Can a simple 'cost-awareness' campaign for laparoscopic hysterectomy change the use and costs of disposable surgical supplies? Pre-post non-controlled study.

OBJECTIVES: Does a cost-awareness campaign for gynaecologists lead to a change in use and costs of disposable surgical supplies for laparoscopic hysterectomy (LH) without increasing hospital utilisation measures (operating room (OR) time or hospital length of stay (LOS))? DESIGN: Pre-post non-controlled study. The OR database was used to identify relevant cases before and after the cost-awareness intervention, and provided information on quantity of each supply item, operative details and LOS. SETTING: Lois Hole Hospital for Women, Edmonton, Alberta, Canada. PARTICIPANTS: 12 laparoscopic trained gynaecologists (7 female, 5 male) participated in both phases of the study. Eligible surgical cases were all LH cases for any indication for women aged ≥18 years. 201 cases were undertaken before the intervention (2011-2013) and 229 cases after the intervention (2016-2017). INTERVENTION: The cost-awareness intervention for gynaecologists included site meetings and rounds providing information on costs of disposable and reusable instruments, a full day skills lab, OR posters about cost and effectiveness of disposable and reusable surgical supplies and demonstrations of reusable equipment (2015-2016). PRIMARY OUTCOME MEASURE: Disposable supplies costs per case (standardised for 2016 unit costs). RESULTS: There was a significant (p<0.05) reduction (unadjusted) in disposable supplies cost per case for LH between cases before and after the intervention: from $C1073, SD 281, to $C943 SD 209. Regression analysis found that the adjusted cost per case after the intervention was $C116 lower than before the intervention (95% CI -160 to -71). Neither OR time nor hospital LOS differed significantly between cohorts. CONCLUSIONS: Our study suggests that cost-awareness campaigns may be associated with reduction in the cost of surgery for LH. However, many other factors may have contributed to this cost reduction, possibly including other local initiatives to reduce costs and emerging evidence indicating lack of effectiveness of some surgical practices.

Does Cost Influence the Choice of Disposable Versus Reusable Instruments? Mailed Survey of Obstetrician/Gynaecologists.

OBJECTIVE: A "cost-awareness" campaign was undertaken at a tertiary hospital from 2015 to 2016 to raise awareness about costs of disposable versus reusable instruments in laparoscopic procedures. We undertook a before and after survey of obstetrician/gynecologists (Ob/Gyns) to find out if the campaign had affected their attitudes about choosing disposable versus less expensive reusable instruments. METHODS: In 2015 (before the cost-awareness campaign) and 2017 (after the cost-awareness campaign), all full-time university-associated Ob/Gyns were mailed a cover letter, questionnaire, and coffee card ($5) with a postage-paid return envelope. Responses (with unique identification) from Ob/Gyns who perform laparoscopic procedures were entered into a password-protected REDCap database on a secure server. All statistical analyses were performed using SAS software version 9.4 (SAS Institute Inc, Cary, NC) (Canadian Task Force Classification II-3). RESULTS: A total of 35 of 42 eligible Ob/Gyns (85%) with a median 10 years in practice completed questionnaires before and after the intervention. The majority had undertaken minimally invasive surgery training, mainly during residency (80%) and conferences (71%). Before the intervention, the three most important qualities influencing their decision to use a particular instrument were safety (66%), effectiveness (57%), and personal experience (49%). After the intervention, the three most important qualities were effectiveness (57%), safety (57%), and ease of use (46%). Device cost was ranked sixth (26%) before and seventh (17%) after the intervention. The majority (57%) of participants did not change their choice of disposable or reusable instruments, or they would make the choice according to the specific procedure. CONCLUSION: Given the current economy, operative costs are constantly under review. Knowledge about Ob/Gyns' attitudes provides information to design more effective awareness campaigns to encourage use of less costly instruments. To change practice, a campaign increasing Ob/Gyns' exposure to less expensive but safe and effective instruments may help to increase uptake and potentially lead to cost reduction. Cost awareness alone is unlikely to change practice.

Use of a tissue expander to protect small bowel during radiotherapy in a cervical cancer patient with severe Crohn's disease.

•Inflammatory bowel disease increases the risk of radiation enteritis.•Tissue expanders displace bowel from the radiation field.•Thromboembolism and fistulae may be risks associated with tissue expander placement.A Vicryl mesh hammock may prevent bowel from entering the radiation field.

