They Can Have Our Cake - But Can We Eat It? Access to Raw Genomic Data under Australian Privacy Law

There is an increasing demand for the return of raw genomic data by research participants in translational genomic research. This article discusses the scope and application of privacy and freedom of information legislative provisions in Australia. Whether there is a right to access a copy of such data under Australian privacy legislation is contingent on whether raw genomic data can identify an individual and this article explores the opportunities for genomic data to be linked to individuals. We conclude that despite the complexity and overlapping nature of privacy laws in Australia, there is a clear right on the part of research participants to access their raw genomic data.

Development and validation of a prognostic model for death 30 days after adult emergency laparotomy

The probability of death after emergency laparotomy varies greatly between patients. Accurate pre-operative risk prediction is fundamental to planning care and improving outcomes. We aimed to develop a model limited to a few pre-operative factors that performed well irrespective of surgical indication: obstruction; sepsis; ischaemia; bleeding; and other. We derived a model with data from the National Emergency Laparotomy Audit for patients who had emergency laparotomy between December 2016 and November 2018. We tested the model on patients who underwent emergency laparotomy between December 2018 and November 2019. There were 4077/40,816 (10%) deaths 30 days after surgery in the derivation cohort. The final model had 13 pre-operative variables: surgical indication; age; blood pressure; heart rate; respiratory history; urgency; biochemical markers; anticipated malignancy; anticipated peritoneal soiling; and ASA physical status. The predicted mortality probability deciles ranged from 0.1% to 47%. There were 1888/11,187 deaths in the test cohort. The scaled Brier score, integrated calibration index and concordance for the model were 20%, 0.006 and 0.86, respectively. Model metrics were similar for the five surgical indications. In conclusion, we think that this prognostic model is suitable to support decision-making before emergency laparotomy as well as for risk adjustment for comparing organisations.

Legal Liability of Clinical Ethics Services in Australia: "Should I Be More Worried Than I Am?"

A key function of clinical ethics services (CESs) is to provide decision-making support to health care providers in ethically challenging cases. Cases referred for ethics consultation are likely to involve diverging views or conflict, or to confront the boundaries of appropriate medical practice. Such cases might also attract legal action due to their contentious nature. As CESs become more prevalent in Australia, this article considers the potential legal liability of a CES and its members. With no reported litigation against a CES in Australia, we look to international experience and first principles. We consider the prospects of a claim in negligence, the most likely legal action against a CES, through application of legal principles to a hypothetical case scenario. We conclude that, although unlikely to be successful at this time, a CES could face answerable claims in negligence brought by patients (and families) who are the subject of ethics case consultation.

Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient

BACKGROUND

This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care.

METHODS

Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations.

RESULTS

Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process.

CONCLUSIONS

These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care

BACKGROUND

This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care.

METHODS

Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS^® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS^® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL.

RESULTS

Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process.

CONCLUSIONS

These guidelines are based on best available evidence for an ERAS^® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Snap-shot assessment of adult mosquito (Diptera: Culicidae) densities on the Turks and Caicos Islands, February 2022

In many of the small island communities of the Caribbean, much of the vector surveillance effort is focussed on house-to-house peri-focal surveys to collect data on larval indices. Adult mosquito trapping is not always routine or affordable and is usually focussed on ad hoc biting issues or small-scale investigations. This makes understanding the relative importance and densities of the common urban mosquitoes, such as Aedes aegypti and Culex quinquefasciatus, problematic. This snap-shot survey in February 2022 using BG-Sentinel traps at 30 different locations across five islands of the Turks and Caicos, aimed to provide the first island-wide assessment of urban mosquito densities. In total, 2,820 adult mosquitoes were collected over 285 trap nights. Aedes aegypti was most common on the island of Providenciales, with very low densities recorded on South Caicos, North and Middle Caicos, with Ae. aegypti most highly abundant in the main commercial centres. The highest densities of Cx. quinquefasciatus were trapped on North Caicos. Small numbers of other species were also collected, including the first record of Anopheles in TCI. This established framework of trapping and initial assessment provides a platform for continued monitoring of mosquitoes in TCI to better inform mosquito-borne disease risk assessment and future vector control efforts.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Health-related quality of life among cervical cancer survivors at a tertiary hospital in Ghana

Introduction

Cervical cancer is the second most common female cancer in Ghana. The disease and its treatment significantly affect survivors’ health-related quality of life (HRQoL). We determined the overall quality of life (QoL) and identified its predictors among cervical cancer survivors after treatment.

Materials and methods

A hospital-based cross-sectional analytical study was conducted on 153 disease-free cervical cancer survivors who completed curative treatment between January 2004 and December 2018 at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana. We used the European Organization for Research and Treatment of Cancer core-30 item (EORTC QLQ-C30) and cervical cancer module (EORTC QLQ-CX24) to assess the survivors’ overall QoL. QoL domain scores were dichotomised as affected or unaffected by disease and its treatment. Significant differences between the affected and unaffected groups within each QoL domain were determined using the student T-test. We used Kruskal-Wallis and Dunn’s tests to examine the difference in QoL domains between treatment types, with significance based on Bonferroni corrections. Multivariable logistic regression was performed to identify predictors of overall QoL. A p-value of less than 0.05 was considered statistically significant.

