Effect of transversus abdominis plane block on postoperative outcomes in gynecologic oncology patients managed on an Enhanced Recovery After Surgery pathway.

OBJECTIVES: To characterize the effect of transversus abdominis plane (TAP) blocks on post-operative outcomes in patients undergoing laparotomy for gynecologic malignancy. METHODS: This retrospective cohort study assessed patients undergoing laparotomy in 2016-2017 and 2020 in Alberta, Canada. The primary outcome was opioid consumption in oral morphine milligram equivalent (MME). Secondary outcomes included maximum pain scores, length of stay, and patient-controlled analgesia (PCA) use. Outcomes were compared using t-test with subgroup analysis by NSAID use. Multivariate regression modelling was performed for potential confounders. RESULTS: Data was collected on 956 patients; 828 received a TAP block, 128 did not. Opioid use in the first 24 h was lower in the TAP block group (35.9 mg MME vs 44.5 mg MME, p = 0.0294), without any increase in pain scores, this did not remain significant after regression analysis. Patients with TAP blocks had significant reduced mean length of stay (3.2 days vs. 5.0 days, p < 0.0001), and PCA use (19.9% vs. 56.25%, p < 0.0001). On subgroup analysis of patients that did not receive NSAIDs (n = 160), mean opioid use was decreased in those patients with TAP blocks compared to those without TAP blocks in the first 24 h (36.1 mg vs. 61.2 mg, p = 0.0017), and at 24 to 48 h (16.3 mg vs. 51.0 mg, p < 0.0001). CONCLUSIONS: Surgeon-administered TAP blocks were associated with decreased length of stay and post-operative opioid use in patients not receiving scheduled NSAIDs. This decrease in opioid use was not associated with any increase in average or maximum pain scores.

Cannabis use in gynecologic cancer patients in a Canadian cancer center.

Objective: The primary objective of this study was to estimate the prevalence of cannabis use in patients with gynecologic malignancies and to describe patterns of cannabis use. Secondary objectives included identifying sources of cannabis information used by patients. Methods: This is a single institution cross sectional survey conducted in Calgary, Alberta. Patients with a current or prior gynecologic cancer diagnosis were considered for inclusion. Planned analysis included descriptive statistics of patient demographics, and the patterns of cannabis use were described using frequencies and proportions. Results: Forty-six patients participated in the survey. The most common disease sites were ovarian cancer and uterine cancer, with the majority of patients receiving chemotherapy as part of their treatment (n = 35). Seventeen participants were current cannabis users (37%). The most common symptoms participants used cannabis for were pain (9/17), anxiety (9/17), and insomnia (9/17).Most patients using cannabis did not have a prescription and obtained their cannabis from a recreational dispensary (11/17). Many participants using cannabis had not talked to their doctor about cannabis (9/17). Instead, the most common sources of information about cannabis were cannabis retailers (20/46), and friends/family (20/46). Over 50% of patients would be interested in discussing cannabis if their physician broached the subject (26/46). Conclusions: The results from this survey indicate that patients would like to talk to their oncologist about cannabis. Further research is needed to inform physician training and direct patient education to ensure that patients have access to unbiased, evidence-based information to make decisions about cannabis use.

Perspectives of Indigenous medical students on a postgraduate Indigenous admissions pathway.

Objective: The objective of this study is to assess the perceptions of Indigenous medical students on postgraduate admissions through an Indigenous admissions pathway (IAP), and to determine what factors may influence Indigenous medical students' choice of residency training program. Methods: We distributed a survey to self-identified Indigenous students at settler Canadian medical schools. The survey questioned the students' acceptability of an IAP, and what factors would influence application through an IAP. Analysis included descriptive statistics and thematic analysis of open-ended questions. Results: Thirty-six participants responded to the survey. Location and proximity to family or support system were the most important factors in choosing a residency program. Participants identified mentorship from Indigenous physicians and community involvement as being important features of a residency program that has an IAP. Eighty-one percent of participants felt the availability of an IAP would influence their choice of residency program. Fear of judgement or stigma, concern about entrance requirements, and program logistics were identified as barriers to applying to residency through an IAP. All participants believed that an IAP would have a positive influence on the healthcare system more broadly. Conclusions: An IAP appears to be an acceptable residency application format to Indigenous students but cannot exist in isolation. It is important for programs to consider the needs and safety of Indigenous trainees within residency programs.

