British Gynaecological Cancer Society Recommendations for Evidence Based, Population Data Derived Quality Performance Indicators for Ovarian Cancer.

Ovarian cancer survival in the UK lags behind comparable countries. Results from the ongoing National Ovarian Cancer Audit feasibility pilot (OCAFP) show that approximately 1 in 4 women with advanced ovarian cancer (Stage 2, 3, 4 and unstaged cancer) do not receive any anticancer treatment and only 51% in England receive international standard of care treatment, i.e., the combination of surgery and chemotherapy. The audit has also demonstrated wide variation in the percentage of women receiving anticancer treatment for advanced ovarian cancer, be it surgery or chemotherapy across the 19 geographical regions for organisation of cancer delivery (Cancer Alliances). Receipt of treatment also correlates with survival: 5 year Cancer survival varies from 28.6% to 49.6% across England. Here, we take a systems wide approach encompassing both diagnostic pathways and cancer treatment, derived from the whole cohort of women with ovarian cancer to set out recommendations and quality performance indicators (QPI). A multidisciplinary panel established by the British Gynaecological Cancer Society carefully identified QPI against criteria: metrics selected were those easily evaluable nationally using routinely available data and where there was a clear evidence base to support interventions. These QPI will be valuable to other taxpayer funded systems with national data collection mechanisms and are to our knowledge the only population level data derived standards in ovarian cancer. We also identify interventions for Best practice and Research recommendations.

Disaster education for nursing students: A successful partnership with the American Red Cross.

BACKGROUND: Educating nursing students on disasters is an essential component of baccalaureate nursing curriculum. Implementing effective education during and for rare events, such as disasters or pandemics, can be difficult for nursing programs attempting to cover required content. METHOD: This curriculum improvement project was integrated into our community clinical course over several semesters. Through a no cost partnership with the American Red Cross, we were able to educate students in disaster nursing and complete required clinical hours. A combination of online education with in-person or virtual simulation was facilitated by the American Red Cross and hosted by our university. RESULTS: Students met learning objectives through completion of online learning and a simulation experience. Student perceptions of the learning experience were positive. Through this partnership110 students completed training as new Disaster Health Service volunteers for the American Red Cross. CONCLUSION: This community partnership will remain part of our curriculum and could be replicated in other nursing programs. This model has demonstrated effectiveness in both the in-person and virtual class setting, allowing flexibility in content delivery.

Quality of life from cytoreductive surgery in advanced ovarian cancer: Investigating the association between disease burden and surgical complexity in the international, prospective, SOCQER-2 cohort study.

OBJECTIVE: To investigate quality of life (QoL) and association with surgical complexity and disease burden after surgical resection for advanced ovarian cancer in centres with variation in surgical approach. DESIGN: Prospective multicentre observational study. SETTING: Gynaecological cancer surgery centres in the UK, Kolkata, India, and Melbourne, Australia. SAMPLE: Patients undergoing surgical resection (with low, intermediate or high surgical complexity score, SCS) for late-stage ovarian cancer. MAIN OUTCOME MEASURES: Primary: change in global score on the European Organisation for Research and Treatment of Cancer (EORTC) core quality-of-life questionnaire (QLQ-C30). Secondary: EORTC ovarian cancer module (OV28), progression-free survival. RESULTS: Patients' preoperative disease burden and SCS varied between centres, confirming differences in surgical ethos. QoL response rates were 90% up to 18 months. Mean change from the pre-surgical baseline in the EORTC QLQ-C30 was 3.4 (SD 1.8, n = 88) in the low, 4.0 (SD 2.1, n = 55) in the intermediate and 4.3 (SD 2.1, n = 52) in the high-SCS group after 6 weeks (p = 0.048), and 4.3 (SD 2.1, n = 51), 5.1 (SD 2.2, n = 41) and 5.1 (SD 2.2, n = 35), respectively, after 12 months (p = 0.133). In a repeated-measures model, there were no clinically or statistically meaningful differences in EORTC QLQ-C30 global scores between the three SCS groups (p = 0.840), but there was a small statistically significant improvement in all groups over time (p < 0.001). The high-SCS group experienced small to moderate decreases in physical (p = 0.004), role (p = 0.016) and emotional (p = 0.001) function at 6 weeks post-surgery, which resolved by 6-12 months. CONCLUSIONS: The global QoL of patients undergoing low-, intermediate- and high-SCS surgery improved at 12 months after surgery and was no worse in patients undergoing extensive surgery. TWEETABLE ABSTRACT: Compared with surgery of lower complexity, extensive surgery does not result in poorer quality of life in patients with advanced ovarian cancer.

Do surgical techniques used in groin lymphadenectomy for vulval cancer affect morbidity rates?

OBJECTIVE: To determine the complication rates associated with differing surgical techniques for groin node dissection for vulval cancer. MATERIALS AND METHODS: We performed a retrospective case note review of patients undergoing groin node dissection for vulval cancer between 2001 and 2009 at Nottingham University Hospitals NHS Trust. RESULTS: Notes for 56 patients undergoing a total of 98 groin node dissections were examined. Sixty-four percent of the patients had at least one complication from surgery. The use of suction drains was not associated with an increase in complications. However, when drains were used, a short duration of use was associated with high rates of wound breakdown and a long duration of use was associated with higher rates of lymphedema. The use of staples for skin closure was associated with an increased risk of lymphocysts and chronic lymphedema. The greater the number of nodes collected at lymphadenectomy, the higher the risk of lymphocysts and lymphedema. CONCLUSIONS: We recommend the use of subcuticular suture for wound closure. Patients who undergo lymphadenectomy with a node count per groin of more than 7 should be closely monitored for lymphedema and referred promptly to specialist services. The prolonged use of suction drainage may increase the risk of lymphedema.