Results

One hundred and fifty-three (153) women having a mean age of 58.3 (SD 11.4) years were studied. The overall QoL score was 79.6 (SD 16.0), and 74.5% of survivors reported good QoL score within the median follow up time of 41.8 months (interquartile range [IQR], 25.5–71.1 months) after cervical cancer diagnosis. Although the majority (66.0–84.3%) of the QoL functioning scale were unaffected, about a fifth (22.2%) to a third (34.5%) of the subjects had perceptual impairment in cognitive and role functioning. Financial difficulties, peripheral neuropathy and pain were most common symptoms reported as affected. A third of the survivors were worried that sex would be painful, and 36.6% indicated that their sexual activity as affected. The overall QoL scores for survivors who had surgery, chemoradiation and radiation-alone were 86.1 (SD 9.7), 76.9 (SD 17.7), and 80.7 (SD 14.7), respectively (p = 0.025). The predictors of survivor’s overall QoL were loss of appetite [Adjusted Odd Ratio (AOR) = 9.34, 95% Confidence Interval (CI) = 2.13–35.8, p = 0.001], pain (AOR = 3.53, 95% CI = 1.25–9.31, p = 0.017) and body image (AOR = 5.89, 95% CI = 1.80–19.27, p = 0.003).

Conclusion

About 75% of the survivors had a good overall quality of life. Primary surgical treatment affords the best prospects for quality of life with the least symptom complaints and financial burden. Loss of appetite, pain or diminution in body image perception predicted the overall quality of life of cervical cancer survivors after treatment.

Factors associated with late-stage presentation of cervical cancer in Ghana

Objective: To explore factors associated with late clinical presentation among Ghanaian women with cervical cancerDesign: This is a cross-sectional survey using a paper questionnaire.Setting: Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana.Participants: Participants were women presenting for cervical cancer care at KATH. Inclusion criteria were histo-logically diagnosed cervical cancer and age ≥18 years. The exclusion criteria was age <18. All women presenting from August 2018-August 2019 were recruited.Main outcome measures: The primary outcome was the proportion of participants presenting with late-stage cervical cancer, defined as stage II or higher.Results: Of 351 total participants, 33.6% were unemployed, 35.3% had no formal education, and 96.6% had an aver-age monthly income of less than five hundred Ghana cedis ($86 USD). Time from symptoms to seeing a doctor ranged from fewer than two weeks (16.0%) to more than twelve months (8.6%). Participants’ most common barrier in seeking healthcare was financial constraints (50.0%). Most participants presented at late-stage cervical cancer (95.2%, n=334), with only 4.8% (n=17) presenting at stage I. Of participants presenting with late-stage cervical cancer, the vast major-ity had never had a Papanicolaou (Pap) smear (99.1%) nor a recent gynecologic exam (99.3%). After adjusting for age, parity, and distance to a healthcare facility, a late-stage presentation was associated with lower income and living in a rural area.Conclusions: In Ghana, 95% of women with cervical cancer seek care at a late clinical stage, defined as stage II or greater, when the cancer is inoperable.

Ethical Design and Use of Robotic Care of the Elderly

The Australian Royal Commission into Aged Care Quality and Safety acknowledged understaffing and substandard care in residential aged care and home care services, and recommendations were made that that the Australian Government should promote assistive technology within aged care. Robotic care assistants can provide care and companionship for the elderly-both in their own homes and within health and aged care institutions. Although more research is required into their use, studies indicate benefits, including enabling the elderly to live independently at home, assistance with medication and monitoring of safety. Nevertheless, there are inherent ethical challenges in the use of robots as carers, including loss of privacy, unwarranted restrictions on autonomy, lack of dignity, deception, and the exacerbation of loneliness. Ethics by design can counter these issues in development of robotics and clinical ethics committees have been put forward as a way of dealing with the ethical use of robotic care in healthcare institutions. In this paper I outline the ethical challenges of robotic care assistants and how these may be mediated in their design and use.

Determinants of cervical cancer screening uptake among women with access to free screening: A community-based study in peri-urban Ghana

OBJECTIVE

Cervical cancer can be prevented by regular screening; however, screening rates are low in developing countries. We evaluated the proportion of women screened, modalities of screening utilized, and factors influencing uptake among Ghanaian women with access to free screening services.

METHODS

Participants were women aged 25-65 in Asokore-Mampong, Ghana. A structured questionnaire collected socio-demographic characteristics, risk factors, knowledge of, and utilization of cervical cancer screening. Adjusted logistic regression evaluated predictors of screening.

RESULTS

Of 710 participants, the majority had heard of cervical cancer (64.6%) and screening (57.7%). Screening utilization was 24.6%. Visual inspection with acetic acid was the most common screening method (97.1%). For those who had never been screened, common reasons were believing they were healthy (21.7%), fearing pain (12.9%), lacking awareness of screening (11.8%), and being too busy (11.6%). Participants who were aged 35-44 (aOR 1.82; 95% CI 1.09-3.03; p = 0.023), married (aOR 3.98; 95% CI 1.68-9.40; p = 0.002), formally employed (aOR 9.31; 95% CI 2.86-30.35; p <0.001), and had higher cervical cancer knowledge (aOR 3.98; 95% CI 2.64-6.02; p <0.001) were more likely to have been screened.

CONCLUSION

Despite geographic proximity to a health center that provides free cervical cancer screening, screening uptake among Ghanaian women remains low.

Mosquito Magnet® traps as a potential means of monitoring blackflies of medical and veterinary importance

Mosquito Magnet® traps, deployed in widespread parts of England as part of nationwide mosquito surveillance projects, also caught blackflies. As many as 1242 blackflies were caught in a trapping session lasting 4 days. Principal among the species caught were Simulium equinum, Simulium lineatum and Simulium ornatum s.l. As S. ornatum s.l. is a vector that transmits Onchocerca linealis to cattle and S. equinum is responsible for dermatitis ('sweet itch') in cattle and horses, it is suggested that Mosquito Magnet® traps could be used to monitor and partially control these pests, as well as nuisance anthropophilic blackflies such as Simulium posticatum that can cause simuliidosis in southern England.

