Medical and Paediatric Oncology

Oncoradiology preparedness in the COVID-19 pandemic: Perspective from a tertiary oncology referral center from Eastern India Argha Chatterjee, Bivas K Biswas, Anisha Gehani, Jayanta Das, Saugata Sen, Sumit Mukhopadhyay, Aditi Chandra, Priya Ghosh, Bharat Gupta, Dayanand Lingegowda Indian Journal of Medical and Paediatric Oncology 2020 41(6):789-798 At the time of writing this article, more than 18 million people worldwide have been infected by the severe acute respiratory syndrome-associated coronavirus-2 and about 700,000 people have died from coronavirus disease 2019 (COVID-19). In India, about 190,000 people have been infected and nearly 39,000 people have succumbed to this infection. Infection among health-care workers has emerged as one of the key problems in facing this pandemic. The purpose of this article is to describe the measures taken by the department of oncoradiology at our institution to control the infection and minimize staff exposure during the current lockdown period with reduced patient load and in the post-lockdown period with increased demand for radiology services. The key focus of this article is the continued delivery of cancer imaging services with practical precautions and optimized resources. We have also discussed algorithms and protocols unique to the practice of oncoradiology in the time of the COVID-19 pandemic.

Clinical research in hematology-oncology in India during the COVID-19 era Nishant Jindal, Pankaj Malhotra, Amol N Patil, Deepesh P Lad Indian Journal of Medical and Paediatric Oncology 2020 41(6):799-800

Immunotherapy in rare cancers Venkata Pradeep Babu Koyyala, Padmaj Kulkarni Indian Journal of Medical and Paediatric Oncology 2020 41(6):801-803

Multidisciplinary joint clinics: Talent wins games, but teamwork wins championships Rima Sanjay Pathak, TS Shylasree, Jyoti Bajpai Indian Journal of Medical and Paediatric Oncology 2020 41(6):804-808 Cancer is among the leading causes of deaths worldwide. The treatments of cancer across most sites involve using surgery, systemic therapy, and radiation therapy. The treatment protocols are complex and require careful planning at the beginning of the therapy and coordination between the treating teams, the patient, and the caregivers to ensure compliance and avoid unnecessary treatment delays. This commentary provides an insight into the role the multidisciplinary joint clinics play in providing personalized cancer care. While such joint clinics are advantageous, they are not devoid of drawbacks and these are also enumerated. In this era, when communication platforms are increasingly digitized, we have highlighted the need for virtual tumor boards. The commentary aims to motivate the development of multidisciplinary joint clinics for ensuring holistic cancer care across the country.

Gastrointestinal stromal tumor – An overview Anant Ramaswamy, Vikram Chaudhari, Prabhat Bhargava, Manish Bhandare, Rajiv Kumar, Shailesh V Shrikhande, Vikas Ostwal Indian Journal of Medical and Paediatric Oncology 2020 41(6):809-818 Gastrointestinal stromal tumors (GISTs) are rare tumors but are most common mesenchymal tumors of the digestive tract. They are commonly seen in the stomach (60%) and small intestine (30%). GISTs are likely derived from the interstitial cells of Cajal or their stem cell precursors. They are best characterized by computerized tomography and have a specific staining pattern on immunohistochemistry, i.e., C-Kit and DOG-1. The treatment of GIST is based on the risk assessment for relapse, and patients with localized GIST require resection with or without adjuvant imatinib mesylate (IM). Advanced unresectable tumors are usually treated with IM, with a number of further options available for patients post progression on IM. There is an increasing emphasis on identifying C-Kit and platelet-derived growth factor receptor alpha mutations in all patients with GIST, as these are driver mutations with current and future therapeutic implications.

