Incidence of venous thromboembolism in patients with ovarian cancer receiving neoadjuvant chemotherapy: systematic review and meta-analysis.

OBJECTIVE: Venous thromboembolism is associated with significant patient morbidity, mortality, and can lead to delays in treatment for patients with cancer. The objectives of this study were to identify the incidence of venous thromboembolism in patients with advanced ovarian cancer receiving neoadjuvant chemotherapy, and identify risk factors for venous thromboembolism. METHODS: A systematic literature search of biomedical databases, including Ovid Medline, Web of Science, Scopus, CINAHL, and Embase was performed on December 6, 2022 and updated on December 21, 2023 for peer reviewed articles. Studies were included if they were cohort studies or randomized controlled trials that evaluated the incidence of venous thromboembolism for patients with ovarian cancer receiving neoadjuvant chemotherapy. Risk of bias assessment was performed using the Newcastle Ottawa Scale for cohort studies and the Cochrane risk of bias tool for randomized controlled trials. Random effects meta-analysis was used to pool results across studies. RESULTS: A total of 2636 studies were screened, and 11 were included in the review. Ten were retrospective cohort studies, and one was a randomized controlled trial. The incidence of venous thromboembolism in the included studies ranged from 0% to 18.9%. The pooled incidence rate of venous thromboembolism was 10% (95% confidence interval (CI) 7% to 13%). This remained significant when restricted to only studies with a low risk of bias (pooled incidence of 11%, 95% CI 9% to 14%). Body mass index of ≥30 kg/m2 was a significant risk factor for venous thromboembolism with a pooled odds ratio of 1.76 (95% CI 1.13 to 2.76) CONCLUSIONS: The results from this study demonstrated a 10% incidence of venous thromboembolism for patients with advanced ovarian cancer receiving neoadjuvant chemotherapy. This suggests that there may be a role for universal thromboprophylaxis in this population. TRIAL REGISTRATION: PROSPERO CRD42022339602.

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.

Metabolic adverse effects of off-label use of second-generation antipsychotics in the adult population: a systematic review and meta-analysis.

Prescription rates of second-generation antipsychotics (SGAs) are rapidly increasing for non-indicated (i.e., off-label) usage. SGAs used for approved indications are associated with significant metabolic adverse effects, including weight gain. The objective of this systematic review and meta-analysis is to evaluate the metabolic adverse effects of SGA use for off-label management of psychiatric illnesses in the adult population. We performed a systematic database search to identify randomized controlled trials (RCTs) that reported on weight and other metabolic outcomes with off-label use of SGAs among adults. Thirty-eight RCTs met inclusion criteria for this review; 35 of these studies, with a total of 4930 patients, were included in the quantitative meta-analysis. Patients treated with olanzapine, risperidone, and quetiapine were more likely to report weight gain as a side effect and experience clinically significant (≥7%) weight gain compared to those treated with a placebo. Among studies that reported weight as a continuous outcome, olanzapine was associated with significantly greater weight gain across all disorders (mean difference (MD) = 3.24 kg, 95% CI: 2.57-3.90 p = 0.001, N = 12 studies). Similar trends were noted with quetiapine and risperidone. A meta-regression analysis revealed a positive dose-response association between olanzapine dose and weight gain (regression coefficient: 0.36, p = 0.001). This review demonstrates that off-label use of SGAs, and particularly olanzapine, is associated with significant weight gain among adult patients. Our findings are concerning given the widespread off-label use of SGAs. Further studies are required to better understand the effects of off-label SGA use on other metabolic parameters. The study was registered with the PROSPERO international database of prospectively registered systematic reviews (PROSPERO #143186).

Multicenter Comparison of the Toronto Portable Perimeter with the Humphrey Field Analyzer: A Pilot Study.

