Role of sentinel lymph node evaluation during hysterectomy for preoperative pathology diagnosis of endometrial intraepithelial neoplasia in a community hospital setting.

OBJECTIVE: To determine the utility of sentinel lymph node (SLN) evaluation during hysterectomy for endometrial intraepithelial neoplasia (EIN) in a community hospital setting and identify descriptive trends among pathology reports from those diagnosed with endometrial cancer (EC). METHODS: We reviewed patients who underwent hysterectomy from January 2015 to July 2022 for a pathologically confirmed diagnosis of EIN obtained by endometrial biopsy (EMB) or dilation and curettage. Data was obtained via detailed chart review. Statistical testing was utilized for between-group comparisons and multivariate logistic regression modeling. RESULTS: Of the 177 patients with EIN who underwent hysterectomy during the study period, 105 (59.3%) had a final diagnosis of EC. At least stage IB disease was found in 29 of these patients who then underwent adjuvant therapy. Pathology report descriptors suspicious for cancer and initial specimen type obtained by EMB were independently and significantly associated with increased odds of EC diagnosis (aOR 8.192, p < 0.001;3.746, p < 0.001, respectively). Operative times were not increased by performance of SLN sampling while frozen specimen evaluation added an average of 28 min to procedure length. Short-term surgical outcomes were also similar between groups. CONCLUSION: Patients treated for EIN at community-based institutions might be more likely to upstage preoperative EIN diagnoses and have an increased risk of later stage disease than previous research suggests. Given no surgical time or short-term outcome differences, SLN evaluation should be more strongly considered in this practice setting, especially for patients diagnosed by EMB or with pathology reports indicating suspicion for EC.

Promoting positive physical activity behaviours in children undergoing acute cancer treatment: feasibility of the CanMOVE intervention.

BACKGROUND: Supporting children and adolescents with cancer to be physically active can improve medium- and long-term health outcomes. OBJECTIVE: To assess the feasibility of CanMOVE, a 10-week complex, theoretically-informed, behaviour change intervention to promote physical activity for children and adolescents undergoing acute cancer treatment. METHODS: A feasibility study using a single-group, repeated measures, mixed methods design. Participants completed CanMOVE, which included provision of a Fitbit (child/adolescent and carer) and structured support from a physical therapist. Feasibility domains of demand, acceptability, implementation, practicality, limited efficacy, and integration were evaluated. Data sources included service level data, objective assessment of physical activity, physical function, and health-related quality of life; and qualitative data collected via semi-structured interviews with participants and focus groups with staff. RESULTS: Twenty children/adolescents (median age 13yrs, interquartile-range 9-14) with a mix of cancer diagnoses, 20 parents, and 16 clinicians participated. There was high demand with 95% enrolment rate. CanMOVE was acceptable for participants. All feasibility thresholds set for implementation were met. Under practicality, there were no serious adverse events related to the intervention. Limited efficacy data indicated CanMOVE showed positive estimates of effect in influencing child/adolescent physical activity behaviour, physical function, and health-related quality of life. Positive impacts were also seen in parent and staff attitudes towards physical activity promotion. To improve integration into the clinical setting, it was suggested the duration and scope of CanMOVE could be expanded. CONCLUSION: CanMOVE was feasible to implement in a paediatric cancer setting. CanMOVE is appropriate to be tested in a large-scale trial.

Does a consumer co-designed infographic increase knowledge of physical activity after total knee joint replacement? A randomised controlled trial.

PURPOSE: To determine if a consumer co-designed infographic increased knowledge of physical activity and self-efficacy for exercise after total knee joint replacement surgery. METHODS: Forty-four adults with primary knee joint replacement surgery were recruited from a public and a private hospital in Melbourne, Australia. Participants were randomly allocated to an experimental or control group. The experimental group received a consumer co-designed infographic. All participants received usual care. Primary outcome measures were knowledge of physical activity and self-efficacy for exercise. Outcomes were administered at baseline, week 1 and week 6. Semi-structured interviews with experimental group participants explored the acceptability, implementation and efficacy of the infographic. RESULTS: There were no between-group differences for knowledge of physical activity at week 1 (MD -0.02 units, 95% CI -0.9 to 0.9) or week 6 (MD 0.01 units, 95% CI -0.9 to 0.9). Self-efficacy for exercise increased at week 1 (MD 14.2 units, 95% CI 2.9-25.4) but was not sustained. Qualitative data showed that the infographic was embraced by some participants but not by others. CONCLUSIONS: A consumer co-designed infographic did not improve knowledge of physical activity but may have had a short-term positive effect on self-efficacy for exercise after knee joint replacement. Trial registration ACTRN12621000910808.

