Risk Factors and Clinical Features of Fistula after Concurrent Chemoradiation and Brachytherapy for Locally Advanced Cervical Cancer

PURPOSE/OBJECTIVE(S)

The standard treatment for locally advanced cervical cancer (LACC) is concurrent chemoradiation and brachytherapy (CRT-B). Fistula formation is a serious complication of treatment; however, risk factors and clinical outcomes are not well described. We sought to identify the incidence, risk factors and prognosis of radiation-induced fistula in women who underwent CRT-B for LACC.

MATERIALS/METHODS

A single institution retrospective review of patients treated with CRT-B for LACC from July 2013 to August 2022 across 3 centers was performed. Inclusion criteria were Stage IB-IVB cervical cancer treated with definitive intent. Patients with upfront or adjuvant surgery were excluded. Cox-proportional hazards model was performed to assess factors associated with fistula. Local control and fistula-free survival were estimated using the Kaplan-Meyer method. Clinical significance was defined as p < 0.05.

RESULTS

A total of 105 patients met the inclusion criteria and were included in this analysis. Patients consisted of FIGO Stage I (n = 20, 19%), Stage II (n = 22, 21%), Stage III (n = 46, 43.8%) or Stage IV disease (n = 17, 16.2%). 12 (11.4%) patients developed fistula following CRT-B; 1/12 patients (8.3%) had fistula present at time of diagnosis. Median time to fistula development was 12 months. Fistula was characterized as vesicovaginal/urethrovaginal in 58.3% (n = 7) and rectovaginal/intestinovaginal in 83.3% (n = 10), including 8 patients (66.7%) who had more than one type of fistula. 4/12 (33.3%) of patients with fistula had concurrent local recurrence. Patients were treated with conservative management (41.7%), hyperbaric oxygen (16.7%) and/or surgery (83.3%). Complications included infection (50.0%), urinary/bowel diversion (83.3%), hospitalization (50.0%) and death (8.3%). Fistula was resolved in 7/12 patients (58.3%) at time of last follow up. Higher BMI (p = 0.04) and use of hybrid applicators (p = 0.02) were associated with decreased likelihood of fistula development. Disease extension into bladder was associated with increased likelihood of fistula development (p = 0.03). Compared to former and never smoking, current smoking was associated with a higher risk of developing fistula (p = 0.04, OR 4.42, CI:1.07-18.34). Compared to intracavitary and hybrid applicators, the use of a Syed applicator was associated with increased likelihood of fistula development (p = 0.02, OR 8.00, CI: 1.37-46.55). Two-year local control was 82.5% (CI: 64.5-91.9) for Stage I-II, 80.7% (CI: 62.8-90.6) for Stage III, and 62.2% (CI: 30.1-82.9) for Stage IV. Two-year fistula free survival was 89.9% (CI: 80.6 - 94.9).

CONCLUSION

Women who undergo definitive chemoradiation for treatment of LACC have a 11.4% risk of fistula formation overall. The risk is higher amongst patients with current smoking, disease extension into bladder and Syed applicators. Overall two-year local control was 78.7% and fistula free survival was 89.9%.

Single Institution Experience of the Effect of Adjuvant Radiation on Outcomes for Patients with Uterine Carcinosarcoma

PURPOSE/OBJECTIVE(S)

Uterine carcinosarcoma (UCS) is a rare but aggressive malignancy with poor outcomes. Due to its low incidence, there is no well-established optimal treatment. Standard treatment involves surgery and chemotherapy (CT) +/- adjuvant radiation therapy (RT). Our primary aim was to determine if patients who underwent adjuvant RT had improved distant metastasis free survival (DMFS) and locoregional recurrence free survival (LRRFS). Our secondary aim was to determine the effect of adjuvant RT on overall survival (OS).

MATERIALS/METHODS

We performed a single institutional retrospective review of all patients with UCS who underwent primary surgical resection +/- CT and +/- RT between 2007 to 2021. Patients without at least 3 months of documented follow-up were excluded. We assessed DMFS, LRRFS, and OS between patients who did and did not receive adjuvant RT, consisting of vaginal brachytherapy (VBT), external beam radiation therapy (EBRT), or EBRT + VBT. Statistical analysis was performed with spreadsheet and statistical software.