PURPOSE: To evaluate the agreement between glaucomatous 24-2 visual field (VF) testing performed with the Toronto Portable Perimeter (TPP; VEM Medical Technologies) and the Humphrey Field Analyzer (HFA; Carl Zeiss Meditec). DESIGN: Multicenter prospective cohort analysis. PARTICIPANTS: Patients with suspected or confirmed glaucoma treated at Prism Eye Institute (Oakville, Canada), York Finch Eye Associates (North York, Canada), or the Ontario Mobile Medical Eye Care Unit (Cochrane, Canada) between March 2019 and March 2020. METHODS: Patients underwent consecutive VF tests on the same eye using the HFA Swedish Interactive Threshold Algorithm Standard 24-2 test and TPP Standard 24-2 test in randomized order. Bland-Altman analysis and paired t tests were used to compare VF results obtained by the TPP and the HFA. Participants completed a 5-question validated questionnaire after completing both testing methods. MAIN OUTCOME MEASURES: Mean difference and degree of agreement in mean deviation (MD), pattern standard deviation (PSD), visual field index (VFI), and test duration between VF modalities. RESULTS: One hundred fifty eyes from 91 patients were included in analysis. Average MD of the overall cohort using HFA and TPP VF testing was -4.32 ± 5.47 dB and -4.53 ± 5.22 dB, respectively (P = 0.74). Bland-Altman analysis showed good agreement between HFA and TPP tests. The mean differences (95% limits of agreement) between HFA and TPP for MD, PSD, VFI, and test duration were 0.21 dB (-4.25 to 4.67 dB), -0.13 dB (-3.72 to 3.47 dB), 0.66% (-10.94% to 12.26%), and 0.65 seconds (-97.51 to 98.81 seconds), respectively. No statistically significant mean difference was found between HFA and TPP tests for MD, PSD, VFI, or test duration. Mean deviation (R2 = 0.830) and VFI (R2 = 0.866) were correlated strongly with both modalities. Questionnaire results demonstrated that patients significantly preferred the TPP over the HFA for VF testing (P < 0.001). CONCLUSIONS: Mean deviation, PSD, and VFI outcomes measured by the TPP were statistically similar to corresponding parameters obtained with the HFA. Test time duration did not differ significantly between the TPP and HFA, and patients significantly preferred the TPP to the HFA examination experience. These pilot results suggest that the TPP may offer an accessible alternative to HFA VF testing.

Evaluating and implementing an opportunity for diversity and inclusion in case-based learning.

Problem-based learning (PBL) and case-based learning (CBL) often mention social identities only if this information is directly relevant to diagnosis, which can inadvertently perpetuate stereotypes in trainee learning. Using a student-developed resource entitled "Portraying Social Identities in Medical Curriculum: A Primer," we analyzed cases for social identities, identified gaps, and proposed changes, including use of a validated name bank to reflect diversity as represented by local census data. Through this innovation, suggestions were provided to represent the social determinants of health in CBL cases. Other medical schools can use our innovation to improve the social diversity of their medical curriculums.

Bien souvent, l'apprentissage par résolution de problèmes (ARP) et l'apprentissage par les cas (APC) ne touchent aux identités sociales que si ce type d'information contribue directement au diagnostic, ce qui peut involontairement perpétuer les stéréotypes dans l'apprentissage des étudiants. À l'aide d'une ressource élaborée par les étudiants, intitulée « Portraying Social Identities in Medical Curriculum : A Primer ¼ (la représentation des identités sociales dans les programmes d'études médicales : une introduction), nous avons analysé des cas d'identités sociales, identifié des lacunes et proposé des changements, notamment l'utilisation d'une banque de noms validée reflétant la diversité qui ressort des données du recensement local. Grâce à cette innovation, des suggestions ont été faites pour représenter les déterminants sociaux de la santé dans les cas étudiés dans l'APC. Nous invitons les facultés de médecine à se servir de notre ressource pour mieux rendre compte de la diversité sociale dans leurs programmes d'études.

Persistent sciatic artery presenting as an acutely ischemic limb.

Persistent sciatic artery (PSA) is an extremely rare vascular phenomenon, with a prevalence of 0.025% to 0.04% in the general population. We present the case of a 72-year-old man with a thrombus-containing PSA aneurysm that caused embolic acute limb ischemia. We also discussed the PSA classification systems, common presentations, rarity of the pathology, and high rates of severe complications.