Structural and mechanistic basis of substrate transport by the multidrug transporter MRP4.

Multidrug resistance-associated protein 4 (MRP4) is an ATP-binding cassette (ABC) transporter expressed at multiple tissue barriers where it actively extrudes a wide variety of drug compounds. Overexpression of MRP4 provides resistance to clinically used antineoplastic agents, making it a highly attractive therapeutic target for countering multidrug resistance. Here, we report cryo-EM structures of multiple physiologically relevant states of lipid bilayer-embedded human MRP4, including complexes between MRP4 and two widely used chemotherapeutic agents and a complex between MRP4 and its native substrate. The structures display clear similarities and distinct differences in the coordination of these chemically diverse substrates and, in combination with functional and mutational analysis, reveal molecular details of the transport mechanism. Our study provides key insights into the unusually broad substrate specificity of MRP4 and constitutes an important contribution toward a general understanding of multidrug transporters.

Hsp70-A Universal Biomarker for Predicting Therapeutic Failure in Human Female Cancers and a Target for CTC Isolation in Advanced Cancers.

Heat shock protein 70 (Hsp70) is frequently overexpressed in many different tumor types. However, Hsp70 has also been shown to be selectively presented on the plasma membrane of tumor cells, but not normal cells, and this membrane form of Hsp70 (mHsp70) could be considered a universal tumor biomarker. Since viable, mHsp70-positive tumor cells actively release Hsp70 in lipid micro-vesicles, we investigated the utility of Hsp70 in circulation as a universal tumor biomarker and its potential as an early predictive marker of therapeutic failure. We have also evaluated mHsp70 as a target for the isolation and enumeration of circulating tumor cells (CTCs) in patients with different tumor entities. Circulating vesicular Hsp70 levels were measured in the peripheral blood of tumor patients with the compHsp70 ELISA. CTCs were isolated using cmHsp70.1 and EpCAM monoclonal antibody (mAb)-based bead approaches and characterized by immunohistochemistry using cytokeratin and CD45-specific antibodies. In two out of 35 patients exhibiting therapeutic failure two years after initial diagnosis of non-metastatic breast cancer, progressively increasing levels of circulating Hsp70 had already been observed during therapy, whereas levels in patients without subsequent recurrence remained unaltered. With regards to CTC isolation from patients with different tumors, an Hsp70 mAb-based selection system appears superior to an EpCAM mAb-based approach. Extracellular and mHsp70 can therefore serve as a predictive biomarker for therapeutic failure in early-stage tumors and as a target for the isolation of CTCs in various tumor diseases.

What's in a Name? The Many Classifications of Acute Myeloid Leukemia with Dysplasia.

OBJECTIVES: Acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) is a high-risk subtype of AML that has recently undergone significant reclassification. Proper classification requires the integration of clinical history and diagnostic studies including peripheral blood and bone marrow morphology, flow cytometry, cytogenetic and molecular studies. The latter have significant clinical and prognostic implications. We present a case of a 55-year-old male diagnosed with AML-MRC with a pathogenic variant in TP53 and amplification of KMT2A (MLL) without rearrangement. We discuss presentation, importance of diagnostic testing through multiple modalities, and the changes in classification and diagnostic criteria between the 2017 World Health Organization (WHO) revised 4th edition and the WHO 5th edition and International Consensus Classification (ICC).

Implementation of an enhanced recovery after surgery (ERAS) protocol for total abdominal hysterectomies in the division of gynecologic oncology: a network-wide quality improvement initiative.

