that the preceptorship has increased their sense of independence with patient care and enhanced their satisfaction with the clinical experience.

Clinical management of the pregnant trauma victim.

The pregnant trauma victim presents unique challenges to medical care providers because two lives must be treated concurrently. Physiologic changes inherent in the normal pregnancy, modify the assessment and treatment routines. Care directed to the mother impacts the fetus. Management of the pregnant trauma victim requires a high index of suspicion. Accurate assessment and timely interventions will enhance the probability of healthy outcomes for both mother and infant.

Reestablishing self-feeding in a nursing home resident.

An attempt was made to teach an elderly person to reacquire and maintain self-feeding skills. A single-subject ABAB reversal strategy, including assessment for generalization, was planned as experimental design. The treatment procedure consisted of a continuous, immediate reinforcement program contingent on self-feeding responses. Fast and stable control of self-feeding was obtained. A drop in feeding behavior resulted when the patient returned to base-line procedures. The patient died before the second treatment procedure could be carried out. The study found, however, that nursing home staff could facilitate healthy behavior through better use of behavioral management skills.