Combined methotrexate-dactinomycin: an effective therapy for low-risk gestational trophoblastic neoplasia.

OBJECTIVE: The objective of this study is to examine the outcomes of combined chemotherapy using methotrexate and dactinomycin in the management of women with low-risk gestational trophoblastic neoplasia (GTN). The primary outcome is the total number of cycles of chemotherapy required to achieve a normal level of human chorionic gonadotropin (hCG). The secondary outcome is treatment-related toxicity. METHODS: A retrospective chart review of all patients with GTN treated between 1996-2007 and 1991-2007 was performed at the Alberta Cross Cancer Institute and the British Columbia Cancer Agency, respectively. Patients with low-risk GTN, treated with 0.6 mg/m(2) dactinomycin (days 1 and 2) and methotrexate 100mg/m(2) were included. Toxicities were graded using the National Cancer Institute Common Terminology Criteria for Adverse Events. The number of cycles to achieve normalization of hCG was determined, and multivariate analyses were performed to identify factors associated with treatment duration. RESULTS: One hundred women were eligible. The average age was 29 years (range 15-46). The median number of cycles to achieve a normal hCG was 3 (range 1-11). Two patients required second-line treatment and one patient chose to proceed with hysterectomy. Ninety-eight percent of patients were primarily cured with this regimen, and 2 were cured with second line treatment. Grade 3 and 4 hematologic toxicities were experienced by 12% and 8% of patients, respectively. Grade 2 and 3 stomatitis or mucositis were noted in 44% and 3% of patients, respectively. CONCLUSIONS: Low-risk GTN is reliably and rapidly cured with combined methotrexate-dactinomycin. Toxicity is modest.

Assessment of outcomes in surgically staged I/II endometrial adenocarcinoma patients treated with postoperative vaginal vault radiotherapy only.

OBJECTIVE: To examine the efficacy of vaginal vault radiotherapy as adjuvant treatment for patients with high-grade, stage I/II endometrial adenocarcinoma who have been surgically staged. METHODS: A retrospective chart review of 77 women between 1995 and 2006 with high-grade surgically staged I and II endometrial adenocarcinoma, who were treated with postoperative vaginal vault radiotherapy alone, was performed. The primary study end points were recurrence risk and sites of recurrence. The secondary end points were disease-free and overall survival. Kaplan-Meier estimates were calculated for overall and disease-free survival. RESULTS: Seventy-seven women were identified and met inclusion criteria. Sixty-seven (87%) had grade 3 histologic features on final pathologic report. Forty-two patients (55%) were classified as stage IB, having superficial myometrial invasion; 21 (27%) were stage IC, with deep invasion; and 6 (8%) were stage II, involving the cervix. The median follow-up was 80 months (6.6 years). There were 10 recurrences (13.0%), of which 3 were local: 1 involving the vaginal apex; 1, the lower vagina and pelvic sidewall; and 1, the lower vagina. The 5-year recurrence risk was 11.2% and the 5-year survival probability 88.9%. CONCLUSIONS: It seems that for this cohort of 77 patients with surgically staged I and II grade 3 endometrial adenocarcinoma, adjuvant vaginal vault radiotherapy alone leads to acceptable recurrence rates and survival while minimizing morbidity.

Urine metabolite analysis offers potential early diagnosis of ovarian and breast cancers.

PURPOSE: Metabolomics is a new, rapidly expanding field dedicated to the global study of metabolites in biological systems. In this article metabolomics is applied to find urinary biomarkers for breast and ovarian cancer. EXPERIMENTAL DESIGN: Urine samples were collected from early- and late-stage breast and ovarian cancer patients during presurgical examinations and randomly from females with no known cancer. After quantitatively measuring a set of metabolites using nuclear magnetic resonance spectroscopy, both univariate and multivariate statistical analyses were employed to determine significant differences. RESULTS: Metabolic phenotypes of breast and ovarian cancers in comparison with normal urine and with each other revealed significance at Bonferroni-corrected significance levels resulting in unique metabolite patterns for breast and ovarian cancer. Intermediates of the tricarboxylic acid cycle and metabolites relating to energy metabolism, amino acids, and gut microbial metabolism were perturbed. CONCLUSIONS: The results presented here illustrate that urinary metabolomics may be useful for detecting early-stage breast and ovarian cancer.