CONTEXT: Enhanced Recovery After Surgery (ERAS) protocols have been shown to decrease length of stay and postoperative opioid usage in colorectal and bariatric surgeries performed at large academic centers. Hysterectomies are the second most common surgical procedure among women in the United States. Hysterectomies performed in an open fashion, or total abdominal hysterectomies (TAHs), account for a large portion of procedures performed by gynecologic oncologists secondary to current oncology guidelines and surgical complexity. Implementation of an ERAS protocol for gynecologic oncology TAHs is one way in which patient outcomes may be improved. OBJECTIVES: An ERAS protocol for gynecologic oncology surgeries performed in a community hospital was instituted with the goal to optimize patient outcomes preoperatively. The primary outcome of interest was to reduce patient opioid usage. Secondary outcomes included compliance with the ERAS protocol, length of stay, and cost. Thirdly, this study aimed to demonstrate the unique challenges of implementing a large-scale protocol across a community network. METHODS: An ERAS protocol was implemented in 2018, with multidisciplinary input from the Departments of Gynecologic Oncology, Anesthesia, Pharmacy, Nursing, Information Technology, and Quality Improvement to develop a comprehensive ERAS order set. This was implemented across a 12-site hospital system network that consisted of both urban and rural hospital settings. A retrospective review of patient charts was performed to assess measured outcomes. Parametric and nonparametric tests were utilized for statistical analysis with p<0.05 denoting statistical significance. If the p value was >0.05 and <0.09, this was considered a trend toward significant. RESULTS: A total of 124 patients underwent a TAH utilizing the ERAS protocol during 2018 and 2019. The control arm consisted of 59 patients who underwent a TAH prior to the ERAS protocol intervention, which was the standard of care in 2017. After 2 years of implementation of the ERAS protocol intervention, we found that 48 % of the ERAS patients had minimal opioid requirements after surgery (oral morphine equivalent [OME] range 0-40) with decreased postoperative opioid requirements in the ERAS group (p=0.03). Although not statistically significant, utilization of the ERAS protocol for gynecologic oncology TAHs trended toward shorter hospital length of stay from 5.18 to 4.17 days (p=0.07). The median total hospital costs per patient also showed a nonsignificant decrease in cost from $13,342.00 in the non-ERAS cohort and $13,703.00 in the ERAS cohort (p=0.8). CONCLUSIONS: A large-scale quality improvement (QI) initiative is feasible utilizing a multidisciplinary team to implement an ERAS protocol for TAHs in the division of Gynecologic Oncology with promising results. This large-scale QI result was comparable to studies that conducted quality-improvement ERAS initiatives at single academic institutions and should be considered within community networks.

Development, multi-institutional external validation, and algorithmic audit of an artificial intelligence-based Side-specific Extra-Prostatic Extension Risk Assessment tool (SEPERA) for patients undergoing radical prostatectomy: a retrospective cohort study.

BACKGROUND: Accurate prediction of side-specific extraprostatic extension (ssEPE) is essential for performing nerve-sparing surgery to mitigate treatment-related side-effects such as impotence and incontinence in patients with localised prostate cancer. Artificial intelligence (AI) might provide robust and personalised ssEPE predictions to better inform nerve-sparing strategy during radical prostatectomy. We aimed to develop, externally validate, and perform an algorithmic audit of an AI-based Side-specific Extra-Prostatic Extension Risk Assessment tool (SEPERA). METHODS: Each prostatic lobe was treated as an individual case such that each patient contributed two cases to the overall cohort. SEPERA was trained on 1022 cases from a community hospital network (Trillium Health Partners; Mississauga, ON, Canada) between 2010 and 2020. Subsequently, SEPERA was externally validated on 3914 cases across three academic centres: Princess Margaret Cancer Centre (Toronto, ON, Canada) from 2008 to 2020; L'Institut Mutualiste Montsouris (Paris, France) from 2010 to 2020; and Jules Bordet Institute (Brussels, Belgium) from 2015 to 2020. Model performance was characterised by area under the receiver operating characteristic curve (AUROC), area under the precision recall curve (AUPRC), calibration, and net benefit. SEPERA was compared against contemporary nomograms (ie, Sayyid nomogram, Soeterik nomogram [non-MRI and MRI]), as well as a separate logistic regression model using the same variables included in SEPERA. An algorithmic audit was performed to assess model bias and identify common patient characteristics among predictive errors. FINDINGS: Overall, 2468 patients comprising 4936 cases (ie, prostatic lobes) were included in this study. SEPERA was well calibrated and had the best performance across all validation cohorts (pooled AUROC of 0·77 [95% CI 0·75-0·78] and pooled AUPRC of 0·61 [0·58-0·63]). In patients with pathological ssEPE despite benign ipsilateral biopsies, SEPERA correctly predicted ssEPE in 72 (68%) of 106 cases compared with the other models (47 [44%] in the logistic regression model, none in the Sayyid model, 13 [12%] in the Soeterik non-MRI model, and five [5%] in the Soeterik MRI model). SEPERA had higher net benefit than the other models to predict ssEPE, enabling more patients to safely undergo nerve-sparing. In the algorithmic audit, no evidence of model bias was observed, with no significant difference in AUROC when stratified by race, biopsy year, age, biopsy type (systematic only vs systematic and MRI-targeted biopsy), biopsy location (academic vs community), and D'Amico risk group. According to the audit, the most common errors were false positives, particularly for older patients with high-risk disease. No aggressive tumours (ie, grade >2 or high-risk disease) were found among false negatives. INTERPRETATION: We demonstrated the accuracy, safety, and generalisability of using SEPERA to personalise nerve-sparing approaches during radical prostatectomy. FUNDING: None.