Good enough? Parental decisions to use DIY looping technology to manage type 1 diabetes in children

People are using innovative internet of things technologies to gain individualised management of their type 1 diabetes. The #WeAreNotWaiting movement supports them to build their own hybrid closed loop systems and access their real time blood sugar data via any web connected device. A small number of parents in Australia use such DIY looping systems to manage their child's type 1 diabetes, but these systems have not been approved by the Therapeutic Goods Administration in Australia, creating ethical dilemmas for clinicians about how to respond to the use of medical devices that are not registered on the Australian Register of Therapeutic Goods. This article considers whether the use of DIY looping is in the best interests of the child and, if not, whether intervention in parental decision making is justified to prevent harm to the child. It addresses the ongoing duty of healthcare professionals to provide care to children who are 'looping.' Reference is made to findings from a study, Personalised Closed Loop Systems for Childhood Diabetes, to illustrate stakeholders' perceptions of benefits and harms of DIY looping systems. I conclude that the decision of parents to use DIY looping technology could be considered to be in a child's best interests, broadly defined, and falls within the Zone of Parental Discretion, however healthcare practitioners who support parents may have professional concerns in doing so.

Nurse-Family Partnership nurses' attitudes and confidence in identifying and responding to intimate partner violence: An explanatory sequential mixed methods evaluation

AIMS

To evaluate the effect of an intimate partner violence intervention education component on nurses' attitudes in addressing intimate partner violence; complementary aims included understanding nurses' perceptions of the education and how it influenced their attitudes and confidence to address intimate partner violence in practice.

DESIGN

An explanatory sequential mixed methods design embedded within a 15-site cluster randomized clinical trial that evaluated an intimate partner violence intervention within the Nurse-Family Partnership programme.

METHODS

Data were collected between February 2011 and September 2016. Quantitative assessment of nurses' attitudes about addressing intimate partner violence was completed by nurses in the intervention (n = 77) and control groups (n = 101) at baseline, 12 months and at study closure using the Public Health Nurses' Responses to Women Who Are Abused Scale. Qualitative data were collected from nurses in the intervention group at two timepoints (n = 14 focus groups) and focused on their perceptions of the education component. Data were analysed using content analysis.

RESULTS

Nurses in the intervention group reported large improvements in their thoughts, feelings and perceived behaviours related to addressing intimate partner violence; a strong effect of the education was found from baseline to 12 months and baseline to study closure timepoints. Nurses reported that the education component was acceptable and increased their confidence to address intimate partner violence.

CONCLUSION

Nurses reported improved attitudes about and confidence in addressing intimate partner violence after receiving the education component. However, these findings need to be considered together with trial results showing no main effects for clients, and a low level of intervention fidelity.

IMPACT

These evaluation findings underscore that improvement in nurses' self-reported educational outcomes about addressing intimate partner violence cannot be assumed to result in adherence to intervention implementation or improvement in client outcomes. These are important considerations for developing nurse education on intimate partner violence.

Investigations into the synthesis of a nucleotide dimer via mechanochemical phosphoramidite chemistry

Liquid-assisted mechanochemistry as a versatile approach for the coupling of a nucleoside phosphoramidite with a 5'-OH partially protected nucleoside has been investigated. Noted advantages over reported methods were a simplified reaction protocol, a drastic reduction in the use of toxic solvents, the facilitation of mechanochemical reactions through the improved mixing of solid reagents, and low hydrolytic product formation.

Two rare presentations of embryonal rhabdomyosarcoma of the cervix in teenagers at a low-resource teaching hospital in Ghana: A case series

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We report on two cases of embryonal rhabdomyosarcoma of the cervix in Ghana.

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Only 20% of rhabdomyosarcoma diagnoses in children occur in the genitourinary tract.

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Embryonal rhabdomyosarcoma of the cervix is rare, with no standardized treatment.

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The teenaged patients underwent fertility-sparing surgery followed by chemotherapy.

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This treatment regimen is accessible in low-income countries.

We report two cases of embryonal rhabdomyosarcoma (ERMS) of the cervix in teenagers presenting to Komfo Anokye Teaching Hospital in Kumasi, Ghana within one month of each other. Between October and November 2019, two patients presented with ERMS of the cervix. They both underwent fertility-sparing surgery followed by chemotherapy with vincristine, actinomycin-D, and cyclophosphamide. Preoperative workup for the two patients was minimal due to limited availability and high cost of imaging in a low-resource setting. Both patients were discussed at a multidisciplinary tumor board meeting to guide best management practices. Both patients had local surgical resection with histological confirmation of ERMS and negative margins, followed by six cycles of vincristine, actinomycin-D, and cyclophosphamide. Neither of the patients had perioperative complications or received radiation therapy. At the time of publication, both patients are currently alive and without evidence of recurrence. Fertility-sparing surgery followed by chemotherapy for patients with ERMS of the cervix is accessible in low-income countries.

Gynecologic Oncology Sub-Specialty Training in Ghana: A Model for Sustainable Impact on Gynecologic Cancer Care in Sub-Saharan Africa

African women have double the risk of dying from cancer than women in high-income countries. In Ghana, most women with gynecological malignancies present with advanced-stage disease when treatment is less effective. Barriers to improved cancer outcomes include the availability of cancer screening, affordability of treatment, and access to gynecologic oncology specialists. In response to a paucity of gynecologic oncology providers, an in-country fellowship training program was established at Komfo Anokye Teaching Hospital (KATH) in 2013. Historically, Ghanaian resident physicians were sent to other countries for fellowship training and were unlikely to repatriate. The establishment of an in-country training program not only addresses the challenge of "brain drain," but also builds local capacity in gynecologic oncology education and emphasizes culturally relevant and accessible healthcare. The four-years gynecologic oncology fellowship program at KATH was developed as part of a longitudinal multi-decade partnership between the University of Michigan and academic medical centers in Ghana. The fellowship trains obstetricians and gynecologists to provide subspecialist clinical and surgical care to patients with gynecologic malignancies. Fellows collaborate with the radiation, oncology and pathology departments, participate in monthly inter-institutional tumor board meetings, conduct research, advise on health policy issues, and train subsequent cohorts. This fellowship is representative of emerging twenty-first-century trends in which subspecialty training programs in low-income countries are strengthened by international collaborations. Providing specialized training in gynecologic oncology can help develop and maintain resources that will improve clinical outcomes for women in low-resources settings.

