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PURPOSE: The development of supportive care interventions delivered by surgeons for their patients is a major research priority. Designing such interventions requires understanding patients' supportive care needs for major operations. This qualitative analysis aimed to determine the supportive care needs of patients undergoing major abdominal operations for cancer. METHODS: We conducted semi-structured interviews with a subset of participants in a randomized, controlled trial of a specialist palliative care intervention for patients undergoing abdominal resections for cancer (NCT03436290). Sampling was designed to balance the population by sex, age (older vs. younger than 65 years), and treatment group assignment (intervention vs. control). The interview guide was developed to elicit patient perceptions of their supportive care needs from diagnosis to the time of interview, about 1 month after their operation. Two coders used an iterative, inductive method to identify recurring themes in the interviews. RESULTS: Analysis of interview transcripts revealed five primary themes: preoperative preparation, postoperative recovery, expectation setting, coordination of care, and provider characteristics. Cutting across these themes were patients' focus on time, timeliness, and timelines, as well as their desires for information both from their surgeons and other sources. Surgeons inspired trust through the quality of their communication and their responsiveness to questions. Patients were sensitive to perceived deviations from their expectations and spoke of the need to develop patience and to expect the unexpected. CONCLUSIONS: Patients expressed several needs for supportive care that surgical teams can potentially address to improve the experience of major cancer surgery.
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Neoplasias , Humanos , Neoplasias/terapia , Atención Perioperativa , Comunicación , Músculos AbdominalesRESUMEN
We conducted in-depth, semi-structured interviews with LGBTQ+-identified individuals (n = 31) to explore the range of LGBTQ+ perspectives on genomic research using either sexual orientation or gender identity (SOGI) data. Most interviewees presumed that research would confirm genetic contributions to sexual orientation and gender identity. Primary hopes for such confirmation included validating LGBTQ+ identities, improved access to and quality of healthcare and other resources, and increased acceptance in familial, socio-cultural, and political environments. Areas of concern included threats of pathologizing and medicalizing LGBTQ+ identities and experiences, undermining reproductive rights, gatekeeping of health or social systems, and malicious testing or misuse of genetic results, particularly for LGBTQ+ youth. Overall, interviewees were divided on the acceptability of genomic research investigating genetic contributions to sexual orientation and gender identity. Participants emphasized researchers' ethical obligations to LGBTQ+ individuals and endorsed engagement with LGBTQ+ communities throughout all aspects of genomic research using SOGI data.
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Identidad de Género , Minorías Sexuales y de Género , Adolescente , Femenino , Genómica , Humanos , Masculino , Conducta SexualRESUMEN
OBJECTIVE: The aim of the study was to characterize surgeon perspectives regarding the benefits and downsides of conducting overlapping surgery. BACKGROUND: Although surgeons are key stakeholders in current discussions surrounding overlapping surgery, little has been published regarding their opinions on the practice. Further characterization of surgeon perspectives is needed to guide future studies and policy development regarding overlapping surgery. METHODS: Study information was sent to all members of 3 professional surgical societies. Interested individuals were eligible to participate if they identified as attending surgeons in an academic setting who work with trainees. Purposive selection was used to diversify surgeons interviewed across multiple dimensions, including subspecialty and opinion regarding appropriateness of overlapping surgery. In-depth, qualitative interviews were conducted with participants regarding their opinions on overlapping surgery. RESULTS: The 51 surgeons interviewed identified a wide array of potential benefits and disadvantages of overlapping surgery, some of which have not previously been measured, including downsides to surgeon wellness and patient experience, less surgeon control over procedures, and difficulty in scheduling cases. Interviewees often disagreed as to whether overlapping surgery negatively or positively affects each dimension discussed, particularly regarding the impact on resident training. CONCLUSIONS: The utilization of the novel perspectives presented here will allow for targeted assessment of physician perspectives in future quantitative studies and increase the likelihood that variables measured encompass the range of factors that surgeons find meaningful and relevant. Priority areas of future research should include examining effects of overlapping surgery on surgical training and surgeon wellness.
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Competencia Clínica , Cirugía General/educación , Internado y Residencia/métodos , Investigación Cualitativa , Cirujanos/educación , Femenino , Humanos , Masculino , Sociedades Médicas , Procedimientos Quirúrgicos Operativos , Estados UnidosRESUMEN
[This corrects the article DOI: 10.3389/fped.2022.1049661.].