Efficacy of antiemetic regimens for prevention and treatment of chemotherapy-induced nausea and vomiting in patients of breast cancer receiving highly emetogenic chemotherapy Soumya Vij, Dilip Chander Dhasmana, Suman Bala, Sanjiv Kumar Verma Indian Journal of Medical and Paediatric Oncology 2020 41(6):819-824 Background: Chemotherapy is fraught with serious and troublesome adverse effects, of which nausea and vomiting appears earliest and is the most disturbing. Therefore, this study was planned to investigate the antiemetic drug regimens used for chemotherapy-induced nausea vomiting (CINV) in patients with breast cancer receiving highly emetogenic chemotherapy (HEC). Subjects and Methods: An observational follow-up study was conducted to assess the efficacy of antiemetic regimens in breast cancer patients receiving HEC. A total of 71 newly diagnosed patients with breast cancer were included in the study. Patients were assessed for nausea by the visual analog scale, and a history of emetic episodes and need for rescue medication were recorded at 0 h, 6 h, 24 h, 48 h, and 120 h post-chemotherapy till three cycles. Results: The patients were prescribed a combination of ondansetron and dexamethasone (n = 23, n = 17, and n = 13 in first, second, and third cycle, respectively) or a combination of aprepitant, ondansetron, and dexamethasone (n = 48, n = 54 and n = 56 in the first, second, and third cycle, respectively). The intensity of nausea was higher for the patients who were prescribed ondansetron and dexamethasone regimen as compared to patients prescribed aprepitant additionally. Complete response, i.e., no emesis and no rescue medication, was higher in triple-drug regimen (52% vs. 0.4%, 63% vs. 17.6%, and 69% vs. 23% in three cycles, respectively). Conclusion: The control of CINV was better with a combination of aprepitant, ondansetron, and dexamethasone as compared to a regimen without aprepitant.

Patient-reported shoulder morbidity and fatigue among breast cancer survivors: An insight from a tertiary care cancer hospital Abhishek Basu, Janmenjoy Mondal, Bhukya Swetha, Shinjini Chakrabarty, Debjit Ghosh, Subhendu Gangopadhyay, Bidyut Mandal Indian Journal of Medical and Paediatric Oncology 2020 41(6):825-831 Context: Breast cancer is the most common cancer in Indian women with an annual mortality of around 87,000. Treatment for breast carcinoma may lead to swelling of the ipsilateral arm, shoulder stiffness, arm pain, and cancer-related fatigue. Very few centers in India have reported the arm and shoulder morbidity treated in their hospitals. Aims: The aim was to evaluate the predictive factors of arm and shoulder morbidity and fatigue among breast cancer survivors. Settings and Design: This was a retrospective analysis based on a prospectively maintained database. Materials and Methods: Early and locally advanced cases of breast cancer patients were screened for the study during 2015–2018. Eligible participants were invited to fill up the predetermined questionnaire, and their demographic and treatment-related information was accrued from a file archive. Follow-up period was estimated from the date of tissue diagnosis to last contact/time of interview. Results: Shoulder stiffness was the most common complaint followed by arm numbness. Obesity and diabetes played a crucial role in most of the morbidities and fatigue. The median fatigue score was 34, and the median time of appearance of lymphedema was 13 months. Modified radical mastectomy and radiotherapy to axilla were statistically significantly (P = 0.04 and 0.01, respectively) associated with greater shoulder stiffness and arm swelling. Conclusions: Obesity, diabetes, type of surgery, the extent of axillary dissection, and radiation plan are the major predictive factors of arm and shoulder morbidity. Further prospective validation is necessary for future breast cancer survivorship programs.

Does neoadjuvant chemotherapy increase the survival in patients with locally advanced gastric cancer patients? – A real-world evidence Murugesan Janarthinakani, Selvaraj Kalaiselvi, Rajamani Priyadarshini, Seshachalam Arun, K Shashidhar, R Krishnakumar, N Manjunath, Sirigeri Roopa, SG Raman Indian Journal of Medical and Paediatric Oncology 2020 41(6):832-840 Background: In locally advanced gastric cancer (LAGC), perioperative chemotherapy has shown to improve the survival to a larger extent compared to surgery alone. In India, the treatment followed for gastric carcinoma widely varies based on the type of health-care provider and treatment access. There is a paucity of data on the role of neoadjuvant chemotherapy on survival among LAGC patients in the Indian context. Aim: The aim of this study was to compare the disease-free survival (DFS) and overall survival (OS) between neoadjuvant and adjuvant chemotherapies among LAGC patients. Subjects and Methods: This was a retrospective cohort study involving clinical record review of LAGC patients enrolled between 2015 and 2017 from four tertiary cancer centers in South India. The date for the following events, namely diagnosis, recurrence, death, and last day of visit, was extracted in a mobile-based open-access tool. The median duration of OS and DFS between the neoadjuvant and adjuvant groups was compared using Kaplan–Meier survival curves. Results: Of the 137 patients, 70 (51%) had received neoadjuvant chemotherapy followed by surgery and 67 (49%) had adjuvant chemotherapy following the surgery. The mean (standard deviation) age of participants was 55.4 (11.4) years. Seventy-eight percent of the patients were diagnosed at Stage 3 or 4. Regional lymph nodes were involved in 83.9%. The median duration of follow-up was 15 months. The OS in the neoadjuvant and adjuvant groups was 18.6 months and 8.3 months, respectively. Nonregional lymph node involvement and adjacent organ involvement had independently increased the risk of death. Conclusion: Among LAGC patients, the neoadjuvant chemotherapy indicated a better median and DFS compared to the adjuvant group. However, these findings were statistically not significant. The current study has contributed an important finding to the existing evidences of clinical practice in an Indian setting. Further large-scale studies are required to validate the promising trend of using neoadjuvant chemotherapy in LAGC.

