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OBJECTIVE: Alexithymia, a deficit in identifying and describing feelings, is prevalent in traumatic brain injury (TBI). Sometimes referred to as "emotional unawareness," we sought to investigate whether alexithymia after TBI was related to, or distinct from, impaired self-awareness (ISA) and whether the two predicted differentiable emotional and aggression profiles. Further, the mediating role of frontal system behaviors (disinhibition, dysexecutive function, apathy) was explored. METHOD: Participants with TBI (N = 40) from diverse backgrounds completed self-report measures of alexithymia, emotional distress, aggression, and frontal system behaviors. For the assessment of ISA, significant other ratings were obtained to identify discrepancies from self-ratings. Data were analyzed quantitatively using independent samples t tests, correlations, partial correlations, and simple mediation. RESULTS: There was a negative correlation between alexithymia and ISA. Alexithymia, but not ISA, was associated with higher expressions of emotional distress and aggression even after controlling for the effects of ISA via partial correlations. Exploratory analyses found that frontal system behaviors mediated the relationships between alexithymia and aggression and alexithymia and emotional distress. CONCLUSIONS: Alexithymia is more accurately conceptualized as an emotional processing deficit than an awareness deficit. Indeed, self-awareness may be a prerequisite for the ability to identify alexithymic tendencies. Negative psychological effects of alexithymia are compounded by poorer executive function and disinhibition and call for the development of TBI-specific alexithymia screening tools and interventions. Alexithymia interventions are best delivered in conjunction with rehabilitation of emotion regulation and executive function. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
Subject(s)
Brain Injuries, Traumatic , Psychological Distress , Humans , Affective Symptoms/diagnosis , Affective Symptoms/etiology , Aggression , Emotions , Brain Injuries, Traumatic/complications , Brain Injuries, Traumatic/psychologyABSTRACT
INTRODUCTION: Although the benefits of post-operative rehabilitation in cancer surgery are well established, the role of prehabilitation is less defined. Oesophagogastric cancers present a unique opportunity to study the impact of prehabilitation during the neoadjuvant window, whether with chemotherapy or chemoradiotherapy (NCT) in patients who are frequently nutritionally depleted. This trial examines the impact of a community-based exercise program on patient fitness during and after the neoadjuvant window. METHODS: A pragmatic, randomized controlled multi-centre trial was undertaken in three centres. Inclusion criteria were patients aged ≥ 18 years planned for NCT and esophagectomy or gastrectomy. Participants were randomized 1:1 to an exercise prehabilitation group (EX) or to usual care (UC). The primary endpoint was cardiorespiratory fitness between baseline and pre-surgery timepoint using the 6-min walk test. Secondary endpoints included hand dynamometer, 10-sec sit to stand, activity behaviour, body mass index, semi-structured interviews, questionnaires assessing quality of life, surgical fear, general self-efficacy and mastery. RESULTS: Between March 2019 and December 2020, 71 participants were recruited: EX (n=36) or UC (n=35). From baseline to pre-surgery, the difference-in-difference for EX showed a significant improvement in 6MWT of 50.7m (P=0.05) compared to UC [mean (SD): 522.1m (+/-104.3) to 582.1m (+/-108) vs. 497.5m (+/-106.3) to 506.0 m (+/-140.4). There was no statistically significant DID for secondary outcome measures. CONCLUSIONS: This community exercise prehabilitation program significantly improves physical fitness for surgery, is feasible and provides a standardized framework for prescription of exercise in esophagogastric cancer patients undergoing NCT.