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INTRODUCTION: Surgical oncology patients have a high symptom burden and increased risk of morbidity. The aim of palliative care is to evaluate and treat the patient in a holistic manner focusing on the unique attributes of each patient. This goal-concordant approach could help surgical patients cope with the stress and uncertainty that often accompany serious illness and surgery, improving overall outcomes. This qualitative analysis sought to explore whether unmet specialist palliative care or end-of-life needs exist in this population. METHODS: Qualitative interviews were completed with a subset of participants in a randomized, controlled trial of a specialist palliative care intervention for patients undergoing abdominal oncologic surgery. The interview guide sought to elicit respondents' perceptions of palliative care and end-of-life needs perioperatively and postoperatively. Recurring themes were identified by two independent coders. RESULTS: Analysis of 47 interview transcripts revealed few serious concerns about end-of-life issues, however appreciation for the supportive presence offered by palliative care was present. Among participants who received specialist palliative care, many found the intervention helpful, but few were able to articulate issues that the intervention improved. CONCLUSION: These findings suggest low levels of unmet palliative care needs among this population, which is consistent with the results of the parent trial. Targeting patients with a higher symptom burden perioperatively may allow for improved symptom management and better adherence to the treatment plan postoperatively, as well as be a more focused use of specialist palliative care clinicians' efforts.
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PURPOSE: Studies relying on standardized instruments to measure patient-centered harms and benefits of cancer treatment may fail to capture important elements of the lived experience of cancer patients. Further, qualitative studies on the survivorship experience of men with localized prostate cancer (PCa) are limited. We sought to explore the early experience, long-term experience, and advice provided for others among long-term survivors of localized PCa. METHODS: Semi-structured qualitative interviews with a subset (n = 66) of respondents to a survey of 10-year PCa survivors who underwent active surveillance, radical prostatectomy, or radiotherapy. Topics included early and long-term experiences and advice to other men and physicians. RESULTS: Immediately after treatment, men were mostly satisfied with radiation and active surveillance due to remaining whole and avoiding surgical removal of the prostate. Meanwhile, men treated with surgery felt relieved by the removal of cancer. Some early negative perception was related to short-term anxiety, particularly among men who underwent active surveillance. Long-term experiences included accepting the trade-offs of urinary and sexual side effects with survival. Most men fared well financially, some had strengthened relationships, and many reported greater appreciation and compassion. Men provided essential advice to other men and physicians on the importance of gathering detailed information on treatments and establishing a strong relationship with physicians. CONCLUSIONS: Long-term survivors of localized PCa generally do well by accepting the long-term effects of contemporary treatments, experiencing strengthened relationships, and developing a better overall life approach. IMPLICATIONS FOR CANCER SURVIVORS: We provide useful perspectives and insights for men opting to use current-day treatments for localized PCa.
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Objective: To describe United States (US) pediatric oncologists' experiences with treatment refusal or abandonment, exploring types and frequency of decision-making conflicts, and their impact. Study design: We conducted exploratory qualitative interviews of pediatric oncologists (n = 30) with experience caring for a pediatric patient who refused or abandoned curative treatment. Interviewees were recruited using convenience and nominated expert sampling, soliciting experiences from diverse geographic locations and institution sizes across the US. We analyzed transcripts using applied thematic analysis to identify and refine meaningful domains. Results: Many oncologists reported multiple experiences with refusal and abandonment. Most anticipated case frequency would increase due to misinformation, particularly on the internet. Interviewees described cases of treatment refusal and abandonment, but also a wider variety of cases than previously described in existing publications, including cases involving: non-adherence; negotiations for different treatments; negotiations for complementary and alternative medicine; delayed treatment initiation; and refusal of a component of recommended therapy. Cases often involved multiple stages or types of conflicts. Recurring patient/family behaviors emerged: clear opposition to treatment from the outset; hesitancy about treatment despite initiating therapy; and psychosocial circumstances becoming an obstacle to treatment completion. Oncologists revealed substantial professional and personal repercussions of these cases. Conclusion: Oncologist interviews highlight a broad range of conflicts, yielding a taxonomy of treatment refusal, non-adherence and abandonment (TRNA) that accounts for the heterogeneity of situations described. Cases' complexity and interrelatedness points to a functional model of TRNA that includes families' behaviors. This preliminary taxonomy and model warrant further research and examination to refine the model and generate strategies to prevent and mitigate TRNA.