Common obstetrics and gynecologic topics in critical care: A narrative review.

The fields of Obstetrics and Gynecology and Critical Care often share medically and surgically complex patients. Peripartum anatomic and physiologic changes can predispose or exacerbate certain conditions and rapid action is often needed. This review discusses some of the most common conditions responsible for the admission of obstetrical and gynecological patients to the critical care unit. We will consider both obstetrical and gynecologic concepts including postpartum hemorrhage, antepartum hemorrhage, abnormal uterine bleeding, preeclampsia and eclampsia, venous thromboembolism, amniotic fluid embolism, sepsis and septic shock, obstetrical trauma, acute abdomen, malignancies, peripartum cardiomyopathy, and substance abuse. This article aims to be a primer for the Critical Care provider.

Prehabilitation to improve outcomes afteR Autologous sTem cEll transplantation (PIRATE): A pilot randomised controlled trial protocol.

BACKGROUND: Autologous stem cell transplant is a common procedure for people with haematological malignancies. While effective at improving survival, autologous stem cell transplant recipients may have a lengthy hospital admission and experience debilitating side-effects such as fatigue, pain and deconditioning that may prolong recovery. Prehabilitation comprising exercise and nutrition intervention before stem cell transplant aims to optimise physical capacity before the procedure to enhance functional recovery after transplant. However, few studies have evaluated prehabilitation in this setting. We aim to explore preliminary efficacy of improving physical capacity of prehabilitation for people undergoing autologous stem cell transplant. METHODS: The PIRATE study is a single-blinded, parallel two-armed pilot randomised trial of multidisciplinary prehabilitation delivered prior to autologous stem cell transplantation. Twenty-two patients with haematological malignancy waitlisted for transplant will be recruited from a tertiary haematology unit. The intervention will include up to 8 weeks of twice-weekly, supervised tailored exercise and fortnightly nutrition education delivered via phone, in the lead up to autologous stem cell transplant. Blinded assessments will be completed at week 13, approximately 4 weeks after transplant and health service measures collected at week 25 approximately 12 weeks after transplant. The primary outcome is to assess changes in physical capacity using the 6-minute walk test. Secondary measures are time to engraftment, C-reactive protein, physical activity (accelerometer), grip strength, health-related quality of life (EORTC QLQ-C30 and HDC29 supplement), self-efficacy and recording of adverse events. Health service data including hospital length of stay, hospital readmissions, emergency department presentations and urgent symptom clinic presentation at will also be recorded. DISCUSSION: This trial will inform design of a future definitive randomised controlled trial and implementation of prehabilitation for people receiving autologous stem cell transplant by providing data on efficacy and safety. TRIAL REGISTRATION: The PIRATE Trial has been approved by the Eastern Health Human Research Ethics Committee (E20/003/61055) and is funded by the Eastern Health Foundation. This trial is registered with the Australian New Zealand Clinical Trials Registry ACTRN12620000496910. Registered April 20, 2020.

Limb salvage in octogenarians with critical limb ischemia after lower extremity bypass surgery.