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INTRODUCTION: The emergence of the novel coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and the coronavirus disease COVID-19 has impacted enormously on non-COVID-19-related hospital care. Curtailment of intensive care unit (ICU) access threatens complex surgery, particularly impacting on outcomes for time-sensitive cancer surgery. Oesophageal cancer surgery is a good example. This study explored the impact of the pandemic on process and short-term surgical outcomes, comparing the first wave of the pandemic from April to June in 2020 with the same period in 2019. METHODS: Data from all four Irish oesophageal cancer centres were reviewed. All patients undergoing resection for oesophageal malignancy from 1 April to 30 June inclusive in 2020 and 2019 were included. Patient, disease, and peri-operative outcomes (including COVID-19 infection) were compared. RESULTS: In 2020, 45 patients underwent oesophagectomy, and 53 in the equivalent period in 2019. There were no differences in patient demographics, co-morbidities, or use of neoadjuvant therapy. The median time to surgery from neoadjuvant therapy was 8 weeks in both 2020 and 2019. There were no significant differences in operative interventions between the two time periods. There was no difference in operative morbidity in 2020 and 2019 (28% vs 40%, p = 0.28). There was no in-hospital mortality in either period. No patient contracted COVID-19 in the perioperative period. CONCLUSIONS: Continuing surgical resection for oesophageal cancer was feasible and safe during the COVID-19 pandemic in Ireland. The national response to this threat was therefore successful by these criteria in the curative management of oesophageal cancer.
Subject(s)
COVID-19 , Esophageal Neoplasms , Esophageal Neoplasms/epidemiology , Esophageal Neoplasms/surgery , Humans , Ireland/epidemiology , Pandemics , SARS-CoV-2ABSTRACT
Obesity and its associated metabolic syndrome (MetS) are recognized risk factors for breast cancer. The molecular basis for this association remains largely unknown. Adipokines, in particular leptin and adiponectin, are thought to form part of the mechanism linking obesity with cancer through their altered expression/production either systemically (endocrine pathway) or locally (paracrine/autocrine pathway). Using quantitative PCR, mRNA expression of adiponectin (AdipoQ) and leptin (Ob) in mammary adipose tissue (MAT), intratumoral leptin and associated ligand receptors (ObR, AdipoR1, and AdipoR2) was examined in 77 patients with complete anthropomorphic and serological data. Expression of Ob in MAT, and ObR in matched tumor tissue was significantly higher in patients with MetS compared to obese only or normal weight cancer patients (P < 0.005). There was no difference in intratumoral leptin adiponectin or its ligand receptors in the same groups. Individual features of MetS correlated with Ob and ObR expression, but not obesity markers (BMI, waist circumference). mRNA expression of leptin (Ob) and ObR, in adipose tissue and matched tumor samples, respectively, appear to be associated with obesity status in breast cancer. Increasing insulin resistance is a predominant feature of this higher Ob/ObR expression observed. These novel data indicate that the MetS may be an amenable risk factor for breast cancer.
Subject(s)
Breast Neoplasms/etiology , Breast Neoplasms/genetics , Gene Expression Regulation, Neoplastic , Leptin/genetics , Metabolic Syndrome/complications , Receptors, Leptin/genetics , Adiponectin/genetics , Adipose Tissue/metabolism , Adult , Aged , Aged, 80 and over , Breast/metabolism , Cohort Studies , Female , Humans , Metabolic Syndrome/genetics , Middle Aged , RNA, Messenger/genetics , Receptors, Adiponectin/geneticsABSTRACT
BACKGROUND: There is a need to compare the proportions, risk factors, and natural histories of postesophagectomy paraconduit hernias in minimally invasive and open esophagectomies. METHODS: This is a single-center, retrospective cohort study of esophageal cancer surgery performed between 2007 and 2017. Postesophagectomy paraconduit hernias were identified on cross-sectional imaging. Patient charts were reviewed to describe the management and natural history. RESULTS: Between 2007 and 2017, 391 esophagectomies were performed. After exclusions, 347 patients remained, 135 of whom were total minimally invasive esophagectomies (MIEs) (39%). Postoperative paraconduit hernias developed in 10% of patients. Median time to diagnosis was 258 days. Of 135 MIEs, 20 had a paraconduit hernia (15%) compared with 16 of 212 open or hybrid esophagectomies (8%; P = .03). Hernias were symptomatic in 13 patients (36%) and asymptomatic in 23 (64%), which were detected radiographically. Repair was performed in 11 of 13 symptomatic patients (85%), compared with 3 of 23 asymptomatic patients (13%). In the asymptomatic group, only 1 required emergency repair (4.3%). There was a trend toward a greater proportion of symptomatic paraconduit hernias compared with asymptomatic patients (77% versus 43%; P = .08) in MIE patients. Factors associated with the development of paraconduit hernias on univariate analysis were younger age (P = .02) and not receiving neoadjuvant chemotherapy (P = .01) or neoadjuvant radiation (P = .03). CONCLUSIONS: Postesophagectomy paraconduit hernia is more common after totally minimally invasive esophagectomy compared with open or hybrid techniques. One third are symptomatic and the remainder are detected only radiographically. Repair of asymptomatic hernias consider the patient's cancer prognosis.
