Implementation of routine venous thromboembolism prophylaxis during neoadjuvant chemotherapy for patients with ovarian cancer

OBJECTIVE

To compare the venous thromboembolism (VTE) rate in patients with ovarian cancer undergoing neoadjuvant chemotherapy before and after implementing routine thromboprophylaxis.

METHODS

This is a quasi-experimental pre-post study evaluating the VTE rate in patients with ovarian cancer who received neoadjuvant chemotherapy following a quality improvement initiative of routine thromboprophylaxis within a single healthcare system that started in January 2017. Patients were excluded if VTE was diagnosed before initiating chemotherapy. Patient factors and perioperative variables of interest were investigated for their association with VTE through univariate and multivariate models.

RESULTS

Of the 136 patients in the pre-implementation group, 3.7% (n = 5) received thromboprophylaxis. Of the 154 patients in the post-implementation group, 65.6% (n = 101) received thromboprophylaxis. Provider compliance varied from 51% in 2019 to 79.3% in 2021. The overall rate of VTE, from the start of chemotherapy to the end of treatment, was 21.3% (n = 29) pre- and 8.4% (n = 13) in the post-implementation group (p < 0.01). There was no difference in major bleeding events between groups (0% vs. 0.68%, p = 0.63). On univariate analysis, thromboprophylaxis (OR 0.19; 95% CI 0.07-0.52) and post-implementation period (OR 0.34; 95% CI 0.17-0.69) were associated with a decreased risk of any VTE during primary treatment. On multivariate analysis, only thromboprophylaxis remained significantly associated with reduced VTE rates (aOR 0.19; 95% CI 0.07-0.53).

CONCLUSION

Routine thromboprophylaxis during neoadjuvant chemotherapy is associated with reduced risk of VTE throughout primary treatment and is not associated with increased bleeding events.

Implementation of a standardized voiding management protocol to reduce unnecessary re-catheterization - A quality improvement project

OBJECTIVE

To design and implement a standardized postoperative voiding management protocol that accurately identifies patients with urinary retention and reduces unnecessary re-catheterization.

METHODS

A postoperative voiding management protocol was designed and implemented in patients undergoing major, inpatient, non-radical abdominal surgery with a gynecologic oncologist. No patients had epidural catheters. The implemented quality improvement (QI) protocol included: 1) Foley removal at six hours postoperatively; 2) universal bladder scan after the first void; and 3) limiting re-catheterization to patients with bladder scan volumes >150 ml. A total of 96 patients post-protocol implementation were compared to 52 patients pre-protocol. Along with baseline demographic data and timing of catheter removal, we recorded the presence or absence of urinary retention and/or unnecessary re-catheterization and postoperative urinary tract infection rates. Fisher's exact test and student's t-tests were performed for comparisons.

RESULTS

The overall rate of postoperative urinary retention was 21.6% (32/148). The new voiding management protocol reduced the rate of unnecessary re-catheterization by 90% (13.5% vs 2.1%, p = 0.01), without overlooking true urinary retention (23.1% vs 20.8%, p = 0.83). Additionally, there was a significant increase in hospital-defined early discharge prior to 11:00 AM (4.0% vs 22.0%, p = 0.022). There was no difference in the postoperative urinary tract infection rate between the groups (p = 1.00). Risk factors associated with urinary retention included older age (p < 0.01), use of medications with anticholinergic properties (p < 0.01), and preexisting urinary dysfunction (p < 0.01).

CONCLUSIONS

Implementation of this new voiding management protocol reduced unnecessary re-catheterization, captured and treated true urinary retention, and facilitated early hospital discharge.

The decline in attitudes toward physician-nurse collaboration from medical school to residency

While interprofessional collaboration is a critical aspect of optimal patient care, practicing physicians often have sub-optimal attitudes regarding the importance of collaboration with their nursing colleagues. The impact of clinical training on medical students' and residents' attitudes toward physician-nurse collaboration has not been investigated. The primary goal of our study was to examine if learners at different stages in their medical training had more or less favorable attitudes regarding interprofessional collaboration (IPC). A secondary goal was to compare residents in procedural versus non-procedural specialties to determine if attitudes toward IPC varied by specialty type. Third-year medical students and residents at a large public university completed the Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration. Student (n = 129) and resident (n = 292) scores were compared using Student's t-tests. Resident responses were further analyzed by specialty type. Students' perceptions of the physician-nurse relationship were significantly more favorable than the views of residents, particularly in the "Authority" and "Responsibility" domains. Residents in procedural specialties had less favorable attitudes toward physician-nurse collaboration than those in non-procedural specialties. Our findings highlight the importance of developing effective interventions for improving interprofessional collaboration during medical training.

Trends in surgical complexity and treatment modalities utilized in the management of ovarian cancer in an era of neoadjuvant chemotherapy

OBJECTIVES

To investigate the impact of the increased use of neoadjuvant chemotherapy on the complexity of cytoreductive surgeries for ovarian cancer.