OBJECTIVES: Peripheral artery disease is a worldwide epidemic that affects millions of patients, especially the elderly. It has a prevalence of 20% in individuals >80 years old. Although peripheral artery disease affects >20% of octogenarians, information about limb salvage rates in this patient population is limited. Therefore, this study aims to understand the impact of bypass surgery on limb salvage in patients aged >80 years with critical limb ischemia. METHODS: We conducted a retrospective analysis by querying the electronic medical records at a single institution from 2016 through 2022 to identify the population of interest and analyzed their outcomes after lower extremity bypass. The primary outcomes were limb salvage and primary patency, with hospital length of stay and 1-year mortality as secondary outcomes. RESULTS: We identified 137 patients who met the inclusion criteria. The lower extremity bypass population was divided into two cohorts: <80 years old (n = 111) with a mean age of 66 or ≥80 years old (n = 26) with a mean age of 84 years. The gender distribution was similar (P = .163). No significant difference was found in the two cohorts when it came to coronary artery disease, chronic kidney disease, or diabetes mellitus. However, when current and former smokers were grouped together, they were significantly more common in the younger cohort when compared with nonsmokers (P = .028). The primary end point of limb salvage was not significantly different between the two cohorts. Hospital length of stay was not significantly different between the two cohorts with 4.13 days vs 4.17 days in the younger vs octogenarian cohorts, respectively (P = .95). The 30-day all-cause readmissions were also not found to be significantly different between the two groups. The primary patency at 1 year was 75% and 77% (P = .16) for the <80-year-old and ≥80-year-old cohorts, respectively. Mortality was low in both cohorts, with two and three for the younger and octogenarian populations, respectively; thus, no analysis was performed. CONCLUSIONS: Our study shows that octogenarians who undergo the same preoperative risk assessment as younger populations have similar outcomes when it comes to primary patency, hospital length of stay, and limb salvage when comorbidities were considered. Further studies need to be done to determine the statistical impact on mortality in this population with a larger cohort.

Understanding the hidden epidemic of metabolic syndrome in people accessing community rehabilitation: a cross-sectional study of physical activity, dietary intake, and health literacy.

PURPOSE: To determine the prevalence of metabolic syndrome in patients attending outpatient community rehabilitation in Melbourne, Australia and to compare health literacy, physical activity, and dietary intake of people with and without metabolic syndrome. MATERIALS AND METHODS: A cross-sectional, multi-centre, observational study of adults (n = 193) presenting to rehabilitation with various health complaints. Metabolic syndrome was determined according to the International Diabetes Federation joint consensus worldwide definition. Health literacy was assessed using the Rapid Estimate of Adult literacy in Medicine (REALM) and the Short Test of Functional Health Literacy in Adults (S-TOFHLA). Physical activity was assessed using accelerometers and dietary intake was assessed using a food frequency questionnaire. RESULTS: One hundred and twenty three participants (64%) had metabolic syndrome. Of these, only three (2%) knew they had it. People with metabolic syndrome scored lower on health literacy (S-TOFHLA MD -2.10, 95% confidence interval (CI) -3.98 to -0.22) and took 1311 (95%CI 375 to 2246) fewer daily steps than those without metabolic syndrome. There were no differences in dietary intake. CONCLUSIONS: Metabolic syndrome is a prevalent and under-recognised condition in community rehabilitation. Community healthcare professionals and health services may need to consider a broader approach to management including lifestyle assessment and intervention of patients with various conditions. Implications for rehabilitationAlmost two-thirds of adults in community rehabilitation had underlying, undetected metabolic syndrome.Adults with metabolic syndrome completed less objectively measured physical activity and had lower health literacy levels than those without metabolic syndrome.A broader approach to management may need to be considered in community rehabilitation where patients presenting for rehabilitation of various conditions would likely benefit from lifestyle assessment and intervention.

Promoting positive physical activity behaviors for children and adolescents undergoing acute cancer treatment: Development of the CanMOVE intervention using the Behavior Change Wheel.