Phosphorus stocks and flows in an intensive livestock dominated food system

Current use and management of phosphorus (P) in our food systems is considered unsustainable and considerable improvements in the efficiency of P use are required to mitigate the environmental impact of poor P stewardship. The inherent low P use efficiency of food production from animals means food systems dominated by livestock agriculture can pose unique challenges for improving P management. This paper presents the results of a substance flow analysis for P in the Northern Ireland (NI) food system for the year 2017 as a case study for examining P stewardship in a livestock dominated agricultural system. Imported livestock feed was by far the largest flow of P into the NI food system in 2017 (11,700 t ± 1300 t) and P from livestock excreta the largest internal flow of P (20,400 ± 1900t). The P contained in livestock slurries and manures alone that were returned to agricultural land exceeded total crop and grass P requirement by 20% and were the largest contributor to an annual excess soil P accumulation of 8.5 ± 1.4 kg ha^-1. This current livestock driven P surplus also limits the opportunities for P circularity and reuse from other sectors within the food system, e.g. wastewater biosolids and products from food processing waste. Management of livestock P demand (livestock numbers, feed P content) or technological advancements that facilitate the processing and subsequent export of slurries and manures are therefore needed.

Quality improvement and emergency laparotomy care: what have we learnt from recent major QI efforts?

More than 1.53 million adults undergo inpatient surgery in the UK NHS. Patients undergoing emergency abdominal surgery have a much greater risk of death than patients admitted for elective surgery. Widespread variations in key standards of care between hospitals exist and are associated with differences in mortality rates.Recently there have been three large-scale initiatives to improve quality of care for emergency laparotomy patients: the National Emergency Laparotomy Audit, the enhanced perioperative care for high-risk patients trial and the Emergency Laparotomy Collaborative. Here we provide a critical review of what we currently know about the use of structured methods for improving the quality of healthcare services, with reference to the three initiatives. We find that using structured methods to improve care is the hallmark of quality improvement but attention must too be paid to the context in which these methods are used.

NCCN Guidelines Insights: Ovarian Cancer, Version 1.2019

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer in the United States, with less than half of patients living >5 years from diagnosis. A major challenge in treating ovarian cancer is that most patients have advanced disease at initial diagnosis. The best outcomes are observed in patients whose primary treatment includes complete resection of all visible disease plus combination platinum-based chemotherapy. Research efforts are focused on primary neoadjuvant treatments that may improve resectability, as well as systemic therapies providing improved long-term survival. These NCCN Guidelines Insights focus on recent updates to neoadjuvant chemotherapy recommendations, including the addition of hyperthermic intraperitoneal chemotherapy, and the role of PARP inhibitors and bevacizumab as maintenance therapy options in select patients who have completed primary chemotherapy.

Health Care Workers and Patients as Trojan Horses: a COVID19 ward outbreak

Background

Transmission in healthcare settings can result in significant infections in healthcare workers and patients. Understanding infection dynamics has important implications for methods employed in hospitals to prevent nosocomial transmission events.

Methods

In this case series report we describe a cluster of COVID-19 (Coronavirus disease 2019) in a tertiary care university hospital, in the early phases of the epidemic, after hospital visiting had been stopped and when the UK lockdown was in place.

Findings

A 48 year old patient developed COVID-19 31 days post-admission and four days after admission to a medical ward from ITU. Infection was likely acquired from an asymptomatic or minimally symptomatic healthcare worker (HCW). Subsequent investigation over a 14 day period revealed symptoms in 23 staff members and five linked cases in patients on the same ward.

Nine of the 23 affected staff members provided care for and had direct exposure with the index case. Four staff reported caring for the index case without use of personal protective equipment. One was coughed on directly by the patient 24 hours prior to the onset of symptoms.

Conclusion

SARS CoV2 infection can be introduced to a ward area by asymptomatic and minimally symptomatic healthcare workers. Staff members and patients can act as Trojan horses carrying infection into and around the hospital, setting up unexpected transmission events.

Transmission of infection from pre-symptomatic, asymptomatic and minimally symptomatic individuals means that universal use of measures to prevent transmission is required for successful reduction of transmission events in the hospital setting.

Abstract A07: A phase II study of metformin therapy in ovarian cancer with translational endpoints