RESULTS

Sixty-four patients underwent primary surgical resection for FIGO stage I-IV UCS. Sixty six percent (n = 42) had early stage, FIGO I-II disease and 34% (n = 22) had late stage, FIGO III-IV disease. Eleven percent (n = 7) underwent surgery alone, 28% (n = 18) underwent surgery + CT, 6% (n = 4) underwent surgery + adjuvant RT, and 55% (n = 35) underwent surgery + CT + RT. Most patients who underwent surgery + CT + EBRT + VBT (n = 9) had worse clinicopathologic features including late stage (56%), lymphovascular invasion positive (78%) disease with 50% or greater myometrial invasion (56%). EBRT doses ranged from 45-50.4 Gray (Gy) in 1.8 Gy per fraction. VBT doses ranged from 21-25 Gy in 3-5 fractions when delivered alone and 10-15 Gy in 2-3 fractions when delivered as a boost. Median DMFS was 20.3 months, median LRRFS was 22.6 months, median DFS was 19.4 months, and median OS was 24.7 months. Rate of distant metastasis appeared to drive rate of disease-free survival (Table 1). Patients who underwent adjuvant RT had improved median DMFS (71.5 vs. 11.3 months, p = .002), median LRRFS (71.5 vs 22.5 months, p = .002), and median OS (60.7 vs. 22.5 months, p = .002) compared to those who did not receive RT.

CONCLUSION

Prognosis of patients with UCS remains poor; however, adjuvant RT delivered after CT may offer potential benefit in survival outcomes despite worse clinicopathologic features in these patients.

Whole recombinant yeast vaccine activates dendritic cells and elicits protective cell-mediated immunity

There is currently a need for vaccines that stimulate cell-mediated immunity-particularly that mediated by CD8+ cytotoxic T lymphocytes (CTLs)-against viral and tumor antigens. The optimal induction of cell-mediated immunity requires the presentation of antigens by specialized cells of the immune system called dendritic cells (DCs). DCs are unique in their ability to process exogenous antigens via the major histocompatibility complex (MHC) class I pathway as well as in their ability to activate naive, antigen-specific CD8+ and CD4+ T cells. Vaccine strategies that target or activate DCs in order to elicit potent CTL-mediated immunity are the subject of intense research. We report here that whole recombinant Saccharomyces cerevisiae yeast expressing tumor or HIV-1 antigens potently induced antigen-specific, CTL responses, including those mediating tumor protection, in vaccinated animals. Interactions between yeast and DCs led to DC maturation, IL-12 production and the efficient priming of MHC class I- and class II-restricted, antigen-specific T-cell responses. Yeast exerted a strong adjuvant effect, augmenting DC presentation of exogenous whole-protein antigen to MHC class I- and class II-restricted T cells. Recombinant yeast represent a novel vaccine strategy for the induction of broad-based cellular immune responses.

Psychometric analysis of the problem rating scale for outcomes

The current emphasis on outcomes management and outcomes research projects is stimulating interest in the psychometric properties of computerized clinical data bases among nurses and other health care providers. The knowledge, behavior, and status subscales of the Omaha System's Problem Rating Scale for Outcomes (PRSO) were evaluated for interrater reliability and content validity. The authors describe the methods used and the results of that research.

The Nightingale Tracker: information technology for community nursing education

The international health care delivery system is evolving to include an increased emphasis on community care and automated clinical information and communication systems. These trends are dramatically affecting nursing education in the U.S. as faculty consider the strategies needed to communicate with their students at multiple clinical sites, and to educate students to fulfill their changing practice roles. In response to these changes, FITNE, Inc. is using triangulated research methods to develop an information technology system for use in community nursing education. Named the Nightingale Tracker, this system will: (1) facilitate real time voice and data distance communication between students at the point of care and their instructors, and (2) electronically process clinical data related to community nursing education visits. The Nightingale Tracker was pilot tested in 1996; findings will be used to plan a national beta test. Project completion is scheduled for late 1997.

Characterization of charge change super-repressor mutants of trp repressor: effects on oligomerization conformation, ligation and stability

We have carried out a physical characterization of mutant repressor proteins of the trp repressor system of Escherichia coli by circular dichroism, chemical denaturation, and 8-anilino-1-naphthalenesulfonate binding. We have also probed the protein-protein interactions via fluorescence anisotropy and lifetime measurements and measured the thermodynamics of ligand (L-tryptophan) binding by isothermal titration calorimetry. Here, we present investigations of four charge change super-repressor mutants: EK13, EK18, DN46 and EK49, and compare these results with those previously obtained for wild-type trp repressor and the AV77 super-repressor mutant. These studies demonstrate that super-repressor phenotypes may result from changes in operator affinity (DN46, EK49), protein-protein interactions (EK18), as well as the coupling of folding to ligand binding (AV77, EK13, EK18). Correlations between the oligomerization behavior and cooperativity of DNA binding for some of these mutants indicate that coupling of oligomerization to DNA binding modulates operator site occupation giving rise to the super-repressor phenotype. The present results underscore the complex interplay between the multiple equilibria in this system. Moreover, they provide insights into the structural basis for the mutational perturbation of the energetics of this classical allosterically controlled transcriptional regulator.