Background: Increasing participation in physical activity has the potential to improve outcomes for children and adolescents with cancer during treatment and into survivorship. The aim of this study is to outline the theoretical process behind development of CanMOVE, a behavior change intervention designed to increase physical activity for children and adolescents with cancer. Study design: This study followed a theoretical design process consistent with the Behavior Change Wheel to inform the design of a complex intervention. Materials and methods: The three stages of the Behavior Change Wheel intervention design process include: (1) understanding physical activity behavior within the pediatric cancer setting, (2) identifying potential intervention functions, and (3) identifying appropriate behavior change and implementation strategies. Qualitative and behavior change literature relevant to the pediatric cancer treatment setting were used to inform each stage. Results: An individualized and flexible approach to physical activity promotion that considers intrinsic factors specific to the child/adolescent and their environment is required. Fifteen behavioral change strategies were identified to form the intervention components of CanMOVE. Implementation strategies were identified to build motivation, opportunity and capacity toward increasing physical activity behaviors. Key intervention components of CanMOVE include standardized assessment and monitoring (physical activity, physical function, and health-related quality of life), provision of an activity monitor to both child/adolescent and parent, and one-on-one capacity building sessions with a healthcare professional. Capacity building sessions include education, goal setting, an active supervised physical activity session, barrier identification and problem solving, and action planning. Conclusion: CanMOVE is a novel approach to physical activity promotion in the pediatric cancer treatment setting. The use of a theoretical intervention design process will aid evaluation and replication of CanMOVE when it is assessed for feasibility in a clinical setting. The design process utilized here can be used as a guide for future intervention development.

Patient Preferences in the Management of Wet Age-Related Macular Degeneration: A Conjoint Analysis.

INTRODUCTION: To identify patient preference drivers related to the management of wet age-related macular degeneration (wet AMD). METHODS: In this cross-sectional study, a self-explicated 'conjoint analysis' survey was administered online to eligible patients with wet AMD (receiving anti-vascular endothelial growth factor [VEGF] treatment for at least 12 months) from the USA, Canada, UK, France, Spain, Germany, Italy, Japan, Taiwan, and Australia. The survey consisted of six domains with 21 attributes, which were selected on the basis of a literature review, social media listening, and tele-interviews/discussions with patients, clinical experts, and patient groups. Utility and relative importance scores were generated for each attribute and utility difference significance testing was performed using 'unequal variances t tests'. The Patient Activation Measure (PAM-13) questionnaire was administered to assess patients' knowledge, skill, and confidence in self-management. RESULTS: A total of 466 patients (mean age, 68 years; women, 54%; binocular wet AMD, 28%) with an average anti-VEGF treatment duration of 3.9 years completed the survey. The most important preference domains were 'treatment effects on vision' (non-significant) and 'vision-related symptom burdens' (p < 0.001), followed by 'treatment risk' (p < 0.05), 'impact on daily activities' (p < 0.05), 'burden of clinic/hospital visits' (p < 0.001), and 'impact on psychological well-being'. The five most important attributes in order of importance were clarity of vision, treatment effect on symptoms, quality of vision, time to treatment effect, and time to re-administration. The two most important attributes globally were also in the top three attributes across countries. The majority of participants in the study were level 3 or level 4 of the PAM-13 questionnaire. CONCLUSIONS: This study identified the most important disease and treatment attributes to patients using patient-centred methods. The data showed the degree of harmonization of preferences across geographies and that participants actively adopt behaviours required for improved treatment outcomes. The identified preference drivers may inform future clinical development.

Does Dose Matter? Ionizing Radiation Exposure of the Veterinary Patient From Computed Tomography: A Discussion.

Advanced imaging techniques such as computed tomography are commonplace in human medicine and increasingly, are being utilized by the veterinary profession as scanners become more available and affordable. The benefit of computed tomography imaging is the provision of detailed cross-sectional imaging and 3D reconstruction, but this incurs higher doses of ionizing radiation to the patient. This paper reviews risks and effects associated with ionizing radiation, making comparisons to human models, and a hypothetical scenario is discussed using the human risk model for age at time of exposure and increased lifetime risk of cancer with a dog to human year's formula. Various issues are considered with respect to dose reduction, training, equipment and the reported "greater need for guidance and the establishment of best practice" which may lead to future guidance from the International Commission on Radiological Protection.

Efficacy of Group Exercise-Based Cancer Rehabilitation Delivered via Telehealth (TeleCaRe): Protocol for a Randomized Controlled Trial.