Treating acute myeloid leukemia among children with down syndrome Rajan Kapoor, Karthik Ram Mohan, Shuvendu Roy, Suman Kumar Pramanik, Sanjeev Khera, AK Simalti Indian Journal of Medical and Paediatric Oncology 2020 41(6):841-845 Background: Down Syndrome (DS) children with acute myeloid leukemia (AML) have unique differences in clinical features, epidemiologic nature, and biologic patterns of disease compared with AML in children without DS. Aims and Objective: AML in DS children should be considered distinct disorder from AML in Non DS population and treatment needs to be customized for this population. In this retrospective study spanning from 2014 to 2019 we present our experience of managing leukemia in children with DS. Materials and Methods: From 2014 and 2019, 72 children aged below 18 years were managed at our institute with acute myeloid leukemia (AML). Out of these 72 children with AML, 7 children were with DS which was confirmed by karyotyping. Majority of these children had M7 while M2 and M4 subtypes were seen in one child each. On conventional karyotyping in addition to trisomy 21 additional cytogenetic abnormalities were seen in 4 patients. Two children had trisomy 8. One child had deletion of 11 chromosomes and one had translocation between 8 and 21 chromosomes. Results: All 7 children were administered intensive chemotherapy with curative intent after informed parental consent. All 7 children achieved complete remission. Four out of 7 children had complications related to severe neutropenia. Conclusion: All patients of DS with AML should be offered chemotherapy with curative intent. Endeavour should be to give less aggressive chemotherapy protocol to bring down treatment related mortality.

Daratumumab plus carfilzomib: An optimistic approach in relapsed/refractory multiple myeloma AP Dubey, Sameer Khatri, Sachin Maggo, Nilabh K Singh, Durgesh Sharma Indian Journal of Medical and Paediatric Oncology 2020 41(6):846-849 Background: Although with the introduction of novel agents, clinical outcomes have significantly improved in patients of multiple myeloma (MM); however, nearly all relapse, requiring subsequent treatment. Patients who have been heavily treated for relapsed/refractory MM (RRMM) have limited options and poor survival outcomes. Carfilzomib plus daratumumab combination have been evaluated in a phase 1b study in patients of RRMM progressing after 1–3 lines of therapies including bortezomib and an immune-modulatory drug. However, data are lacking evaluating the efficacy of this combination in RRMM patients who have progressed or have suboptimal response on either of these drugs (carfilzomib or daratumumab). Methods: Prospective analysis of data of 19 RRMM patients who progressed after multiple lines of therapy (including bortezomib and lenalidomide/pomalidomide) and had suboptimal response/stable/progressive disease after receiving carfilzomib or daratumumab based combination as last therapy. All patients received combination of carfilzomib plus daratumumab along with dexamethasone (DKd) after prior consent. Daratumumab (16 mg/kg IV) was administered weekly (days 1, 8, 15, and 22) during cycles 1 and 2, every 2 weeks (days 1 and 15) during cycles 3–6, and every 4 weeks thereafter. Carfilzomib was administered weekly on days 1, 8, and 15 of each 28-day cycle. Patients received an initial carfilzomib dose of 20 mg/m2 on day 1,2; 27 mg/m2 on day 8, 9, 15, 16 of cycle 1, which increased to 70 mg/m2 on day 1, 8, 15 from cycle 2 onwards if deemed tolerable. Dexamethasone was given as fixed-dose of 40 mg weekly. Results: Eighteen of 19 patients (including 3 high risk cytogenetics) to DKd (CR-4, very good partial response-10, partial response-02). After median follow-up of 16 months, progression-free survival (PFS) was 95%. Median PFS was not reached. Three patients who were transplant eligible received high-dose chemotherapy followed by autologous stem-cell transplantation and achieved minimal residual disease negativity. The most frequent all grade side effects were hematological, which included neutropenia 30%, anemia 70%, and thrombocytopenia 42%. Most frequent non hematological side effects were nausea 40%, vomiting, cough, respiratory tract infections, asthenia, and loss of appetite. Conclusion: Carfilzomib plus daratumumab based combination in RRMM patients has shown promising results in phase Ib study, where patients with prior exposure to either of these drugs were excluded. Our data show similar or better response of this combination in patients who had progressive disease/stable disease/minimal response to either of carfilzomib or daratumumab. This combination can be a better option in heavily treated RRMM (with prior exposure to either of carfilzomib or daratumumab) producing deeper and durable responses. A larger study may be required to prove this benefit.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Bone and Joint Surgery