Objectif: L'objectif de cette étude était d'avoir le point de vue des étudiants en médecine autochtones sur une éventuelle voie d'admission aux études postdoctorales réservée aux candidats autochtones et de relever les facteurs qui influenceraient leur choix de programme de résidence. Méthodes: Nous avons fait parvenir un questionnaire aux étudiants inscrits dans les facultés de médecine canadiennes qui se définissent comme Autochtones. L'enquête portait sur l'acceptabilité par les étudiants d'un programme d'admission pour candidats autochtones (PACA) et sur les facteurs qui influenceraient leur choix de poser leur candidature dans le cadre d'un PACA. Les données ont été évaluées par des méthodes statistiques descriptives et par une analyse thématique des questions ouvertes. Résultats: Trente-six participants ont répondu à l'enquête. Le lieu et la proximité de la famille ou du réseau de soutien ressortent comme les facteurs les plus importants dans le choix d'un programme de résidence. Les répondants attachent également de l'importance à l'existence d'un mentorat de la part de médecins autochtones et à une participation de la communauté dans le cadre d'un programme de résidence doté d'un PACA. Quatre-vingt-un pour cent des participants ont estimé que l'existence d'un PACA influencerait leur choix de programme de résidence. La crainte d'être jugé ou stigmatisé, et une inquiétude par rapport aux conditions d'admission et la logistique du programme ont été identifiées comme des obstacles à la présentation d'une demande de résidence dans le cadre d'un PACA. Les participants sont unanimes quant à l'influence positive d'un tel programme sur le système de soins de santé en général. Conclusions: Les étudiants autochtones trouvent la formule d'une voie d'admission à la résidence réservée aux candidats autochtones acceptable, à condition qu'elle ne soit pas un élément isolé et qu'on tienne compte des besoins et de la sécurité des étudiants dans le cadre des programmes de résidence eux-mêmes.

Venous Thromboembolism in Patients Receiving Neoadjuvant Chemotherapy for Advanced Ovarian Cancer and Impact on Survival.

OBJECTIVE: To determine the incidence of venous thromboembolism (VTE) in patients with ovarian cancer receiving neoadjuvant chemotherapy (NACT), identify risk factors for VTE, and assess the effect of VTE on treatment trajectory and overall survival. METHODS: This is a retrospective cohort study of patients diagnosed with ovarian, fallopian tube, or primary peritoneal cancer treated with NACT between 2013 to 2016 in Alberta, Canada. The primary outcome was incidence of VTE during NACT. Secondary outcomes were risk factors for VTE and overall survival. Data related to patient demographics, cancer treatment, and incidence of VTE were collected. Statistical analyses included Kaplan-Meier estimates and univariate and multivariate Cox regression analysis. RESULTS: A total of 284 patients were included in this study. Average age at diagnosis was 63.8 years. The incidence of VTE during NACT was 13.3%. Patients with VTE were less likely to undergo interval debulking surgery (58.3%) than patients without VTE (78.6%). Kaplan-Meier estimates demonstrated a decrease in overall survival in patients who had VTE during NACT (15.0 mo; 95% CI 14.5-16.5) compared with patients who did not (26.8 mo; 95% CI 22.8-30.9) (P < 0.0001). Multivariate analysis identified albumin <35 g/L, BMI >30 kg/m2, and non-serous histology as risk factors for VTE. CONCLUSION: The risk of VTE in this cohort was 13.3%, which was associated with decreased overall survival. These findings suggest that thromboprophylaxis may have a role in this patient population.

Forced and Coerced Sterilization of Indigenous Peoples: Considerations for Health Care Providers.

Forced and coerced sterilization refers to the provision of permanent contraception without true informed consent. In Canada, this topic is particularly relevant to Indigenous Peoples because of this country's history of racialized eugenics programs. In this commentary, we briefly review the history of forced and coerced sterilization in Canada, describe the clinical considerations for health care providers who work with Indigenous patients in this context, and outline calls to action for health care providers and organizations to support the provision of culturally appropriate reproductive health care to Indigenous people.

Development of a medical education podcast in obstetrics and gynecology.

Podcasts are used in medical education to supplement conventional teaching methods such as lectures and reading. We identified a lack of Canadian medical education podcasts covering obstetrics and gynecology (Ob/Gyn) content and created a podcast specific for Canadian medical students and residents. The podcast called "OB-G in YEG" is freely available and currently has fourteen episodes that cover common topics in Ob/Gyn. We describe the process for creating a high-quality medical education resource that is widely accessible to learners that readers may be able to replicate in their own discipline.