Epidemiologic studies suggest that metformin can improve outcomes for patients with ovarian cancer. Preclinical studies suggest metformin may work in part via effects on cancer stem-like cells (CSCs) to maintain platinum sensitivity. We therefore performed a phase II clinical trial evaluating adjuvant metformin therapy in nondiabetic patients with advanced-stage epithelial ovarian cancer (EOC). The primary aims were translational studies evaluating the impact of metformin on CSC and chemotherapy resistance. Secondary aims included progression-free and overall survival. Thirty-eight patients with confirmed stage IIC (n=1)/III (n=25)/IV (n=12) EOC were treated with either (i) neoadjuvant metformin followed by primary debulking surgery and adjuvant chemotherapy + metformin, or (ii) three cycles of neoadjuvant chemotherapy and metformin, followed by interval debulking surgery, and adjuvant chemotherapy + metformin. Thirty-two patients (84%) completed six cycles metformin + chemotherapy. Metformin was well tolerated with one grade III/IV treatment-related adverse event (3%). Median PFS was 18.0 months (95% CI 14.0-21.6). Median OS was surprisingly long at 57.9 months (95% CI 28.0 – not estimable). For patients with recurred platinum sensitive disease, response to second-line therapy was 85%. Translational studies comparing metformin-treated tumors and historical controls found that metformin-treated tumors had a 2.6-fold decrease in ALDH+/CD133+ CSC (p&lt;0.0001). Consistent with this, metformin-treated tumor cells (i) had an increased sensitivity to cisplatin in vitro, (ii) maintained cisplatin sensitivity over time (p&lt;0.001), and (iii) demonstrated reduced ability to amplify CSC with serial passages (p&lt;0.001). To understand the mechanism of metformin-induced maintenance of platinum response, we evaluated tumor cells and carcinoma-associated mesenchymal stem cells (CA-MSC), cells in the TME we previously reported could increase “stemness” and chemotherapy resistance. While we could not identify significant changes in bulk tumor cells, analysis of DNA methylation in CA-MSC demonstrated metformin treatment resulted in an epigenetic shift. Suggesting CA-MSC alteration drives metformin impact, compared to control CA-MSC, CA-MSC from metformin-treated patients were unable to drive chemotherapy resistance ex vivo. In conclusion, this is the first prospective study of metformin in EOC patients. Metformin therapy was associated with better than expected overall survival, reduction in CSC number, and epigenetic modification of cells in the TME. This was associated with maintenance of platinum sensitivity in vitro and could explain the better than expected median overall survival. This work supports the use of metformin in phase III studies.

Citation Format: Ronald J. Buckanovich, Daniel Chan, Jessica Shank, Kent Griffith, Huihui Fan, Robert Szulawski, Kun Yang, Kevin Reynolds, Carolyn Johnston, Karen McLean, Shitanshu Uppal, Rebecca Liu, Laura Cabrera, Sarah Taylor, Hui Shen, Geeta Mehta, Lan Coffman. A phase II study of metformin therapy in ovarian cancer with translational endpoints [abstract]. In: Proceedings of the AACR Special Conference on Advances in Ovarian Cancer Research; 2019 Sep 13-16, 2019; Atlanta, GA. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(13_Suppl):Abstract nr A07.

Phase II clinical trial of metformin as a cancer stem cell-targeting agent in ovarian cancer

BACKGROUNDEpidemiologic studies suggest that metformin has antitumor effects. Laboratory studies indicate metformin impacts cancer stem-like cells (CSCs). As part of a phase II trial, we evaluated the impact of metformin on CSC number and on carcinoma-associated mesenchymal stem cells (CA-MSCs) and clinical outcomes in nondiabetic patients with advanced-stage epithelial ovarian cancer (EOC).METHODSThirty-eight patients with stage IIC (n = 1)/III (n = 25)/IV (n = 12) EOC were treated with either (a) neoadjuvant metformin, debulking surgery, and adjuvant chemotherapy plus metformin or (b) neoadjuvant chemotherapy and metformin, interval debulking surgery, and adjuvant chemotherapy plus metformin. Metformin-treated tumors, compared with historical controls, were evaluated for CSC number and chemotherapy response. Primary endpoints were (a) a 2-fold or greater reduction in aldehyde dehydrogenase-positive (ALDH+) CD133+ CSCs and (b) a relapse-free survival at 18 months of more than 50%.RESULTSMetformin was well tolerated. Median progression-free survival was 18.0 months (95% CI 14.0-21.6) with relapse-free survival at 18 months of 59.3% (95% CI 38.6-70.5). Median overall survival was 57.9 months (95% CI 28.0-not estimable). Tumors treated with metformin had a 2.4-fold decrease in ALDH+CD133+ CSCs and increased sensitivity to cisplatin ex vivo. Furthermore, metformin altered the methylation signature in CA-MSCs, which prevented CA-MSC-driven chemoresistance in vitro.CONCLUSIONTranslational studies confirm an impact of metformin on EOC CSCs and suggest epigenetic change in the tumor stroma may drive the platinum sensitivity ex vivo. Consistent with this, metformin therapy was associated with better-than-expected overall survival, supporting the use of metformin in phase III studies.TRIAL REGISTRATIONClinicalTrials.gov NCT01579812.

Diagnostic accuracy of SUVmax in predicting malignancy of supraclavicular lymph nodes from primary oesophageal cancer

PURPOSE

To determine the diagnostic accuracy and optimum cut-off value of SUVmax on PET to predict malignancy of supraclavicular lymph nodes (SCLNs) in patients with oesophageal carcinoma.

MATERIAL AND METHODS

All diagnosed cases of oesophageal cancer were retrospectively reviewed (2010-2016). Patients that had a confirmed diagnosis of oesophageal cancer with avid SCLNs on staging PET were included in the study. 33 SCLNs that subsequently underwent ultrasound guided biopsy for staging were analysed. The maximum uptake values (SUVmax) of the SCLNs and primary tumours were measured. A receiver operating characteristic (ROC) analysis was performed to determine the optimum cut off of SUVmax in predicting malignancy.

RESULTS

24/33 PET-detected SCLNs were malignant. ROC analysis identified the best nodal SUVmax cut-off to be 3.0. The diagnostic accuracy of PET was 76.0 % (sensitivity = 78.9 %, specificity = 66.6 %). For SCLNs with SUVmax > 3.0, PET showed a positive predictor value of 88.2 %; for SCLNs < 3.0, PET showed a negative predictor value of 50 %. The median SUVmax of pathologically negative and positive nodes were 2.8 (range 1.8-6.0) and 5.3 (range 1.9-13.4). The median primary tumour SUVmax was 13.8 (range 3.7-30.0). The SUVmax of metastatic lymph nodes were significant higher than those of benign lesions (p < 0.05).