Comparison of Surgical Site Infection Risk Between Warfarin, LMWH, and Aspirin for Venous Thromboprophylaxis in TKA or THA: A Systematic Review and Meta-Analysis Background: Infection following arthroplasty can have devastating effects for the patient and necessitate further surgery. Venous thromboembolism (VTE) prophylaxis is required to minimize the risk of deep venous thrombosis and pulmonary embolism. Anticoagulation has been demonstrated to interfere with wound-healing and increase the risk of infection. We hypothesized that different anticoagulation regimes will have differing effects on rates of periprosthetic joint infection. The aim of this study was to compare the surgical site infection risk between the use of warfarin, low-molecular-weight heparin (LMWH), and aspirin for VTE prophylaxis following total knee or hip arthroplasty. Methods: A systematic literature search was conducted in November 2018 using the PubMed, CINAHL, and Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify studies that compared warfarin, LMWH, and/or aspirin with regard to surgical site infection rates following hip or knee arthroplasty. Meta-analyses were performed to compare the infection and VTE risks between groups. Results: Nine articles involving 184,037 patients met the inclusion criteria. Meta-analysis showed that warfarin prophylaxis was associated with a higher risk of deep infection (or infection requiring reoperation) (odds ratio [OR] = 1.929, 95% confidence interval [CI] = 1.197 to 3.109, p = 0.007) and surgical site infection overall (OR = 1.610, 95% CI = 1.028 to 2.522, p = 0.038) compared with aspirin in primary total joint arthroplasty, with similar findings also seen when primary and revision procedures were combined. There was no significant difference in infection risk between warfarin and LMWH and between LMWH and aspirin. There was a nonsignificant trend for VTE risk to be higher with warfarin compared with aspirin therapy for primary procedures (OR = 1.600, 95% CI = 0.875 to 2.926, p = 0.127), and this was significant when both primary and revision cases were included (OR = 2.674, 95% CI = 1.143 to 6.255, p = 0.023). Conclusions: These findings caution against the use of warfarin for VTE prophylaxis for hip and knee arthroplasty. Further randomized head-to-head trials and mechanistic studies are warranted to determine how specific anticoagulants impact infection risk. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Complications and Controversies in the Management of 5 Common Pediatric Sports Injuries »Growing participation in sports among children, along with increasingly intense training regimens, has contributed to an increasing rate of sports-related injuries.»Despite the similarities to adult sports injuries, pediatric patients have distinctive injury patterns because of the growing physis and therefore necessitate unique treatment algorithms.»Caring for these injured children requires in-depth knowledge of not only pediatric injury patterns, but also the scope of age-specific treatments, the associated complications, and the controversies.»When treating motivated pediatric athletes, one must be able to strike a delicate balance between patients' eagerness to return to sport and the need to ensure their long-term health and function.»Knowledge of controversies and complications will help both patients and physicians make informed decisions about how best to restore pediatric athletes back to health.

Return-to-Driving Recommendations After Lower-Extremity Orthopaedic Procedures »Following lower-extremity orthopaedic surgery, recommendations for safe return to driving include at least 6 to 12 weeks for a right ankle fracture, 2 days to 2 weeks for a right ankle arthroscopy, 6 to 9 weeks for a total ankle arthroplasty, 6 to 7 weeks for a right Achilles tendon rupture repair, 1 to 4 weeks for a right total knee arthroplasty, 2 weeks for a left total knee arthroplasty, 3 to 6 weeks for a right anterior cruciate ligament repair, and 1 to 4 weeks for a total hip arthroplasty.»Important individual factors such as extent of injury, laterality of injury, current driving habits, type of vehicle transmission (manual or automatic), and medical comorbidities must be taken into consideration.»State laws vary widely and often use vague language to describe the legal responsibilities that orthopaedic surgeons have when providing return-to-driving recommendations.