BACKGROUND: Access to rehabilitation to support cancer survivors to exercise is poor. Group exercise-based rehabilitation may be delivered remotely, but no trials have currently evaluated their efficacy. OBJECTIVE: We aimed to evaluate the efficacy of a group exercise-based cancer rehabilitation program delivered via telehealth compared to usual care for improving the quality of life of cancer survivors. METHODS: A parallel, assessor-blinded, pragmatic randomized controlled trial with embedded cost and qualitative analysis will be completed. In total, 116 cancer survivors will be recruited from a metropolitan health network in Melbourne, Victoria, Australia. The experimental group will attend an 8-week, twice-weekly, 60-minute exercise group session supervised via videoconferencing supplemented by a web-based home exercise program and information portal. The comparison group will receive usual care including standardized exercise advice and written information. Assessments will be completed at weeks 0 (baseline), 9 (post intervention), and 26 (follow-up). The primary outcome will be health-related quality of life measured using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire at week 9. Secondary measures include walking capacity (6-minute walk test), physical activity (activPAL accelerometer), self-efficacy (Health Action Process Approach Questionnaire), and adverse events. Health service data including hospital length of stay, hospital readmissions, and emergency department presentations will be recorded. Semistructured interviews will be completed within an interpretive description framework to explore the patient experience. The primary outcome will be analyzed using linear mixed effects models. A cost-effectiveness analysis will also be performed. RESULTS: The trial commenced in April 2022. As of June 2022, we enrolled 14 participants. CONCLUSIONS: This trial will inform the future implementation of cancer rehabilitation by providing important data about efficacy, safety, cost, and patient experience. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12621001417875; https://tinyurl.com/yc5crwtr. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/38553.

The frequency and persistence of lymphedema diagnosis and self-reported symptoms over 5 years in patients with endometrial carcinoma.

A potentially debilitating sequela of diagnosis or treatment for endometrial cancer islower limb lymphedema (LLL), which can have significant impacts on quality of life. Theobjective of this study was to determine the frequency of LLL symptoms in uterinecancer survivors over a 5-year study period. An IRB-approved prospective study of quality of life of endometrial cancer patients whounderwent surgical intervention was undertaken. The Gynecologic CancerLymphedema Questionnaire (GCLQ) was used to survey patients in 2011 and again in2016 to evaluate for symptoms of LLL.205 patients initially answered the survey, and 75 patients completed the follow upsurvey as well, with no differences in demographics between the cohorts. 90.7% ofpatients underwent lymph node dissection. Patients commonly reported symptoms ofnumbness (66.83%), aching (54.2%), and poor physical function (47.8%). On initialsurvey, 14.7% (n = 11) of patients met criteria for LLL by GCLQ criteria, with 8 patientsreporting improvement in symptoms and 3 reporting persistent diagnosis at follow up. At follow up survey, 12.0% (n = 9) patients meeting criteria five years later, with 6patients newly meeting criteria. The most persistent symptoms were poor physicalfunction (70.6%), numbness (72.5%), general swelling (55.6%), aching (64.1%), andlimb-related swelling (60%).While the rate of LLL was similar to previous reports, there were a number of newdiagnoses of LLL at interval follow up distant from surgery, up to 7 years later.Symptoms of LLL also persisted for many years after diagnosis.

A Cancer Exercise Toolkit Developed Using Co-Design: Mixed Methods Study.

BACKGROUND: Access to exercise therapy for cancer survivors is poor. Professional development to support exercise professionals in delivering these interventions is needed. Few online resources exist for exercise professionals to address this issue. OBJECTIVE: To develop and evaluate a freely available online toolkit to support exercise professionals working with cancer survivors. METHODS: A 2-phase, experience-based co-design approach was used to develop and evaluate the online toolkit. The two phases were as follows: 1) needs identification and co-design of resources and platform and 2) pilot evaluation. Four co-design workshops were conducted, transcribed, and thematically analyzed to identify key elements for the toolkit. For the pilot evaluation, a customized survey (the Determinants of Implementation Behavior Questionnaire) was distributed to exercise professionals at baseline and 3 months after launch of the online toolkit to determine its usability, utility, and effectiveness in improving their knowledge, confidence, and behavior. Results were reported as the median and interquartile range and changes were calculated using non-parametric tests. Website analytics described site usage after the initial evaluation. RESULTS: Twenty-five exercise professionals participated in co-designing 8 key elements of the online Cancer Exercise Toolkit: the homepage and pages for getting started, screening and safety, assessment, exercise prescription, education, locations, and resources. For the pilot evaluation, 277/320 respondents (87% of whom were physiotherapists) from 26 countries completed the survey at baseline, with 58 exercise professionals completing follow-up surveys at 3 months. Exercise professionals' knowledge, skills, and confidence in delivering exercise therapy to cancer survivors increased 3 months after baseline (items 1, 6, and 8: median score 5, IQR 3 to 6) to follow-up (items 1 and 6: median score 6, IQR 5 to 6; item 8: median score 5, IQR 5 to 7; P<.001) on a 1 to 7 Likert scale. Most participants (35/44, 80%) agreed or strongly agreed they would recommend the toolkit to colleagues. In the 6 months following the pilot evaluation, the toolkit received an average of 866 views per month. CONCLUSIONS: The co-designed online Cancer Exercise Toolkit was a useful resource for exercise professionals that may increase their knowledge, skills, and confidence in providing exercise therapy to cancer survivors.