CONCLUSION

Our study revealed an accuracy rate of 76 % for PET detected SCLNs in patients with oesophageal carcinoma. For SCLNs with SUVmax > 3.0, PET had a high PPV (88 %), which can minimize the need for further diagnostic tests.

Phase II Trial of Cabozantinib in Recurrent/Metastatic Endometrial Cancer: A Study of the Princess Margaret, Chicago, and California Consortia (NCI9322/PHL86)

PURPOSE

The relevance of the MET/hepatocyte growth factor pathway in endometrial cancer tumor biology supports the clinical evaluation of cabozantinib in this disease.

PATIENTS AND METHODS

PHL86/NCI#9322 (NCT01935934) is a single arm study that evaluated cabozantinib (60 mg once daily) in women with endometrial cancer with progression after chemotherapy. Coprimary endpoints were response rate and 12-week progression-free-survival (PFS). Patients with uncommon histology endometrial cancer (eg, carcinosarcoma and clear cell) were enrolled in a parallel exploratory cohort.

RESULTS

A total of 102 patients were accrued. Among 36 endometrioid histology patients, response rate was 14%, 12-week PFS rate was 67%, and median PFS was 4.8 months. In serous cohort of 34 patients, response rate was 12%, 12-week PFS was 56%, and median PFS was 4.0 months. In a separate cohort of 32 patients with uncommon histology endometrial cancer (including carcinosarcoma), response rate was 6% and 12-week PFS was 47%. Six patients were on treatment for >12 months, including two for >30 months. Common cabozantinib-related toxicities (>30% patients) included hypertension, fatigue, diarrhea, nausea, and hand-foot syndrome. Gastrointestinal fistula/perforation occurred in four of 70 (6%) patients with serous/endometrioid cancer and five of 32 (16%) patients in exploratory cohort. We observed increased frequency of responses with somatic CTNNB1 mutation [four partial responses (PRs) in 10 patients, median PFS 7.6 months] and concurrent KRAS and PTEN/PIK3CA mutations (three PRs in 12 patients, median PFS 5.9 months).

CONCLUSIONS

Cabozantinib has activity in serous and endometrioid histology endometrial cancer. These results support further evaluation in genomically characterized patient cohorts.

Disclosure of Genetic Results to At-risk Relatives without Consent: Issues for Health Care Professionals in Australia

Disclosure of genetic information without consent of the patient (proband) challenges the legal frameworks of privacy and confidentiality. Changes to privacy legislation enable and provide guidelines for undertaking disclosure, with the purpose of reducing the harm to genetic relatives who, armed with such information, may seek predictive testing themselves. Nevertheless, significant uncertainty remains for health care professionals in the application of the discretion to disclose genetic information to at-risk relatives. First, jurisdictional inconsistencies in privacy legislation present challenges for the provision of genetic services across the country. Second, the current guidelines provide insufficient clarity regarding the justification for disclosure of genetic information to reduce psychological harm to relatives. Third, the implications of a potential expansion of a legal duty of care to inform genetic relatives in some circumstances indicates that such a duty would be unduly burdensome for health care professionals, and suggests that revision of the threshold for use - rather than disclosure - of depersonalised genetic information may represent a pragmatic way forward.

Risk Factors for Endometrial Cancer or Hyperplasia in Adolescents and Women 25 Years Old or Younger

STUDY OBJECTIVE

To evaluate characteristics of young women with endometrial hyperplasia or cancer.

DESIGN

Retrospective chart review.

SETTING

Tertiary care referral center.

PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES

We included 10- to 25-year-old young women seen at a single institution between 2006 and 2017 with International Classification of Diseases 9th and 10th revision codes for endometrial cancer or hyperplasia (cases), or who underwent an endometrial biopsy with other benign pathologic diagnoses (controls). Exclusions included a diagnosis of Lynch syndrome. Comparisons were made using χ², Fisher exact, and nonparametric Wilcoxon rank tests.

RESULTS

Sixty-nine patients were identified: 13 cases, 54 controls, and 2 exclusions. Of the 13 cases, 3 had endometrial cancer, 5 had complex atypical hyperplasia (now called endometrioid intraepithelial neoplasia), and 5 had hyperplasia without atypia. A higher proportion of cases had a body mass index (BMI) greater than 30, compared with controls (76.9% vs 40.4%; P < .03). The proportion of patients who had a BMI greater than 30 and were smokers was significantly higher among cases (38.5% vs 9.3%; P < .02). The proportion of patients with a history of polycystic ovary syndrome (PCOS) and smoking was also significantly different between groups (30.8% vs 3.7%; P < .01).

CONCLUSION

In women aged 25 years and younger with endometrial sampling, a BMI greater than 30 was statistically more common in patients with endometrioid intraepithelial neoplasia or cancer. Although smoking or PCOS alone was not related to endometrial hyperplasia or cancer in this small cohort study, there might be a relationship between endometrial abnormalities and multiple exposures, including smoking and BMI greater than 30 or smoking and a history of PCOS.

Hospital-level evaluation of the effect of a national quality improvement programme: time-series analysis of registry data

BACKGROUND AND OBJECTIVES

A clinical trial in 93 National Health Service hospitals evaluated a quality improvement programme for emergency abdominal surgery, designed to improve mortality by improving the patient care pathway. Large variation was observed in implementation approaches, and the main trial result showed no mortality reduction. Our objective therefore was to evaluate whether trial participation led to care pathway implementation and to study the relationship between care pathway implementation and use of six recommended implementation strategies.

METHODS

We performed a hospital-level time-series analysis using data from the Enhanced Peri-Operative Care for High-risk patients trial. Care pathway implementation was defined as achievement of >80% median reliability in 10 measured care processes. Mean monthly process performance was plotted on run charts. Process improvement was defined as an observed run chart signal, using probability-based 'shift' and 'runs' rules. A new median performance level was calculated after an observed signal.