Subject(s)
Esophageal Neoplasms/surgery , Esophagectomy/adverse effects , Esophagectomy/methods , Hernia, Hiatal/etiology , Laparoscopy , Postoperative Complications/etiology , Adult , Aged , Aged, 80 and over , Cohort Studies , Female , Hernia, Hiatal/diagnosis , Hernia, Hiatal/epidemiology , Humans , Male , Middle Aged , Postoperative Complications/diagnosis , Postoperative Complications/epidemiology , Retrospective Studies , Risk FactorsABSTRACT
BACKGROUND: Feeding jejunostomy is frequently used to ensure nutritional intake after esophagectomy. Early return to diet is demonstrated to enhance recovery in major abdominal surgery. Early oral feeding is safe and effective in recent randomized controlled trials in esophagectomy. This study assesses the implications of eliminating the insertion of jejunostomy after esophagectomy. METHODS: A retrospective study was undertaken between 2014 and 2017 with follow-up over the first year. Fifty patients did not have a jejunostomy, compared with 46 patients who had conventional treatment. Outcomes measured included change in relative weight and body mass over 1 year, complications, and nutritional reinterventions. RESULTS: Median weight loss at 1 year was 10.7 kg (range, -8 to 55.6) whereas median percent weight loss was 12% (range, -10.1% to 39.2%). Patients without jejunostomy lost more weight during the first month (P = .002). Thereafter, at 6 of 12 months, there were no differences in actual or relative weight loss. Obese patients lost more weight in the group without jejunostomy compared with those who had it (9.9 versus 5 kg; P = .004). This effect was not seen in normal or overweight patients. Complications were similar, whereas leaks were more common in the jejunostomy group (15.2% versus 2%; P = .019). Nutritional reinterventions were similar during index admission and subsequent readmissions (7 versus 5 patients; P = .640). CONCLUSIONS: Routine jejunostomy use delays rather than prevents weight loss after esophagectomy. Oral route nutrition allows patients to maintain sufficient nutrition and does not increase complications or requirement for nutritional interventions after surgery. Routine use of jejunostomy may not be required in modern practice.
Subject(s)
Enteral Nutrition/adverse effects , Esophagectomy , Jejunostomy/adverse effects , Postoperative Care , Adult , Aged , Aged, 80 and over , Esophagectomy/adverse effects , Female , Humans , Male , Middle Aged , Outcome Assessment, Health Care , Retrospective Studies , Weight LossABSTRACT
BACKGROUND: Minimally invasive esophagectomy (MIE) is performed in nearly 50% of patients worldwide. The effectiveness of the technique arises from a single randomized control trial and multiple single series cohorts. Consistent reporting of complications is varied. We describe our experience of transitioning to MIE compared with open esophagectomy (OE) with the use of Esophageal Complications Consensus Group (ECCG) standardized complication benchmark definitions. METHODS: Between 2007 and 2017, all patients undergoing esophagectomy were identified with the use of a prospectively curated database. Complications were defined by the ECCG and graded with the Clavien-Dindo (most severe complication) and comprehensive complication index (complexity of complications during hospital stay). RESULTS: Of 383 patients, 299 (76%) were men with a median age of 64.5 years (range, 56-72 years). MIE was performed in 49.6%. No differences were found in age, histologic finding (P = .222), pT stage (P = .136), or nodal positivity (P = .918). Stage 3 cancers accounted for 42.0% of OEs and 47.9% of MIEs. A thoracic anastomosis was more frequent in MIEs (156 of 190; 82.1%) than in OEs (113 of 193; 58.5%; P = .001). Frequency, severity (Clavien-Dindo), and complexity (comprehensive complication index) of complications were better in the MIE group, without compromising operative outcomes. No differences were identified in individual complication groupings or grade in MIEs compared with OEs (pneumonia: 19.5% versus 26.9% ([P = .09]; intensive care unit readmission: 7.4% versus 9.3% [P = .519]; atrial fibrillation: 11.1% versus 6.7% [P = .082], or grade of leak [P = .99]). CONCLUSIONS: These results compare favorably to those reported by ECCG. MIE can be the standard approach for surgical management of esophageal cancer. Introduction of the approach in each surgeon's practice should be benchmarked to international standards.