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OBJECTIVES: To examine opinions on trainee independence and attending presence among a cross-section of the general population and explore how perceptions of trust, past experiences, and demographics interacted with comfort consenting to these surgical scenarios. STUDY DESIGN: Mixed-methods METHODS: Based on prior qualitative analysis, we designed a survey of patient preferences and values that focused on trust in healthcare practitioners and processes, which also included comfort ratings of three surgical scenarios (including overlapping surgery). The survey was administered to a sample from the general public using Mechanical Turk. We identified discreet domains of trust and examined the association of responses to these domains with comfort ratings, prior healthcare experiences, and demographics. RESULTS: We analyzed 225 surveys and identified four patient subgroups based on responses to the surgical scenarios. Subjects that were more comfortable with overlapping surgery were more trusting of trainees and delegation by the attending. Past experiences in healthcare (positive and negative) were associated with multiple domains of trust (in trainees, surgeons, and the healthcare system). Demographics were not predictive of trust responses or comfort ratings. CONCLUSION: Patients express varying degrees of comfort with overlapping surgery, and this is not associated with demographics. Past negative experiences have an impact on trust in the healthcare system overall, and trust in trainees specifically predicts comfort with attending absence from the operating room. Efforts to increase patient comfort with overlapping surgery and surgical training should include strategies to address past negative experiences and foster trust in trainees and the delegation process. LEVEL OF EVIDENCE: IV Laryngoscope, 130:2728-2735, 2020.
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Internado y Residencia/métodos , Quirófanos/organización & administración , Prioridad del Paciente/psicología , Cirujanos/educación , Confianza/psicología , Adolescente , Adulto , Anciano , Competencia Clínica , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Comodidad del Paciente , Percepción , Autonomía Profesional , Investigación Cualitativa , Proyectos de Investigación , Encuestas y Cuestionarios , Adulto JovenRESUMEN
The ability to culture porcine islets for extended times allows for both their functional assessment and the assurance of their microbiological safety prior to transplantation. We have previously shown that agarose-encapsulated porcine islets can be cultured for at least 24 weeks. In the current study, porcine islet agarose macrobeads cultured for up to 67 weeks were assessed for their ability to restore normoglycemia, respond to an intraperitoneal glucose challenge, maintain spontaneously diabetic BB rats free of insulin therapy for more than 6 months, and for their biocompatibility. Porcine islets were encapsulated in agarose macrobeads and subjected to weekly static perifusion assays for the assessment of insulin production. After in vitro culture for either 9, 40, or 67 weeks, 56-60 macrobeads were transplanted to each spontaneously diabetic BB rat. Transplanted rats were monitored daily for blood glucose levels. Glucose tolerance tests and assessments for porcine C-peptide were conducted at various intervals throughout the study. Normoglycemia (100-200 mg/dl) was initially restored in all islet transplanted rats. Moderate hyperglycemia (200-400 mg/dl) developed at around 30 days posttransplantation and continued throughout the study period of 201-202 days. Importantly, all rats that received encapsulated porcine islets continued to gain weight and were free of exogenous insulin therapy for the entire study. Porcine C-peptide (0.2-0.9 ng/ml) was detected in the serum of islet recipients throughout the study period. No differences were detected between recipient animals receiving islet macrobeads of various ages. These results demonstrate that the encapsulation of porcine islets in agarose macrobeads allows for extended culture periods and is an appropriate strategy for functional and microbiological assessment prior to clinical use.
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Glucemia/análisis , Diabetes Mellitus Tipo 1/cirugía , Trasplante de Islotes Pancreáticos/métodos , Animales , Materiales Biocompatibles , Diabetes Mellitus Experimental/sangre , Diabetes Mellitus Experimental/cirugía , Diabetes Mellitus Tipo 1/sangre , Estudios de Factibilidad , Supervivencia de Injerto , Insulina/metabolismo , Secreción de Insulina , Masculino , Microesferas , Ratas , Ratas Endogámicas BB , Ratas Wistar , Sefarosa , Porcinos , Trasplante Heterólogo , Resultado del TratamientoRESUMEN
For clinical xenogenic islet transplantation to be successful, several requirements must be met. Among them is a sizeable and reliable source of fully functional and microbiologically safe islets. The inherent variability among porcine pancreases, with respect to islet yield, prompted us to develop a Biopsy Score technique to determine the suitability of each pancreas for islet isolation processing. The Biopsy Score consists of an assessment of five variables: warm ischemia time, pancreas color, fat content, islet size, and islet demarcation, each of which is assigned a value of -1 or +1, depending on whether or not the established criteria is met. For determination of islet size and demarcation, fresh biopsies of porcine pancreases are stained with dithizone (DTZ) solution and examined under a dissecting microscope. Based on the scoring of such biopsies in pancreases from 26-56-month-old sows, we report here that the presence of large (>100 microm diameter), well-demarcated islets in the pancreas biopsy is a reliable predictor of isolation success. Encapsulation of the isolated porcine islets within the inner layer of a 1.5% agarose and an outer layer of 5.0% agarose macrobead, containing 500 equivalent islet number (EIN), provides for extended in vitro functional viability (>6 months of insulin production in response to glucose), as well as for comprehensive microbiological testing and at least partial isolation of the xenogeneic islets from the host immune system. All microbiological testing to date has been negative, except for the presence of porcine endogenous retrovirus (PERV). Taken together, we believe that the Biopsy Score enhancement of our islet isolation technique and our agarose-agarose macroencapsulation methodology bring us significantly closer to realizing clinical porcine islet xenotransplantation for the treatment of insulin-dependent diabetic patients.