The Omaha System: a model for describing practice

Diverse data and information are becoming increasingly important to clinicians, administrators, and educators as they work in rapidly changing settings. A number of classification systems or vocabularies have been developed that offer structure for client records and clinical information systems. Such structure is needed to generate reliable, valid, and useful data. The research-based Omaha System is one such classification system. It consists of nursing diagnoses/client problems, interventions, and client outcomes. The Omaha System is being used in many settings, including home care, nursing centers, colleges of nursing, and school health programs.

Symposium on Nursing Centers: Past, Present and Future

A call for articles related to nursing centers was generated (Tanner, 1994), based on the fact that many existing nursing centers operate out of schools of nursing. Proceedings of a symposium on nursing centers presented at the Midwest Nursing Research Society (MNRS) meeting in April 1994 are shared as a way of advancing the development, implementation, and evaluation of nursing centers. The four contributions represent a review of the historical, empirical, and anecdotal literature, key elements in creating and maintaining a research laboratory, data sets useful for practice and research, and policy issues germane to nursing centers, which are a cornerstone of health care reform.

Informatics issues for nursing's future

Automated clinical databases are crucial to the future of nursing but presently are not meeting the needs of clinicians, administrators, educators, or researchers. This article examines theoretical, empirical, and practical issues relating to the development of automated nursing clinical databases that will foster safe, effective practice and further nursing's knowledgebase. A series of key questions are identified relevant to each issue. These issues must be resolved if nurses are to take full advantage of the possibilities inherent in the evolving information technology.

Electrostatic forces contribute to interactions between trp repressor dimers

The trp repressor of Escherichia coli (TR), although generally considered to be dimeric, has been shown by fluorescence anisotropy of extrinsically labeled protein to undergo oligomerization in solution at protein concentrations in the micromolar range (Fernando, T., and C. A. Royer 1992. Biochemistry. 31:3429-3441). Providing evidence that oligomerization is an intrinsic property of TR, the present studies using chemical cross-linking, analytical ultracentrifugation, and molecular sieve chromatography demonstrate that unmodified TR dimers form higher order aggregates. Tetramers and higher order species were observed in chemical cross-linking experiments at concentrations between 1 and 40 microM. Results from analytical ultracentrifugation and gel filtration chromatography were consistent with average molecular weight values between tetramer and dimer, although no plateaus in the association were evident over the concentration ranges studied, indicating that higher order species are populated. Analytical ultracentrifugation data in presence of corepressor imply that corepressor binding destabilizes the higher order aggregates, an observation that is consistent with the earlier fluorescence work. Through the investigation of the salt and pH dependence of oligomerization, the present studies have revealed an electrostatic component to the interactions between TR dimers.

Home health clients: characteristics, outcomes of care, and nursing interventions

OBJECTIVES

The purpose of the study was to provide descriptive data about the characteristics of home health clients, the services that nurses provide, and the outcomes of those services. Such data have been sparse.

METHODS

This study examined 2403 home health clients served by four agencies in Nebraska, New Jersey, and Wisconsin. Demographic, health history, and clinical data were analyzed. The Omaha System was used as the model for describing and measuring data specific to clients' health-related problems, nursing interventions, and outcomes of care.

RESULTS

The median age of home health clients was 68.6 years. Nurses conducted 70% of all home visits, identified 9107 client problems, and provided over 96,000 interventions. Between admission and dismissal, clients improved by at least 0.52 point on three 5-point problem-specific outcome subscales (Knowledge, Behavior, and Status).

CONCLUSIONS

These data show important characteristics of home health clients in a large national sample. They also support the usefulness of the Omaha System in describing and quantifying nursing practice in the community health setting. The magnitude of positive client change between admission and dismissal suggests that community health services do make a difference.

Indoor woodsmoke pollution causing lower respiratory disease in children

Suggested aetiological factors were evaluated in 244 consecutive children presenting with lower respiratory disease at Marondera Hospital, Zimbabwe. Data obtained from these children were compared with information obtained from 500 children seen at the local well baby clinic. There were no differences in the prevalence of malnutrition, breast feeding, overcrowding, poor housing conditions and poverty in these two groups of children. A significant association was identified between lower respiratory disease and exposure to atmospheric woodsmoke pollution in young children. Air sampling within the kitchens of 40 children revealed levels of atmospheric pollution far in excess of the WHO recommended exposure limit. Elevated carboxyhaemoglobin concentrations confirmed childhood smoke inhalation. We suggest that in many Third World communities a chemical pneumonitis resulting from the inhalation of noxious constituents of woodsmoke predisposes to lower respiratory disease in children.

Application of the nursing process to a continuing education course

The nursing process is a fundamental component of curricula in schools of nursing. The nursing process also is adaptable to continuing education offerings provided by a nursing education and research department of an urban, community teaching hospital. This article describes how nurse educators used the nursing process as the basis for development, implementation, and evaluation of an advanced medical-surgical continuing education program.