Subject(s)
Carcinoma, Squamous Cell/surgery , Cytoreduction Surgical Procedures/methods , Esophageal Neoplasms/surgery , Esophagectomy/methods , Aged , Benchmarking/standards , Carcinoma, Squamous Cell/mortality , Carcinoma, Squamous Cell/pathology , Cohort Studies , Cytoreduction Surgical Procedures/mortality , Databases, Factual , Disease-Free Survival , Esophageal Neoplasms/mortality , Esophageal Neoplasms/pathology , Female , Humans , Linear Models , Male , Middle Aged , Minimally Invasive Surgical Procedures/methods , Minimally Invasive Surgical Procedures/mortality , Neoplasm Invasiveness/pathology , Neoplasm Staging , Postoperative Complications/mortality , Postoperative Complications/physiopathology , Prognosis , Retrospective Studies , Risk Assessment , Statistics, Nonparametric , Survival Analysis , Treatment OutcomeABSTRACT
BACKGROUND: Advances in peri-operative oncological treatment, surgery and peri-operative care have improved survival for patients with oesophagogastric cancers. Neoadjuvant cancer treatment (NCT) reduces physical fitness, which may reduce both compliance and tolerance of NCT as well as compromising post-operative outcomes. This is particularly detrimental in a patient group where malnutrition is common and surgery is demanding. The aim of this trial is to assess the effect on physical fitness and clinical outcomes of a comprehensive exercise training programme in patients undergoing NCT and surgical resection for oesophagogastric malignancies. METHODS: The PERIOP-OG trial is a pragmatic, multi-centre, randomised controlled trial comparing a peri-operative exercise programme with standard care in patients with oesophagogastric cancers treated with NCT and surgery. The intervention group undergo a formal exercise training programme and the usual care group receive standard clinical care (no formal exercise advice). The training programme is initiated at cancer diagnosis, continued during NCT, between NCT and surgery, and resumes after surgery. All participants undergo assessments at baseline, post-NCT, pre-surgery and at 4 and 10 weeks after surgery. The primary endpoint is cardiorespiratory fitness measured by demonstration of a 15% difference in the 6-min walk test assessed at the pre-surgery timepoint. Secondary endpoints include measures of physical health (upper and lower body strength tests), body mass index, frailty, activity behaviour, psychological and health-related quality of life outcomes. Exploratory endpoints include a health economics analysis, assessment of clinical health by post-operative morbidity scores, hospital length of stay, nutritional status, immune and inflammatory markers, and response to NCT. Rates of NCT toxicity, tolerance and compliance will also be assessed. DISCUSSION: The PERIOP-OG trial will determine whether, when compared to usual care, exercise training initiated at diagnosis and continued during NCT, between NCT and surgery and then during recovery, can maintain or improve cardiorespiratory fitness and other physical, psychological and clinical health outcomes. This trial will inform both the prescription of exercise regimes as well as the design of a larger prehabilitation and rehabilitation trial to investigate whether exercise in combination with nutritional and psychological interventions elicit greater benefits. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03807518 . Registered on 1 January 2019.