METHODS

Using the National Cancer Database, we performed a retrospective cohort study of women diagnosed between 2004 and 2015 with stage III or IV epithelial ovarian cancer who underwent either primary cytoreductive surgery (PDS) followed by adjuvant chemotherapy, neoadjuvant chemotherapy (NACT) followed by interval debulking surgery. Cases were assigned a surgical complexity category as 1) Inadequate, 2) Low, 3) Moderate and, 4) High complexity. The primary outcome was the trend in surgical complexity over time. Secondary outcomes included temporal trends in treatment modality, perioperative mortality, and survival.

RESULTS

At total of 52,582 (76.3%) underwent PDS and 16,307 (23.7%) underwent NACT. The utilization of NACT increased from 7.7% in 2004 to 27.8% in 2015 (p-trend < 0.001). Patients undergoing moderate complexity surgeries increased from 28.9% to 33.5% and high complexity surgeries from 26.3% to 30% (p-trend < 0.001, for both). Trends in increasing surgical complexity were seen in both NACT and PDS cohorts. This increase in surgical complexity was seen most profoundly at the high-volume centers. Overall 30-day mortality decreased from 3.4% in 2004 to 1.4% in 2015; and 90-day mortality decreased from 7.6% to 4%. During the same time, 5-year survival increased from 39.7% to 49%.

CONCLUSIONS

Increase in the utilization of NACT is associated with decreased 30- and 90-day mortality and increase in five-year survival. Moreover, the overall complexity of ovarian cancer surgery has increased in both PDS and NACT cohorts.

Comparison of first-line chemotherapy regimens for ovarian carcinosarcoma: a single institution case series and review of the literature

Background

The optimal first-line chemotherapy for ovarian carcinosarcoma has not yet been determined. We therefore sought to determine the progression-free survival (PFS) and overall survival (OS) for patients with ovarian carcinosarcoma treated at our institution with different first-line chemotherapy regimens.

Methods

This single-institution, retrospective analysis included all patients with ovarian or primary peritoneal carcinosarcoma diagnosed from September 1996 to July 2017. Kaplan Meier analysis with a log-rank Mantel-Cox test was used to compare PFS and OS between treatment groups, and a p-value of < 0.05 was considered statistically significant.

Results

Thirty-one patients met inclusion criteria: two patients were stage IC, 5 were stage II, 21 were stage III, and 3 were stage IV. The median PFS and OS for all stages was 9.3 and 19.7 months respectively. Fifteen patients (48%) received carboplatin/paclitaxel as first therapy, 7 (23%) received ifosfamide/paclitaxel, 6 (19%) received a different regimen, and 3 (10%) did not receive chemotherapy. Patients treated with carboplatin/paclitaxel had a statistically significant longer PFS when compared to those receiving ifosfamide/paclitaxel (17.8 vs. 8.0 months, p = 0.025). OS was similar between all comparisons.

Conclusions

In summary, in our cohort of ovarian carcinosarcoma patients, median PFS is longer in patients treated with carboplatin/paclitaxel compared to ifosfamide/paclitaxel. Overall survival was similar for all treatment groups, potentially due to subsequent treatment crossover. Given the rarity and aggressive nature of this tumor, further study into optimal first-line chemotherapy is warranted.

Ankyrin-rich membrane spanning protein as a novel modulator of transient receptor potential vanilloid 1-function in nociceptive neurons

BACKGROUND

The ion channel TRPV1 is mainly expressed in small diameter dorsal root ganglion (DRG) neurons, which are involved in the sensation of acute noxious thermal and chemical stimuli. Direct modifications of the channel by diverse signalling events have been intensively investigated, but little is known about the composition of modulating macromolecular TRPV1 signalling complexes. Here, we hypothesize that the novel adaptor protein ankyrin-rich membrane spanning protein/kinase D interacting substrate (ARMS) interacts with TRPV1 and modulates its function in rodent DRG neurons.

METHODS

We used immunohistochemistry, electrophysiology, microfluorimetry and immunoprecipitation experiments to investigate TRPV1 and ARMS interactions in DRG neurons and transfected cells.

RESULTS

We found that TRPV1 and ARMS are co-expressed in a subpopulation of DRG neurons. ARMS sensitizes TRPV1 towards capsaicin in transfected HEK 293 cells and in mouse DRG neurons in a PKA-dependent manner. Using a combination of functional imaging and immunocytochemistry, we show that the magnitude of the capsaicin response in DRG neurons depends not only on TRPV1 expression, but on the co-expression of ARMS alongside TRPV1.

CONCLUSION

These data indicate that ARMS is an important component of the signalling complex regulating the sensitivity of TRPV1.