The use of MRI for selecting patients with endometrial cancer and significant co-morbidities for vaginal hysterectomy.

OBJECTIVE: The objective of this study is to ascertain the presence of extrauterine spread in radiologically early stage and grade endometrial cancer. This could be the basis for offering vaginal hysterectomy without salpingo-oophorectomy as an alternative option to primary radical radiotherapy in women with significant medical co-morbidities in whom laparotomy will be contraindicated. MATERIALS AND METHODS: A retrospective cohort study assessing patients with clinically early stage endometrioid adenocarcinoma of the endometrium, treated at the Gynaecological Oncology Centre, Norfolk and Norwich University Hospital and James Paget University Hospital between January 2003 and July 2008. The cancer registry was reviewed, and 542 endometrial cancer cases were identified during the study period, of these 439 were endometrioid type. MR is the standard staging investigation unless there are contraindications. Demographic, clinic-pathologic and surveillance data were collected from hospital records, operative notes and histopathology reports. The histology included tumour type, stage and grade. Post-operative histopathological findings served as a reference standard. Sensitivity and specificity of pre-operative MRI scan were assessed. RESULTS: Of the 439 cases treated during the study periods, 415 patients had an MRI pre-operatively imaging and 14% of these cases showed signs of extrauterine spread. MRI staging was then compared with the histopathology staging; the latter was taken as the gold standard. In 8% of the cases where no spread was seen on MRI, the disease was actually spread outside uterine corpus mainly to the cervix and pelvic lymph nodes. The sensitivity, specificity, positive predictive value and negative predictive value for MRI were 56, 93, 60, and 92, respectively, while predicting early stage disease. There were three cases of adnexal metastases, where the tumour had already spread to uterine serosa. Two cases had poorly differentiated and one had moderately differentiated tumour. CONCLUSIONS: The risk of adnexal metastasis is less than 1% in clinically early stage disease and highly unlikely if MRI suggests that the disease is confined to the inner half of the myometrium and low-grade disease. MRI has a high specificity and negative predictive value in endometrial cancer staging with reduced sensitivity of detecting cervical, adnexal and lymphatic spread. We suggest that vaginal hysterectomy might be a safe alternative to laparotomy in the treatment of radiological early stage disease in medically compromised elderly patients. The possibility of converting a vaginal approach to an abdominal route should be always taken into consideration.

Pelvic mass associated with raised CA 125 for benign condition: a case report.

BACKGROUND: Raised CA 125 with associated pelvic mass is highly suggestive of ovarian malignancy, but there are various other benign conditions that can be associated with pelvic mass and a raised CA 125. CASE PRESENTATION: We present a case of 19 year old, Caucasian British woman who presented initially with sudden onset right sided iliac fossa pain and on imaging was found to have 9.8 x 4.5 cm complex cystic mass in right adnexa with a raised CA 125 of 657, which was initially thought to be highly suspicious of cancer but was subsequently found to be due to pelvic inflammatory disease on histology. CONCLUSION: This case highlights the fact that though a pelvic mass with raised CA 125 is highly suggestive of malignancy, pelvic inflammatory disease should always be considered as a differential diagnosis especially in a young patient and a thorough sexual history and screening for pelvic infection should always be carried out in these patients.

Beyond the basics: brain injuries.

Increased intracranial pressure can be a catastrophic event that may lead to death or permanent disability. Without prompt recognition and reversal of hypoxia, hypotension, hypercarbia, acidosis and increased intracranial pressure, the cerebral blood flow and resultant cerebral perfusion can be inadequate, leading to an exacerbation of secondary brain injury.

Cerebellar abnormalities in infants and toddlers with Williams syndrome.

One commonly observed neuroanatomical abnormality in adults with Williams syndrome is an enlarged cerebellum relative to a small cerebrum. Our study is the first to examine neuroanatomy in young children with Williams syndrome. Clinical brain MRI was examined in nine young children with Williams syndrome (mean age 21 months, range 7 to 43 months) relative to nine age- and sex-matched normally developing control children (mean age 29 months, range 20 to 42 months), and two children with undiagnosed developmental disorders (6 and 41 months). Two neuroradiologists who were blinded to participant classification, hypotheses, and regions of interest for the study, sorted the brain scans into two groups on the basis of six neuroanatomical criteria. The raters placed more of the MR scans from children with Williams syndrome into a separate group when they analyzed features of the cerebellum, but not when they analyzed other brain regions. Based on their written comments, the raters focused on the large size of the cerebellum in the children with Williams syndrome. The results lead us to suggest that abnormal cerebellar enlargement is evident in those with Williams syndrome at an early age. Our results are discussed relative to the cognitive delays observed in Williams syndrome versus other disorders such as autism, leading us to suggest that the cerebellum may play a role in cognition.