Chylothorax post transaxillary first rib resection for thoracic outlet syndrome.

We present a patient who developed high output chyle leak post left transaxillary first rib resection for venous thoracic outlet syndrome. The high output chylorrhoea was successfully treated by conservative measures, bed rest, parenteral nutrition and low-fat diet. The patient was discharged after an 18-day hospital stay with a complete resolution of his chylous fistula prior to discharge. This is the first documented chylothorax post transaxillary first rib resection likely due to anomalous chyle anatomy.

The Glaring Gender Bias in the Operating Room: A Qualitative Study of Factors Influencing Career Selection for First-Year Medical Students.

OBJECTIVE: Despite greater female than male-identifying Canadian medical graduates, women continued to be underrepresented in surgical specialties. The aim of this study was to explore the role of lifestyle challenges and gender-specific considerations in career selection for first-year medical students following early exposure to surgery through an immersive surgical program. DESIGN: A single institution, qualitative study consisting of structured focus groups before and after completion of a 2-week surgical program was used to explore medical student perceptions of surgery. The program consisted of shadowing, surgeon-led talks, and surgical skills workshops in all direct-entry surgical specialties within the Department of Surgery at the University of Toronto. Six entry and exit interviews were conducted by 2 authors. Interviews were recorded, transcribed, and coded for thematic analysis. SETTING: Teaching hospitals affiliated with the University of Toronto, Canada PARTICIPANTS: Thirty first-year medical students with interest in surgery participated in the program and the focus groups. RESULTS: Four prominent themes emerged: gender imbalances in the work environment, the importance of female mentors, gender-specific challenges of parenting, and the importance of flexible work hours for both male and female students. Greater exposure to female surgeons improved the outlook of medical students on work-life balance. Medical students are concerned with the challenges of pregnancy in a surgical profession. Both male and female students consider parenting, supportive partners, and flexibility of work hours in their career selection. CONCLUSION: This study demonstrates the prevalence of gender bias in surgical specialties, raising gender-specific challenges that impact career selection for first-year medical students. In an effort to address these perceptions, this study supports efforts to implement formalized mentorship programs for women in surgery early in medical education. Furthermore, concerns surrounding childbearing further support the need for well-established parental leave policies in the Canadian postgraduate medical education system.

Fenestrated endovascular abdominal aortic aneurysm repair with concomitant horseshoe kidney.

Horseshoe kidney, representing abnormal fusion of the inferior renal poles, is a rare anatomic anomaly posing challenges in the setting of surgical abdominal aortic aneurysm repair. Historically, open repair has been the favoured surgical approach. However, due to the location of the renal isthmus and wide-ranging variation in anomalous renal vasculature, endovascular aneurysm repair (EVAR) has emerged as a popular, less invasive alternative. We describe one of the first published cases of two-fenestration EVAR in a patient with concomitant horseshoe kidney, followed by a discussion of current trends in surgical management. With the increasing availability to customise fenestrated grafts to patients' unique anatomy, this advanced EVAR technique may emerge as the preferred approach in certain cases.

Associations between plasma clozapine/N-desmethylclozapine ratio, insulin resistance and cognitive performance in patients with co-morbid obesity and ultra-treatment resistant schizophrenia.