SIGNIFICANCE

The study identifies ARMS as an important component of the signalling complex regulating the sensitivity of excitatory ion channels (TRPV1) in peripheral sensory neurons (DRG neurons) and transfected cells.

Neuronal Ca2+ sensor VILIP-1 leads to the upregulation of functional alpha4beta2 nicotinic acetylcholine receptors in hippocampal neurons

The neuronal Ca2+-sensor protein VILIP-1, known to affect clathrin-dependent receptor trafficking, has been shown to interact with the cytoplasmic loop of the alpha4-subunit of the alpha4beta2 nicotinic acetylcholine receptor (nAChR), which is the most abundant nAChR subtype with high-affinity for nicotine in the brain. The alpha4beta2 nAChR is crucial for nicotine addiction and the beneficial effects of nicotine on cognition. Its dysfunction has been implicated in frontal lobe epilepsy, Alzheimer's disease and schizophrenia. Here we report that overexpression of VILIP-1 enhances ACh responsiveness, whereas siRNA against VILIP-1 reduces alpha4beta2 nAChR currents of hippocampal neurons. The underlying molecular mechanism likely involves enhanced constitutive exocytosis of alpha4beta2 nAChRs mediated by VILIP-1. The two interaction partners co-localize in a Ca2+-dependent manner with syntaxin-6, a Golgi-SNARE protein involved in trans-Golgi membrane trafficking. Thus, we speculate that regulation of VILIP-1-expression might modulate surface expression of ligand-gated ion channels, such as the alpha4beta2 nAChRs, possibly comprising a novel form of physiological up-regulation of ligand-gated ion channels.

Group I mGlu receptors regulate the expression of the neuronal calcium sensor protein VILIP-1 in vitro and in vivo: implications for mGlu receptor-dependent hippocampal plasticity?

Metabotropic glutamate (mGlu) receptors are involved in several forms of synaptic plasticity in the rat hippocampus. Agonists which activate group I mGlu receptors induce slow-onset potentiation without prior tetanization in the hippocampal area CA1. Activation of group I mGlu receptors induces protein synthesis which may contribute to mGlu receptor-dependent forms of long-term plasticity. Calcium-binding proteins are widely considered to comprise key elements for synaptic plasticity. Therefore, we investigated whether the calcium sensor protein VILIP-1 is associated with group I mGlu receptor-mediated plasticity in the dentate gyrus (DG) in vivo.Application of either the group I and II mGlu agonist (1S,3R)-1-aminocyclopentane-1,3-dicarboxylate (ACPD) or the selective group I agonist (R,S)-3,5-dihydroxyphenylglycine (DHPG) resulted in slow-onset potentiation in the DG of adult rats. In hippocampal cell cultures both agonists elicited an enhanced expression of VILIP-1. In situ hybridization revealed strong hippocampal expression of VILIP-1 and intracerebral application of DHPG to adult rats significantly enhanced hippocampal VILIP-1 expression. The DHPG effects in both, hippocampal cultures and in vivo, were prevented by the group I mGlu receptor antagonist 4-Carboxyphenylglycine (4CPG). Calcium sensor proteins thus appear to be regulated by mGlu receptors in an activity-dependent manner. A specific role for group I mGlu receptors is evident. Furthermore, the sensor proteins may function as molecular switches for the long-term regulation of synaptic plasticity.

Intracellular neuronal calcium sensor (NCS) protein VILIP-1 modulates cGMP signalling pathways in transfected neural cells and cerebellar granule neurones

The family of intracellular neuronal calcium-sensors (NCS) belongs to the superfamily of EF-hand proteins. Family members have been shown by in vitro assays to regulate signal cascades in retinal photoreceptor cells. To study the functions of NCS proteins not expressed in photoreceptor cells we examined Visinin-like protein-1 (VILIP-1) effects on signalling pathways in living neural cells. Visinin-like protein-1 expression increased cGMP levels in transfected C6 and PC12 cells. Interestingly, in transfected PC12 cells stimulation was dependent on the subcellular localization of VILIP-1. In cells transfected with membrane-associated wild-type VILIP-1 particulate guanylyl cyclase (GC) was stimulated more strongly than soluble GC. In contrast, deletion of the N-terminal myristoylation site resulted in cytosolic localization of VILIP-1 and enhanced stimulation of soluble GC. To study the molecular mechanisms underlying GC stimulation VILIP-1 was examined to see if it can physically interact with GCs. A direct physical interaction of VILIP-1 with the recombinant catalytic domain of particulate GCs-A, B and with native GCs enriched from rat brain was observed in GST pull-down as well as in surface plasmon resonance interaction studies. Furthermore, following trituration of recombinant VILIP-1 protein into cerebellar granule cells the protein influenced only signalling by GC-B. Together with the observed colocalization of GC-B, but not GC-A, with VILIP-1 in cerebellar granule cells, these results suggest that VILIP-1 may be a physiological regulator of GC-B.