A population-based study of the determinants of physical activity in ovarian cancer survivors.

BACKGROUND: Regular physical activity is associated with quality of life and other health-related outcomes in ovarian cancer survivors, but participation rates are low. This study investigated the determinants of physical activity in ovarian cancer survivors. METHODS: A population-based, cross-sectional, mailed survey of ovarian cancer survivors in Alberta, Canada, was performed. Measures included self-reported physical activity, medical and demographic factors, and social cognitive variables from the Theory of Planned Behavior. RESULTS: A total of 359 women participated (51.4% response rate), of whom 112 (31.1%) were meeting physical activity guidelines. Variables associated with meeting guidelines were younger age, higher education and income, being employed, lower body mass index, absence of arthritis, longer time since diagnosis, earlier disease stage, and being disease-free. Analysis of the Theory of Planned Behavior variables indicated that 36% of the variance in physical activity guidelines was explained, with intention being the sole independent correlate (?=.56; P < .001). CONCLUSION: Various demographic and medical factors can help identify ovarian cancer survivors at risk for physical inactivity. Interventions should attempt to increase physical activity intentions in this population by focusing on instrumental and affective attitudes as well as perceptions of control.

Physical activity in ovarian cancer survivors: associations with fatigue, sleep, and psychosocial functioning.

UNLABELLED: Physical activity has been associated with better health-related outcomes in several cancer survivor groups but very few data exist for women with ovarian cancer. The purpose of this study was to investigate the associations between physical activity and health-related outcomes in ovarian cancer survivors and to examine any dose-response relationship. PATIENTS AND METHODS: A cross-sectional postal survey of ovarian cancer survivors on and off treatment identified through the Alberta Cancer Registry was performed. Participants completed self-report measures of physical activity, cancer-related fatigue, peripheral neuropathy, depression, anxiety, and happiness, as well as demographic and medical variables. RESULTS: A total of 359 ovarian cancer survivors participated (51.4% response rate) of whom 31.1% were meeting the public health physical activity guidelines of the Centers for Disease Control and Prevention. Those meeting guidelines reported significantly lower fatigue than those not meeting guidelines (mean difference, 7.1; 95% confidence interval, 5.5-8.8; d = 0.87; P < 0.001). Meeting guidelines was also significantly inversely associated with peripheral neuropathy, depression, anxiety, sleep latency, use of sleep medication, and daytime dysfunction and was positively associated with happiness, sleep quality, and sleep efficiency. There was no evidence of a dose-response relationship beyond meeting or not meeting the guidelines for any variables. CONCLUSIONS: Ovarian cancer survivors who were meeting physical activity guidelines reported more favorable outcomes of fatigue, peripheral neuropathy, sleep, and psychosocial functioning.

Physical activity preferences of ovarian cancer survivors.

OBJECTIVE: Regular physical activity is positively associated with quality of life in ovarian cancer survivors, but no data exist on how best to promote activity in this population. This study investigated the interests and preferences of ovarian cancer survivors with regard to physical activity participation. METHODS: A provincial, population-based postal survey of ovarian cancer survivors in Alberta, Canada, was performed including measures of self-reported physical activity, medical and demographic variables, and physical activity preferences. RESULTS: A total of 359 women participated (51.4% response rate). Over half expressed interest in participating in a physical activity program (53.8%), with a further 32.9% maybe interested. The most common preferences were for programs to be home-based (48.9%), start post-treatment (69.5%), and involve walking (62.7%). There were differences in preferences based on demographic, but not medical, factors. CONCLUSION: The majority of ovarian cancer survivors expressed interest in participating in physical activity programs; however, some preferences varied by demographic factors. Designing physical activity interventions according to these preferences may optimize adherence and outcomes in ovarian cancer survivors.

Suprapubic or urethral catheter: what is the optimal method of bladder drainage after radical hysterectomy?