Les baladodiffusions sont utilisées dans l'éducation médicale en complément aux méthodes d'enseignement traditionnelles comme les cours magistraux et la lecture de textes. Ayant constaté un manque de baladodiffusions d'enseignement dans les domaines de l'obstétrique et de la gynécologie (OB/GY) au Canada, nous avons créé une telle émission destinée aux étudiants et aux résidents en médecine de ce pays. La baladodiffusion, intitulée « OB-G in YEG ¼, est disponible gratuitement et elle comporte actuellement onze épisodes sur des sujets d'intérêt général touchant à l'obstétrique et à la gynécologie. Nous décrivons le processus de création d'une ressource d'enseignement médical de qualité, qui est largement accessible aux apprenants et que les lecteurs seraient peut-être en mesure de reproduire dans leur propre discipline.

Epithelioid trophoblastic tumor presenting as a Caesarean scar defect: A case report.

BACKGROUND: Epithelioid trophoblastic tumor is a rare form of gestational trophoblastic neoplasia. We present the first known case of this rare malignancy presenting as a Caesarean scar defect. CASE: A patient with 3 prior Caesarean sections presented with vaginal bleeding 2 months following management of retained products of conception. Her hCG was negative. She underwent surgical repair of a Caesarean scar defect, and pathology was consistent with epithelioid trophoblastic tumor. CONCLUSION: This case highlights the possibility of malignancy presenting to the general gynecologist as a Caesarean scar defect. The diagnosis of gestational trophoblastic neoplasia should always be considered in the differential diagnosis of a patient with postpartum vaginal bleeding. Limited evidence on fertility conserving treatment of epithelioid trophoblastic tumors does not seem favorable.

Retained Shotgun Pellets in the Vulva: Case Report.

BACKGROUND: Vulvar trauma is relatively uncommon and typically occurs in accidental or sports-related injuries. There is limited literature for management of penetrating trauma to the vulva. CASE: A 38-year-old G9, P9 woman presented to the gynaecology service for assessment of vulvar injury after a gunshot wound to the right lateral thigh. She underwent initial stabilization and operative management by the Trauma and Plastic Surgery services for predominantly soft-tissue injuries. Multiple gunshot pellets were found embedded in the right labia majora and medial thigh. On assessment, surgical removal was deemed necessary on the basis of symptoms and potential for functional impairment. CONCLUSION: We present the first reported case on the management of vulvar injury secondary to penetrating trauma. The principles of non-obstetrical vulvar trauma management are discussed.

Postpartum Mental Health Disorders in Indigenous Women: A Systematic Review and Meta-Analysis.

OBJECTIVE: This systematic review synthesized and evaluated the evidence on the prevalence of postpartum mental health disorders in Indigenous women. METHODS: Comprehensive searches of biomedical electronic databases including Medline, EMBASE, PsychINFO, CINAHL, and Web of Science were performed for peer-reviewed literature published from 1990 to September 2018. The search strategy included terms related to the postpartum period, mental health disorders, and Indigenous ancestry. Epidemiological observational studies that evaluated the prevalence of mental health disorders in the postpartum and included Indigenous women from Australia, Canada, New Zealand, and the United States were included. Two independent reviewers screened and evaluated the risk of bias of included studies. A narrative synthesis of study results was conducted. Prevalence estimates from homogeneous studies were pooled in a random-effects meta-analysis (Canadian Task Force Classification II-2). RESULTS: A total of 2297 references were initially identified, of which six studies were included in the review. All included studies evaluated the prevalence of postpartum depression (PPD) and were of moderate or low risk of bias. Other postpartum mental health disorders were not evaluated. Overall, Indigenous women had 87% increased odds of PPD compared with Caucasian groups of women (odds ratio 1.87; 95% confidence interval 1.14-3.09). Substantial heterogeneity across prevalence estimates was observed. CONCLUSION: Limited evidence suggests a greater burden of PPD affecting Indigenous women. There is insufficient evidence informing the prevalence of other postpartum mental health disorders in Indigenous women. More epidemiological research in this area is essential to provide accurate and reliable prevalence estimates of postpartum mental health disorders among Indigenous women.