Treatment Algorithm for Surgical Site Infections Following Extensor Mechanism Repair »Despite general agreement regarding techniques for extensor mechanism repair, there is very limited guidance in the literature for the management of surgical site infections (SSIs) that may occur after these procedures.»Early or mild superficial SSIs, such as cellulitis, can be managed on an outpatient basis while monitoring for improvement, with escalated intervention if the symptoms do not resolve within 1 week.»Deep SSIs should be managed more aggressively with surgical irrigation and debridement (I&D), including the knee joint, depending on the results of the aspiration, removal of all braided nonabsorbable suture (if necessary) with immediate or delayed exchange with monofilament suture, and the administration of parenteral antibiotics based on culture results and an infectious disease consult.»Arthrocentesis should be performed early to monitor for the spread of infection to the joint space, and diagnosis of a septic knee joint should be immediately followed by arthroscopic or open I&D.»For refractory cases (i.e., wound coverage issues or persistent infections despite multiple attempts at debridement), a consult with a plastic surgeon for consideration of a gastrocnemius flap is recommended, and surgeons should remain suspicious of the possibility of the contiguous spread of osteomyelitis.

Optimizing Return to Play for Common and Controversial Foot and Ankle Sports Injuries »Surgical decision-making should consider factors to help optimize return to play for athletes with foot and ankle injuries, including injuries to the syndesmosis, the Achilles tendon, the fifth metatarsal, and the Lisfranc complex. Understanding influential factors on return to play may help orthopaedic surgeons counsel athletes and coaches on expectations for a timeline to return to play and performance metrics.»Outcomes after rigid and flexible fixation for syndesmotic injuries are generally favorable. Some data support an earlier return to sport and higher functional scores with flexible fixation, in addition to lower rates of reoperation and a decreased incidence of malreduction, particularly with deltoid repair, if indicated.»Minimally invasive techniques for Achilles tendon repair have been shown to have a decreased risk of wound complications. Athletes undergoing Achilles repair should expect to miss a full season of play to recover.»Athletes with fifth metatarsal fractures have better return-to-play outcomes with surgical management and can expect a high return-to-play rate within approximately 3 months of surgery.»Percutaneous treatment of Lisfranc injuries may expedite return to play relative to open procedures.

Erratum: The Use of Dual Mobility Implants in Patients Who Are at High Risk for Dislocation After Primary Total Hip Arthroplasty No abstract available

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Orthopaedic

Not All Robotic-assisted Total Knee Arthroplasty Are the Same Because value in healthcare has shifted to a measurement of quality relative to the cost, a greater emphasis exists on improving clinical and functional outcomes and patient satisfaction. Despite advances in implant design, surgical technique, and postoperative rehabilitation, multiple studies demonstrate that nearly 20% of patients remain dissatisfied with their overall outcomes after primary total knee arthroplasty (TKA). Because implant positioning, alignment, and equal soft-tissue balance are critical for a successful TKA, malalignment in the coronal, sagittal, and rotational planes continue to increase failure rates and cause poor clinical outcomes. Robotic-assisted TKA has gained momentum within the past 10 years to better control surgical variables by mitigating technical errors caused by insecure cutting guides and imprecise bone cuts. Contemporary robotic platforms have evolved along with our ability to collect high-quality patient-reported outcome measures data, and this combination is proving the clinical effectiveness. This comprehensive review investigates the advent of robotic-assisted TKA including advantages, disadvantages, historical, and commercially available newer generation systems, clinical outcomes, and cost analysis to better understand the potential added value of this technology.

Management of Partial Tears of the Anterior Cruciate Ligament: A Review of the Anatomy, Diagnosis, and Treatment Partial anterior cruciate ligament (ACL) tears comprise an estimated 10% to 27% of isolated ACL injuries. Partial ACL tears may be challenging to clinically diagnose. We reviewed relevant studies focusing on the anatomy, diagnosis, imaging, and treatment of a partial injury with the goal of providing guidance to clinicians. Although a comprehensive patient history, thorough clinical examination, and imaging studies are helpful in arriving at a diagnosis, the benchmark for diagnosis remains visualization and examination of the ACL at the time of knee arthroscopy. Currently, limited data exist about the long-term outcomes of nonsurgical treatment. Some studies demonstrate that younger, active patients have the risk of progressing to a complete ACL rupture with conservative treatment. The decision to proceed with surgery is based on careful history and physical examination findings that suggest either a "functional" or "nonfunctional" ACL. Surgical treatment consists of augmenting the intact bundle with a selective bundle reconstruction versus a traditional ACL reconstruction. Selective bundle reconstruction has limited data available but is an option. The best evidence supports traditional ACL reconstruction for the surgical management of patients with documented nonfunctional partial tears of the ACL.