Clozapine (CLZ), the sole antipsychotic with superior efficacy for ultra-treatment resistant schizophrenia (TRS), is limited by adverse effects, including metabolic dysregulation. Clozapine's main metabolite, N-desmethylclozapine (NDMC), has potent 5-HT2C antagonist properties which may explain this metabolic dysfunction, thus the CLZ:NDMC ratio is of particular interest. High insulin resistance states could be associated with CYP1A2 induction and lower CLZ:NDMC ratios. Additionally, lower CLZ:NDMC ratios have been associated with better cognitive, but worse metabolic functioning. This study investigated associations between metabolic and cognitive parameters with the CLZ/NDMC ratio. Primary outcomes included relationships between the CLZ:NDMC ratio to the homeostatic model assessment for insulin resistance (HOMA-IR) and Brief Assessment of Cognition in Schizophrenia (BACS) composite z-scores. Secondary outcomes assessed relationships between CLZ:NDMC ratios to fasting insulin, BMI, weight, fasting glucose, and BACS digit sequencing z-scores. 38 patients who were overweight or obese with schizophrenia or schizoaffective disorder completed fasting bloodwork, anthropometric, psychopathological, and cognitive assessments. Multivariate regressions found a statistically significant inverse association between the CLZ/NDMC ratio and HOMA-IR (B = - 1.028, SE B = .473, ß = - 0.348 p = 0.037), which may have been driven by fasting insulin levels (B = - 27.124, SE B = 12.081, ß = - 0.351 p = 0.031). The CLZ/NDMC ratio may predict insulin resistance/metabolic comorbidity among patients with TRS receiving clozapine.

Ten-year trends in iliofemoral deep vein thrombosis treatment and referral pathways.

OBJECTIVES: Iliofemoral deep venous thrombosis is associated with an increased risk of developing post-thrombotic syndrome resulting in reduced quality of life. As there is debate about best management practices, this study aimed to examine the referral and treatment pathways for patients presenting with iliofemoral deep venous thrombosis over an 11-year period at our institution. METHODS: We conducted a retrospective review of patients diagnosed with lower limb deep vein thrombosis between 2010 and 2020. Ultrasound report findings were reviewed for the presence of iliofemoral deep venous thrombosis with acute, occlusive, or proximal clot. Multiple factors were extracted, including patient demographics, risk factors, diagnostic methods, interventions, referrals, and details of follow-up. The CaVenT and ATTRACT trials studied the benefit of thrombolysis in the early phase of iliofemoral deep venous thrombosis management as compared to anticoagulation alone. An analysis was conducted of patients requiring thrombolysis to determine whether these trials impacted physician practice patterns for thrombolysis. Data were organized and examined by year for trends in treatment and referral pathways. RESULTS: The review yielded 2792 patients assessed for lower limb deep venous thrombosis by ultrasound. Four hundred and sixty-seven (16.7%) patients were confirmed to have an occlusive iliofemoral deep venous thrombosis. The average age was 62.7 years (18-101 years). Half (50.4%) of the patients were male. The most common etiology for clot was malignancy-induced hypercoagulable state (39.0%). There was no difference in incidence of iliofemoral deep venous thrombosis diagnosed by ultrasound per year, with an average of 42.5 per year and a peak of 61. There was a trend towards increased rates of computed tomography imaging, ranging between 9.1% and 52.9%. The rate thrombolysis per year ranged between 1.8% and 8.9%, with a range of 4.3% (n = 20) to 8.9% (n = 5) in 2018. The use of pharmacomechanical thrombolysis increased, from 25% (n = 1) in 2010-2012 to 87.5% (n = 7) in 2018-2020. The rate of inferior vena cava filter insertion alone decreased from 18.2% in 2010 (n = 4) to 5.9% (n = 1) in 2020. The length of thrombolysis treatment also decreased, from 100% of patients (n = 4) receiving treatment duration greater than 24 h in 2010-2012 to 0% (n = 0) in 2018-2020. About 45% of patients receiving thrombolysis (n = 9) had venous stenting. No difference in treatment outcomes were observed, with greater than 87.5% of patients reaching intermediate to full resolution of clot burden. No patients experienced intracranial hemorrhage. CONCLUSIONS: The results of this analysis highlight the change in practice in our institution over time. The low rate of intervention likely reflects the current lack of consensus in published guidelines. It is important for future work to elicit the most appropriate management pathways for patients with iliofemoral deep venous thrombosis.

Large pseudoaneurysm arising from the deep femoral artery after hip fracture fixation.