BACKGROUND: Lower urinary tract dysfunction is a common morbidity related to radical hysterectomy (RAH). Although transurethral catheterization (TUC) has traditionally been used for postoperative bladder drainage following RAH, suprapubic catheterization (SPC) is an alternative method that may be advantageous. OBJECTIVES: To determine, by means of a retrospective cohort study, the incidence of urinary tract infection (UTI), duration of postoperative hospital stay, and time to trial of voiding in women catheterized suprapubically or transurethrally after RAH for early stage cervical cancer. METHODS: Two hundred twelve patients who underwent RAH and staging for stage IA1 + LVS, 1A2, and 1B1 cancer of the cervix in Edmonton between 1996 and 2006 were included in the study. Three gynaecologic oncologists performed the surgeries. Operative, postoperative, and demographic data were extracted from patient records. Patients were catheterized either suprapubically (SPC group) or transurethrally (TUC group) according to the surgeon's discretion. Comparative tests and multivariate regression analysis were used to compare outcome measures between the groups and to adjust for confounding variables. RESULTS: The TUC group had a higher proportion of patients with UTI (27%) than the SPC group (6%) (P < 0.001). The SPC group had a shorter postoperative hospital stay (4.8 vs. 5.7 days; P < 0.001) and an earlier trial of voiding (2.7 vs. 4.4 days; P < 0. 001). Following regression analysis, statistically significant differences remained for UTI and time to initiation of a trial of voiding. CONCLUSION: After RAH for early stage cervical cancer, suprapubic catheterization is associated with a lower rate of UTI and an earlier trial of voiding than transurethral catheterization.

Correlates of exercise motivation and behavior in a population-based sample of endometrial cancer survivors: an application of the Theory of Planned Behavior.

BACKGROUND: Despite evidence of the benefits of exercise in cancer survivors, exercise participation rates tend to decline after treatments. Few studies have examined the determinants of exercise in less common cancer sites. In this study, we examined medical, demographic, and social cognitive correlates of exercise in endometrial cancer survivors using the Theory of Planned Behavior (TPB). METHODS: A mailed survey was completed by 354 endometrial cancer survivors (1 to 10 years postdiagnosis) residing in Alberta, Canada. The study was cross-sectional. Exercise behavior was assessed using the Godin Leisure Time Exercise Questionnaire and the TPB constructs were assessed with standard self-report scales. Multiple regression analyses were used to determine the independent associations of the TPB constructs with intention and behavior. RESULTS: Chi-square analyses indicated that marital status (p = .003), income level (p = .013), and body mass index (BMI) (p = .020) were associated with exercise. The TPB explained 34.1% of the variance in exercise behavior with intention (beta = .38, p < .001) and self-efficacy (beta = .18, p = .029) being independent correlates. For intention, 38.3% of the variance was explained by the TPB with self-efficacy (beta = .34, p < .001) and affective attitude (beta = .30, p < .001) being the independent correlates. The TPB mediated the associations of marital status and BMI with exercise but not income level. Age and BMI moderated the associations of the TPB with intention and behavior. CONCLUSION: The TPB may be a useful framework for understanding exercise in endometrial cancer survivors. Exercise behavior change interventions based on the TPB should be tested in this growing population.

Associations between physical activity and quality of life in ovarian cancer survivors.

OBJECTIVES: To estimate the prevalence of physical activity in ovarian cancer survivors and to determine if there is a dose-response relationship between physical activity and quality of life. METHODS: Ovarian cancer survivors identified from a Canadian provincial cancer registry were mailed a questionnaire measuring self-reported leisure time physical activity (Godin Leisure Time Exercise Questionnaire), cancer-specific quality of life (Functional Assessment of Cancer Therapy-Ovarian), and standard demographic and medical variables. RESULTS: Completed questionnaires were received from 359 (51.4%) participants. Analyses indicated that 31.1% were meeting public health physical activity guidelines (i.e., at least 60 min of strenuous or 150 min of moderate/strenuous physical activity per week). Comparisons using different volumes of physical activity showed support for the current guidelines. Specifically, participants meeting current physical activity guidelines reported significantly better quality of life than those not meeting guidelines [mean difference: 12.5; 95% CI: 9.1 to 16.0; p<0.001; d=0.75]. Disease status was the only variable to moderate this association. Adjusting for important demographic and medical variables did not alter the findings. CONCLUSIONS: Few ovarian cancer survivors are meeting public health physical activity guidelines, but those that are meeting guidelines report significantly and meaningfully better quality of life. Clinical trials investigating the causal effects of physical activity on quality of life in ovarian cancer survivors are warranted.

Atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion (ASC-H): a result not to be ignored.

OBJECTIVE: The objective of this study was to determine the risk of a clinically significant lesion associated with the diagnosis of atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion (ASC-H) on cervical cytology (Pap smear). METHODS: This was a retrospective, observational, descriptive study. A computerized database containing cytologic and histologic information for the health region was used to identify women with a diagnosis of ASC-H on a Pap smear performed between January 1 and December 31, 2002. All pertinent pathology data (cytopathology, histopathology, and surgical specimens) were examined. Patients were excluded if they had a diagnosis of cervical cancer, adenocarcinoma in situ (AIS), or high-grade squamous intraepithelial lesion (HSIL) prior to the index Pap smear. RESULTS: During the study period, 727 of 241 841 Pap smears (0.3%) were reported as ASC-H in 655 patients. Ninety-one patients had a previous diagnosis of cervical cancer, AIS, or HSIL and were excluded from analysis, and 12 patients on review did not have ASC-H. There were no follow-up data for 35 of the remaining 552 patients, leaving 517 patients in the study group. In this group, the rates of histologically proven cervical lesions were 2.9% (15/517) for cervical cancer, 1.7% (9/517) for AIS, and 65.6% (339/517) for HSIL. Women undergoing a procedure that included histological examination were more likely to have a significant lesion discovered. CONCLUSION: The diagnosis of ASC-H on Pap smear is associated with an appreciable risk of clinically significant disease. Patients with an ASC-H Pap smear result should undergo timely colposcopic and histologic assessment to rule out HSIL, AIS, and cervical cancer.

Exercise preferences of endometrial cancer survivors: a population-based study.

Exercise has gained recognition as an effective supportive care intervention for cancer survivors, yet participation rates are low. Knowledge of the specific exercise counseling and programming preferences of cancer survivors may be useful for designing effective interventions. In this study, we examined the exercise preferences of 386 endometrial cancer survivors. Participants completed a questionnaire that included measures of past exercise behavior, exercise preferences, and medical and demographic information. Some key findings were as follows: (a) 76.9% of participants said they were interested or might be interested in doing an exercise program and (b) 81.7% felt they were able or likely able to actually do an exercise program. Participants also indicated that walking was their preferred activity (68.6%) and moderate exercise was their preferred intensity (61.1%). Logistic regression analyses showed that meeting public health guidelines for exercise, being overweight or obese, receiving adjuvant treatment, months since diagnosis, income, marital status, and level of education all influenced exercise preferences. These results suggest that endometrial cancer survivors have unique exercise preferences that are moderated by a number of demographic and medical variables. These findings may have implications for the design and implementation of clinical and population-based exercise interventions for endometrial cancer survivors.

Is an interdisciplinary session on ethics and law in obstetrics and gynaecology effective?

OBJECTIVE: To evaluate the effects of an interdisciplinary session on medical ethics and legal issues related to obstetrics and gynaecology on medical students' knowledge, attitudes, and behaviours. METHODS: Second-year medical students at the University of Alberta were asked to complete surveys before and after an interdisciplinary panel session on ethics and legal issues in reproductive health. Survey questions were related to knowledge of ethics and law, attitudes toward controversial topics in reproductive health, and predicted behaviours in specific clinical scenarios. In the postsession survey, students were asked to evaluate the session's usefulness and impact. RESULTS: Fifty-seven students completed both the pre- and postsession surveys. Most students listed family, religion, culture, peer groups, scientific thought and theory, and school and education as influences on their own personal ethics and morality. Fifty-five students (97%) stated that the panel session was useful. Most students (79%) reported that the session increased their knowledge of ethical and legal issues in reproductive health. Many students felt that the panel session would change the way they practise in similar clinical situations (63%). The panel session appeared to affect knowledge and predicted behaviour. CONCLUSION: A large-group interdisciplinary panel session can influence medical students' knowledge and future behaviours related to ethics and law in obstetrics and gynaecology. Medical students gave this session a high rating.

Associations among exercise, body weight, and quality of life in a population-based sample of endometrial cancer survivors.