RESULTS

Of 93 participating hospitals, 80 provided sufficient data for analysis, generating 800 process measure charts from 20 305 patient admissions over 27 months. No hospital reliably implemented all 10 processes. Overall, only 279 of the 800 processes were improved (3 (2-5) per hospital) and 14/80 hospitals improved more than six processes. Mortality risk documented (57/80 (71%)), lactate measurement (42/80 (53%)) and cardiac output guided fluid therapy (32/80 (40%)) were most frequently improved. Consultant-led decision making (14/80 (18%)), consultant review before surgery (17/80 (21%)) and time to surgery (14/80 (18%)) were least frequently improved. In hospitals using ≥5 implementation strategies, 9/30 (30%) hospitals improved ≥6 care processes compared with 0/11 hospitals using ≤2 implementation strategies.

CONCLUSION

Only a small number of hospitals improved more than half of the measured care processes, more often when at least five of six implementation strategies were used. In a longer term project, this understanding may have allowed us to adapt the intervention to be effective in more hospitals.

Association between surgeon special interest and mortality after emergency laparotomy

Background

Approximately 30 000 emergency laparotomies are performed each year in England and Wales. Patients with pathology of the gastrointestinal tract requiring emergency laparotomy are managed by general surgeons with an elective special interest focused on either the upper or lower gastrointestinal tract. This study investigated the impact of special interest on mortality after emergency laparotomy.

Methods

Adult patients having emergency laparotomy with either colorectal or gastroduodenal pathology were identified from the National Emergency Laparotomy Audit database and grouped according to operative procedure. Outcomes included all-cause 30-day mortality, length of hospital stay and return to theatre. Logistic and Poisson regression were used to analyse the association between consultant special interest and the three outcomes.

Results

A total of 33 819 patients (28 546 colorectal, 5273 upper gastrointestinal (UGI)) were included. Patients who had colorectal procedures performed by a consultant without a special interest in colorectal surgery had an increased adjusted 30-day mortality risk (odds ratio (OR) 1·23, 95 per cent c.i. 1·13 to 1·33). Return to theatre also increased in this group (OR 1·13, 1·05 to 1·20). UGI procedures performed by non-UGI special interest surgeons carried an increased adjusted risk of 30-day mortality (OR 1·24, 1·02 to 1·53). The risk of return to theatre was not increased (OR 0·89, 0·70 to 1·12).

Conclusion

Emergency laparotomy performed by a surgeon whose special interest is not in the area of the pathology carries an increased risk of death at 30 days. This finding potentially has significant implications for emergency service configuration, training and workforce provision, and should stimulate discussion among all stakeholders.

Effect of Addition of an Intimate Partner Violence Intervention to a Nurse Home Visitation Program on Maternal Quality of Life: A Randomized Clinical Trial

IMPORTANCE

Intimate partner violence (IPV) is a public health problem with significant adverse consequences for women and children. Past evaluations of a nurse home visitation program for pregnant women and first-time mothers experiencing social and economic disadvantage have not consistently shown reductions in IPV.

OBJECTIVE

To determine the effect on maternal quality of life of a nurse home visitation program augmented by an IPV intervention, compared with the nurse home visitation program alone.

DESIGN, SETTING, AND PARTICIPANTS

Cluster-based, single-blind, randomized clinical trial at 15 sites in 8 US states (May 2011-May 2015) enrolling 492 socially disadvantaged pregnant women (≥16 years) participating in a 2.5-year nurse home visitation program.

INTERVENTIONS

In augmented program sites (n = 229 participants across 7 sites), nurses received intensive IPV education and delivered an IPV intervention that included a clinical pathway to guide assessment and tailor care focused on safety planning, violence awareness, self-efficacy, and referral to social supports. The standard program (n = 263 participants across 8 sites) included limited questions about violence exposure and information for abused women but no standardized IPV training for nurses.

MAIN OUTCOMES AND MEASURES

The primary outcome was quality of life (WHOQOL-BREF; range, 0-400; higher score indicates better quality of life) obtained through interviews at baseline and every 6 months until 24 months after delivery. From 17 prespecified secondary outcomes, 7 secondary end points are reported, including scores on the Composite Abuse Scale, SPAN (Startle, Physiological Arousal, Anger, and Numbness), Prime-MD Patient Health Questionnaire, TWEAK (Tolerance/Worry About Drinking/Eye-Opener/Amnesia/C[K]ut Down on Drinking), Drug Abuse Severity Test, and the 12-Item Short-Form Health Survey (physical and mental health), version 2.

RESULTS

Among 492 participants enrolled (mean age, 20.4 years), 421 (86%) completed the trial. Quality of life improved from baseline to 24 months in both groups (change in WHOQOL-BREF scores from 299.5 [SD, 54.4] to 308.2 [SD, 52.6] in the augmented program group vs from 293.6 [SD, 56.4] to 316.4 [SD, 57.5] in the standard program group). Based on multilevel growth curve analysis, there was no statistically significant difference between groups (modeled score difference, -4.9 [95% CI, -16.5 to 6.7]). There were no statistically significant differences between study groups in any of the secondary participant end points. There were no adverse events recorded in either group.

CONCLUSIONS AND RELEVANCE

Among pregnant women experiencing social and economic disadvantage and preparing to parent for the first time, augmentation of a nurse home visitation program with a comprehensive IPV intervention, compared with the home visitation program alone, did not significantly improve quality of life at 24 months after delivery. These findings do not support the use of this intervention.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01372098.