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Trasplante de Islotes Pancreáticos/normas , Islotes Pancreáticos/citología , Islotes Pancreáticos/microbiología , Páncreas/citología , Técnicas de Cultivo de Tejidos/métodos , Animales , Cápsulas , Islotes Pancreáticos/química , Trasplante de Islotes Pancreáticos/métodos , Masculino , Ratones , Páncreas/química , Páncreas/patología , Seguridad , Porcinos , Supervivencia TisularRESUMEN
The culture of tumor cell lines in three-dimensional scaffolds is considered to more closely replicate the in vivo tumor microenvironment than the standard method of two-dimensional cell culture. We hypothesized that our method of encapsulating and maintaining viable and functional pancreatic islets in agarose-agarose macrobeads (diameter 6-8 mm) might provide a novel method for the culture of tumor cell lines. In this report we describe and characterize tumor colonies that form within macrobeads seeded with mouse renal adenocarcinoma cells. Approximately 1% of seeded tumor cells survive in the macrobead and over several months form discrete elliptical colonies appearing as tumor cell niches with increasing metabolic activity in parallel to colony size. The tumor colonies demonstrate ongoing cell turnover as shown by BrdU incorporation and activated caspase-3 and TUNEL staining. Genes upregulated in the tumor colonies of the macrobead are likely adaptations to this novel environment, as well as an amplification of G(1)/S cell-cycle checkpoints. The data presented, including SCA-1 and Oct4 positivity and the upregulation of stem cell-like genes such as those associated with the Wnt pathway, support the notion that the macrobead selects for a subpopulation of cells with cancer stem cell or cancer progenitor properties.
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Carcinoma de Células Renales/patología , Técnicas de Cultivo de Célula/métodos , Neoplasias Renales/patología , Células Madre Neoplásicas/patología , Animales , Apoptosis/fisiología , Carcinoma de Células Renales/genética , Carcinoma de Células Renales/metabolismo , Procesos de Crecimiento Celular , Línea Celular Tumoral , Técnicas de Cocultivo , Expresión Génica , Humanos , Neoplasias Renales/genética , Neoplasias Renales/metabolismo , Ratones , Ratones Endogámicos BALB C , Células Madre Neoplásicas/metabolismo , Sefarosa , Células Tumorales CultivadasRESUMEN
Cancer cells and their associated tumors have long been considered to exhibit unregulated proliferation or growth. However, a substantial body of evidence indicates that tumor growth is subject to both positive and negative regulatory controls. Here, we describe a novel property of tumor growth regulation that is neither species nor tumor-type specific. This property, functionally a type of feedback control, is triggered by the encapsulation of neoplastic cells in a growth-restricting hydrogel composed of an agarose matrix with a second coating of agarose to form 6- to 8-mm diameter macrobeads. In a mouse cell model of renal adenocarcinoma (RENCA cells), this process resulted in selection for a stem cell-like subpopulation which together with at least one other cell subpopulation drove colony formation in the macrobeads. Cells in these colonies produced diffusible substances that markedly inhibited in vitro and in vivo proliferation of epithelial-derived tumor cells outside the macrobeads. RENCA cells in monolayer culture that were exposed to RENCA macrobead-conditioned media exhibited cell-cycle accumulation in S phase due to activation of a G(2)/M checkpoint. At least 10 proteins with known tumor suppression functions were identified by analysis of RENCA macrobead-conditioned media, the properties of which offer opportunities to further dissect the molecular basis for tumor growth control. More generally, macrobead culture may permit the isolation of cancer stem cells and other cells of the stem cell niche, perhaps providing strategies to define more effective biologically based clinical approaches to treat neoplastic disease.