OBJECTIVES: Lack of exercise and excess body weight may exacerbate treatment-related declines in quality of life (QoL) in endometrial cancer survivors. The primary purpose of this study was to examine the associations among exercise, body weight, and QoL in a population-based sample of endometrial cancer survivors. METHODS: Participants were 386 endometrial cancer survivors residing in Alberta, Canada who completed a mailed survey that assessed self-reported exercise, height, and weight to calculate body mass index (BMI) and QoL using the Functional Assessment of Cancer Therapy-Anemia (FACT-An) scale. RESULTS: Descriptive data indicated that 70% of the sample were not meeting public health exercise guidelines and 72% were overweight or obese. Multivariate analyses of variance demonstrated that endometrial cancer survivors meeting public health guidelines for exercise and body weight reported significantly better QoL than survivors not meeting guidelines. The differences in QoL between the groups were clinically meaningful and were not altered when controlling for important demographic and medical variables. There were no interactions between exercise, BMI, age, or time since diagnosis. Lastly, multiple regression analysis identified that both exercise (beta = .21; P < .001) and BMI (beta = -.17; P < .001) were independently associated with QoL. CONCLUSIONS: These results suggest that exercise and body weight are important independent correlates of QoL in endometrial cancer survivors. Randomized controlled trials designed to test the causal effects of exercise and/or weight loss on QoL in endometrial cancer survivors are warranted.

Labor and delivery nurses: a survey of attitudes toward third-year medical students and their education.

OBJECTIVE: Forty-six percent of third-year medical students at the University of Alberta rated labor and delivery nurses as a negative influence on their obstetrics and gynecology rotation. We hypothesized that the nurses would have mostly negative opinions toward students and their education. STUDY DESIGN: Labor and delivery nurses were surveyed with regard to their views on the following: (1) student learning objectives, (2) factors causing a patient to reject or accept a student, and (3) the role of the nurse in medical student education. RESULTS: Eighty-nine nurses ranked student tasks (objectives) as very appropriate, appropriate, neutral, inappropriate, and very inappropriate. History and physical examination, witnessing deliveries, assisting at deliveries, and following up women in labor were rated very appropriate or appropriate by more than 96% of nurses; 85% approved of students doing supervised deliveries. Nursing staff were equally divided in approving or disapproving of pelvic exams in labour and outpatient assessment by students. Artificial rupture of membranes, fetal scalp electrode application, and episiotomy repair were not approved of by more than 70% of nurses. The most important factors causing a patient to reject or accept a student were felt to be bedside manner and previous experience with a student, with least important being attractiveness, gender, and the nurse's opinion. Eighty-seven percent of nurses declared that one of their roles is to help students gain experience, but 71% said they would protect women from students with whom they were not comfortable. CONCLUSION: Labor and delivery nurses generally have a more positive attitude toward students and their learning than review of evaluations by the students would suggest. However, nurses have reservations about students performing technical procedures in the labor and delivery room. Creation of guidelines (objectives) with nursing input and better briefing of students with regard to nursing expectations may improve the student's experience.

A randomized controlled trial of early versus "traditional" postoperative oral intake after major abdominal gynecologic surgery.

OBJECTIVE: The purpose of this study was to compare early oral intake and the traditional timing of feeding after major gynecologic surgery and the effects on the length of hospital stay. STUDY DESIGN: Gynecologic oncology and urogynecology patients who underwent major abdominal gynecologic surgery were prospectively randomized to 1 of 2 groups. The traditional feeding group (group A, 49 patients) received nothing by mouth until documentation of bowel function. They were then advanced slowly to solid diet. The patients allocated to the early feeding regimen (group B, 47 patients) began clear fluids on the first postoperative day. Once 500 mL of clear fluid was tolerated, they received a regular diet. The groups were compared with regard to length of hospital stay, postoperative day that solids were tolerated, and the incidence of adverse effects. Statistical analyses were performed with the chi(2) test, the Fisher exact test, the Student t test, and analysis of variance. RESULTS: The demographic characteristics of the 2 groups were similar. There was a statistically significant reduction in the length of hospital stay for those patients on the early feeding regimen. The median length of stay for group A was 6.0 days and for group B was 4.0 days (P =.0001). There was no difference in the incidence of emesis, ileus, or other postoperative complications between the 2 groups. CONCLUSION: Early postoperative dietary advancement after major abdominal gynecologic surgery results in a decreased length of hospital stay and appears to be safe, with no increased adverse effects.