Hip fracture is a common condition of increasing global concern. Vascular injury as a complication after hip fracture repair is rare. A 90-year-old woman developed swelling and pain to her proximal thigh 1 month after uneventful hip fracture fixation. Ultrasound revealed a large pseudoaneurysm of the deep femoral artery, which was successfully treated with transcatheter embolization. Pseudoaneurysms have numerous etiologies. In this case, vascular injury is suspected to be a consequence of proximal migration of the lesser trochanteric fragment. Unfortunately, pseudoaneurysms are often not appreciated due to the nonspecific nature of the presenting symptoms. Diagnosis should be confirmed radiologically and management depends on the location and size of the pseudoaneurysm, as well as patient comorbidities. Pseudoaneurysm after hip fracture fixation is a rare but serious complication. Diagnosis is challenging due to nonspecific symptoms. A high index of suspicion is imperative to prevent life-threatening rupture.

Patient-reported outcome measures for retinoblastoma: a scoping review.

BACKGROUND: Retinoblastoma is a childhood retinal cancer with lifelong consequences such as vision loss and increased risk of second cancer. Patient-reported outcome measures (PROMs) are instruments that measure outcomes related to health directly reported by patients. The purpose of this study was to determine the scope, characteristics and quality of PROMs used in retinoblastoma and related fields of pediatric ophthalmology and pediatric oncology. METHODS: Databases MEDLINE and Embase were searched for studies in the English language that reported on PROMs used in retinoblastoma, pediatric oncology, or pediatric ophthalmology; grey literature and studies reporting on developmental PROM phases were excluded. PROMs were grouped by the construct measured and domains assessed, and classified as condition-specific or generic. A subsequent search was then conducted in MEDLINE and Embase for studies assessing measurement properties of the identified PROMs. PROMs with associated studies were assessed for their methodologic quality using the COnsensus-based standard for the Selection of health Measurement INstruments (COSMIN) strategy. RESULTS: Among 110 eligible studies uncovered by the database searches, 143 PROMs were identified: one retinoblastoma-specific, 56 ophthalmology- and 86 oncology-related. The most common construct measured was 'health-related quality of life' and the most common domain assessed was emotional well-being. Of the 143 PROMs, 100 had associated validation studies; the one retinoblastoma-specific PROM was not validated. Quality assessment revealed 34/100 PROMs received a score of sufficient quality in both subcategories of 'overall content validity'; 3/100 received a score of sufficient quality in both subcategories of 'internal structure'; 0/100 received a score of sufficient quality in all three subcategories of 'remaining measurement properties'. The Patient-Reported Outcome Measure Information System (PROMIS) Pediatric Profile-25 was the highest-scoring PROM identified, meeting COSMIN standards for 2/3 measurement property categories (and 5/7 subcategories). Eleven additional PROMs were identified which had sufficient scores in 1/3 measurement property categories (and 5/7 subcategories). CONCLUSION: The study identified several PROMs from the pediatric ophthalmology and pediatric oncology literature that could be relevant to the retinoblastoma population, but many have limits to their validation. Future development of a retinoblastoma-specific PROM, performed in partnership with retinoblastoma patients to support optimal content validity, could first focus on the selection and definition of the optimal construct to measure, followed potentially by adaptation and further validation of the relevant PROMs with strong methodologic quality identified in this study.

Chylous ascites following elective abdominal aortic aneurysm repair.

Postoperative chylous ascites is a rare complication of abdominal surgery. Chyle depletion results in nutritional, immunologic and metabolic deficiencies, making it a serious and potentially life-threatening condition for which prompt diagnosis and management is imperative. A 72-year-old male was referred for open repair of a 62 cm juxtarenal abdominal aortic aneurysm (AAA). Following resumption of diet, he developed abdominal distention. Therapeutic paracenteses confirmed chylous ascites. Failed conservative management and lymphatic embolization lead to surgical sealance of lymphatic leak using glue. Postoperatively, a full diet was tolerated with no further ascites. Paracentesis is the diagnostic modality of choice in evaluating patients with ascites. Management is challenging and should be multifaceted and tailored to individual patient needs. Cornerstones of therapy include correction of the underlying etiology and conservative measures. When conservative measures fail, other interventions can be considered, such as somatostatin analogs, surgical ligation or glue embolization.