Subject(s)
Esophageal Neoplasms/therapy , Exercise Therapy , Neoadjuvant Therapy , Physical Fitness , Preoperative Exercise , Stomach Neoplasms/therapy , Esophageal Neoplasms/surgery , Humans , Multicenter Studies as Topic , Postoperative Care , Quality of Life , Randomized Controlled Trials as Topic , Reference Standards , Stomach Neoplasms/surgery , Treatment OutcomeABSTRACT
Gastrocardiac fistulae are an exceedingly rare complication following esophagectomy with gastric conduit pull up. Unsurprisingly, there is a significant ascribed mortality with the disease process, often only identified postmortem. We report a case of transdiaphragmatic fistula between the intraabdominal gastric conduit and the right ventricle and surgical management thereof.
Subject(s)
Diaphragm , Esophagectomy/adverse effects , Gastric Fistula/etiology , Heart Diseases/etiology , Postoperative Complications/etiology , Vascular Fistula/etiology , Esophageal Neoplasms/surgery , Gastric Fistula/diagnosis , Gastric Fistula/surgery , Heart Diseases/diagnosis , Heart Diseases/surgery , Humans , Male , Middle Aged , Postoperative Complications/diagnosis , Postoperative Complications/surgery , Vascular Fistula/diagnosis , Vascular Fistula/surgeryABSTRACT
BACKGROUND: Adjuvant breast cancer treatment is associated with a number of adverse physical changes, including weight gain, and therefore may represent a critical period for the development of metabolic disturbance. OBJECTIVE: The aim of this study was to evaluate changes in the presentation of the metabolic syndrome (MetSyn) and insulin resistance from breast cancer surgery to postcompletion of adjuvant treatment. METHODS: Sixty-one participants who had completed metabolic screening, including fasting blood samples and anthropometric measurements, on the morning of breast cancer surgery were recruited. Measures were repeated after completion of adjuvant treatment. Change in the proportion of participants presenting with the MetSyn was evaluated using the related-samples McNemar test, and changes in measures of glucose metabolism (fasting insulin, insulin resistance [homeostatic model assessment index], and glycosylated hemoglobin [HbA1c]) were analyzed using paired t tests. The Kruskal-Wallis test was used to compare differences in changes in metabolic parameters across clinical and lifestyle characteristics. RESULTS: There was a significant (P < .001) increase in fasting insulin (mean [SE] change, 2.73 [0.57] mU/L), homeostatic model assessment index (0.58 [0.14]), and HbA1c level (4.49 [5.63] mmol/mol) from baseline to follow-up along with an increase in the proportion diagnosed with the MetSyn (P = .03). Those with the MetSyn at diagnosis experienced a greater increase in insulin resistance. Premenopausal women experienced greatest increases in HbA1c level. CONCLUSIONS: Results demonstrate the development of significant metabolic dysfunction, characterized by glucose dysmetabolism and MetSyn, after adjuvant treatment for breast cancer. IMPLICATIONS FOR PRACTICE: Interventions to improve the metabolic profile of breast cancer survivors are warranted.
Subject(s)
Breast Neoplasms/complications , Insulin Resistance/physiology , Metabolic Syndrome/etiology , Adult , Aged , Breast Neoplasms/metabolism , Breast Neoplasms/surgery , Female , Humans , Metabolic Syndrome/metabolism , Middle Aged , SurvivorsABSTRACT
Little information is available regarding the management of BRCA-related breast cancer in Ireland. A cancer genetics programme was initiated in 1992 at our institution to provide counselling and expert management for those with cancers resulting from inherited predisposition. We examined a cohort of BRCA mutation-carriers treated at a single institution over 16 years. A total of 107 women from 57 families were found to be carriers of mutations in BRCA1/2. Bilateral salpingo-oophorectomy was the most common prophylactic surgery performed. Overall survival between BRCA-related and sporadic breast cancer was equivalent. This is the first publication on surgical management of BRCA-mutation carriers in Ireland. It is imperative that those considered likely to harbour a mutation are referred early to a dedicated clinic so that appropriate counselling, testing and subsequent management to reduce the risk of dying from cancer can be undertaken.