Discussing Voluntary Assisted Dying

One challenge for the legal provision of voluntary assisted dying is to ensure that the person requesting it is not coerced and has made the decision voluntarily. In the State of Victoria, Australia, s 8 of the Voluntary Assisted Dying Act 2017 (Vic) provides that a health practitioner is prevented from initiating a discussion about voluntary assisted dying in the course of providing health services to a person. The aim of the provision was to avoid coercion or undue influence by a health practitioner. In this article we address the meaning and application of s 8 and consider whether in practice this provision might have the effect of excluding access for individuals who may have been interested in voluntary assisted dying but were never aware that this was an option for them.

Outcomes of growing rod surgery for severe compared with moderate early-onset scoliosis: a matched comparative study

Aims

The aim of this study was to compare the outcomes of surgery using growing rods in patients with severe versus moderate early-onset scoliosis (EOS).

Patients and Methods

A review of a multicentre EOS database identified 107 children with severe EOS (major curve ≥ 90°) treated with growing rods before the age of ten years with a minimum follow-up of two years and three or more lengthening procedures. From the same database, 107 matched controls with moderate EOS were identified.

Results

The mean preoperative major curve was 101° (90 to 139) in the severe group and 67° (33° to 88°) in the moderate group (p < 0.001), which was corrected at final follow-up to 57° (10° to 96°) in the severe group and 40° (3° to 85°) in the moderate group (p < 0.001). T1-S1 height increased by a mean of 54 mm (-8 to 131) in the severe group and 27 mm (-4 to 131) in the moderate group at the initial surgery (p < 0.001), and by 50 mm (-17 to 200) and 54 mm (-11 to 212), respectively, during distraction (p = 0.84). The mean number of complications per patient was 2.6 (0 to 14) in the severe group and 1.9 (0 to 10) in the moderate group (p = 0.040). Five patients (4.7%) in the severe group and three (2.8%) in the moderate group developed a neurological deficit postoperatively (p = 0.47).

Conclusion

Severe EOS can be treated effectively using growing rods, but the risk of complications is high. Cite this article: Bone Joint J 2018;100-B:772-9.

Hyponatraemia and Moduretic-Grand Mal Seizures: A Review

Three cases are presented which emphasize the importance of hyponatraemia as a cause of grand mal seizures. The combination of hydrochlorothiazide and amiloride appears to increase the risk of hyponatraemia. We discuss the aetiology and treatment of hyponatraemia and review the necessity for such combination therapy. We recommend caution in prescribing diuretics and preparations such as Moduretic should be used only in those few patients shown to need potassium supplementation.

What do Key Stakeholders Think About HIV Self-Testing in Canada? Results from a Cross-Sectional Survey

Human immunodeficiency virus (HIV) self-testing presents an empowering alternative to facility-based testing for reaching undiagnosed HIV infected individuals, but is not currently available in Canada. We surveyed stakeholders (clinical providers, public health professionals, researchers) engaged in HIV testing initiatives nationwide to identify the concerns, opportunities and challenges to implementing HIV self-testing in Canada. An online cross-sectional survey was disseminated by the Canadian Institutes of Health Research Centre for REACH 2.0 National HIV & sexually transmitted and blood borne infections working group to stakeholders nationwide, with a target sample size of 200. Quantitative and qualitative data were analyzed using a mixed-methods, respondent-informed approach, to inform subsequent HIV self-testing in a country where self-testing is not yet accessible. A total of 183 responses were received. A majority (70.7%) (128/181) felt that self-testing was a necessary investment to reach the undiagnosed. 64.6% (117/181) felt that self-tests should be made available to their clients and 71.5% (128/179) of respondents agreed that self-test instructions required improvements. However, 50% (90/180) felt that self-testing will pose an economic challenge to current HIV testing models. Regardless, 21% urged for timely action and availability of HIV self-tests. Thematic analyses reflected the following concerns: (a) need for affordable self-tests, (b) need for expedited, customized, and accessible linkages to counselling, (c) concern for patients to cope with positive self-test results, (d) accuracy of self-tests to detect acute HIV and (e) liability in the context of non-disclosure. Stakeholders agreed to the provision of an option of HIV self-testing to reach the undiagnosed individuals. Concerns regarding costs and accuracy of self-tests, expedited linkages to counselling, and integration of self-test within prevailing HIV testing models, will need to be addressed before their widespread implementation.

Adherence to Hematologic Hold Parameters in Carboplatin and Dose-Dense Paclitaxel Chemotherapy for Ovarian Malignancies: A Survey of NCCN Member Institutions

OBJECTIVE

To determine the adherence to hematologic chemotherapy hold parameters for the carboplatin and dose-dense paclitaxel chemotherapy regimen in patients with ovarian, fallopian tube, or primary peritoneal cancers.

METHODS

This is a quality assessment survey study. All 26 NCCN Member Institutions were contacted electronically. Hematologic chemotherapy hold parameter values (absolute neutrophil count [ANC] and platelet count) on days 1, 8, and 15 of each cycle were queried. These hold parameters were compared with published data supporting the use of dose-dense chemotherapy regimens in ovarian cancer.

RESULTS

The overall survey response rate was 85% (22/26 sites). Of responders, 27% (6 sites) were fully adherent with all hematologic hold parameters and 64% (14 sites) used hold parameters that differed from the published protocol. Specifically, all of these sites use hold parameters higher than those recommended in the literature. Two centers did not have center-specific hold parameters.

CONCLUSIONS

Carboplatin and dose-dense paclitaxel chemotherapy has been shown to increase progression-free survival and overall survival in patients with stage II-IV ovarian, fallopian tube, or primary peritoneal cancers. However, our study found that two-thirds of queried sites had hold parameters higher than those in the published protocol. Using more stringent hold parameters may lead to compromised clinical outcomes. Further research is necessary to determine the optimal strategy to increase individual site adherence to chemotherapy hematologic hold parameters as specified in published trials.