Osteoarthritis management care pathways are complex and inefficient: A qualitative study of physiotherapist perspectives from specialised osteoarthritis services.

OBJECTIVE: Hip and knee osteoarthritis guidelines internationally provide consistent first-line care recommendations. However, uptake of these recommendations remains suboptimal. This qualitative study explores factors influencing guideline-based care from the perspectives of physiotherapists working in specialised osteoarthritis services across different models of care. METHODS: Nineteen semi-structured interviews were conducted with physiotherapists working in specialist osteoarthritis services across three different Australian models of care (OsteoArthritis Hip and Knee Service n = 10; OsteoArthritis Chronic Care Programme n = 4; Orthopaedic Physiotherapy Screening Clinics and Multidisciplinary Services n = 5). Interviews were audio recorded and transcribed verbatim. Data were coded and analysed inductively using thematic analysis. RESULTS: The overarching theme to emerge was that accessing first-line osteoarthritis care is complex and difficult, regardless of model of care. Subthemes indicated that: (i) services are either unavailable or inadequately funded, (ii) referral pathways are labyrinthine and lengthy, (iii) patients and other health professionals often believe that surgery is the only/best option and (iv) managing patient co-morbidities is challenging. CONCLUSION: Physiotherapists working in specialised osteoarthritis services perceive multiple and complex factors influencing adherence to first-line care. Barriers occur at various levels in all models of care, including patient and health professional beliefs, health service, and system levels. These results suggest improving healthcare for people with osteoarthritis requires urgent system reform.

Are hip movement precautions effective in preventing prosthesis dislocation post hip arthroplasty using a posterior surgical approach? A systematic review and meta-analysis.

PURPOSE: To determine if hip movement precautions reduce hip prosthesis dislocation rates post hip arthroplasty using a posterior surgical approach compared to minimal or no movement restrictions. MATERIALS AND METHODS: This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered prospectively. CINAHL, MEDLINE and Embase were searched from inception until September 2020 supplemented by citation tracking. Studies were included if patients had a hip arthroplasty using a posterior surgical approach with comparative data on hip movement precautions or minimal to no movement restrictions. Methodological quality was evaluated using the Downs and Black checklist. RESULTS: From a yield of 8 studies, meta-analysis of 7 studies and 9599 total hip arthroplasties, there was low quality evidence of no increased risk of dislocation (RR = 0.98, 95%CI 0.58 to 1.67) for patients prescribed minimal or no hip movement restrictions compared with patients prescribed hip movement precautions. There were 121/5440 dislocations (2.2%) in the movement precaution group and 90/4159 dislocations in the minimally restricted group (2.2%). CONCLUSIONS: Dislocation rates after total hip arthroplasty are low irrespective of movement precaution allocation. Resources allocated to implementing hip movement precautions may be better directed towards other clinical areas.IMPLICATIONS FOR REHABILITATIONThere was no difference in hip prosthesis dislocation rate between patients who received hip movement precautions compared to patients who received minimal or no restrictions after total hip arthroplasty using a posterior surgical approach.Health professionals involved in prescribing and monitoring adherence to hip movement precautions after total hip arthroplasty may be better allocating their resources to other areas of clinical care.Falls were associated with the greatest number of prosthesis dislocations, accounting for 24% of dislocations; resources may be better allocated towards evidence-based strategies to reduce falls.