Diagnosis and Management of Traumatic Anterior Shoulder Instability Anterior shoulder instability is the most common form of shoulder instability and is usually because of a traumatic injury. Careful patient selection is key to a favorable outcome. Primary shoulder stabilization should be considered for patients with high risk of recurrence or for elite athletes. Soft-tissue injury to the labrum, capsule, glenohumeral ligament, and rotator cuff influence the outcome. Glenoid bone loss (GBL) and type of bone loss (on-track/off-track) are important factors when recommending treatment strategy. Identification and management of concomitant injuries are paramount. The physician should consider three-dimensional CT reconstructions and magnetic resonance arthrography when concomitant injury is suspected. Good results can be expected after Bankart repair in on-track Hill-Sachs lesions (HSLs) with GBL < 13.5%. Bankart repair without adjunct procedures is not recommended in off-track HSLs, regardless of the size of GBL. If GBL is 13.5% to 25% but on-track, adjunct procedures to Bankart repair should be considered (remplissage and inferior capsular shift). Bone block transfer is recommended when GBL > 20% to 25% or when the HSL is off-track. Fresh tibia allograft or lilac crest autograft are good treatment options after failed bone block procedure.

Staying Out of Trouble With Intramedullary Nailing of Distal Tibia Fractures As the biologically friendly and biomechanically sound technique of intramedullary fixation has been increasingly applied to distal tibia diaphyseal fractures, challenges with the technique have emerged. Malalignment, most often valgus and recurvatum, is more common than with mid-diaphyseal patterns, given the lack of endosteal fit, and this can be challenging to prevent. Key technical steps can ensure success. These include recognition and initial fixation of intra-articular fracture planes, the use of percutaneous clamps, a slightly lateral terminal nail position, and the use of blocking wires or screws to prevent malalignment after nail passage. With thorough preoperative planning and early recognition of troublesome patterns, a variety of techniques can be applied to obtain and maintain a stable reduction throughout the procedure.

Restarting Orthopaedic Care in a Pandemic: Ethical Framework and Case Examples The question about how to resume typical orthopaedic care during a pandemic, such as coronavirus disease 2019, should be framed not only as a logistic or safety question but also as an ethical question. The current published guidelines from surgical societies do not explicitly address ethical dilemmas, such as why public health ethics requires a cessation of nonemergency surgery or how to fairly allocate limited resources for delayed surgical care. We propose ethical guidance for the resumption of care on the basis of public health ethics with a focus on clinical equipoise, triage tiers, and flexibility. We then provide orthopaedic surgery examples to guide physicians in the ethical resumption of care.

Diabetes Status Affects Odds of Body Mass Index–dependent Adverse Outcomes After Total Hip Arthroplasty Introduction: Obesity and diabetes have independently been shown to predispose to adverse outcomes after total hip arthroplasty (THA). These may have a coupled effect on perioperative risks. The purpose of this study was to evaluate the effect of body mass index (BMI) on adverse outcomes in nondiabetic (ND), non–insulin-dependent diabetes mellitus (NIDDM), and insulin-dependent diabetes mellitus (IDDM) patients. Methods: Patients undergoing primary THA were selected from the National Surgical Quality Improvement Program Database from 2012 to 2016 and categorized as ND, NIDDM, and IDDM. BMI, demographics, and 30-day perioperative outcomes were assessed for each group. Multivariate logistic regressions controlling for demographics, functional status, and American Society of Anesthesiologists were used to determine the odds ratio of serious adverse event (SAE) in each diabetes group for patients with BMI ≥ 40 kg/m2 compared with a control group of ND patients with a normal BMI (18.5 to 24.9 kg/m2). Results: A total of 108,177 patients were included. The results demonstrate that ND (odds ratio 1.65; P < 0.001) and NIDDM (odds ratio 1.75; P = 0.007) patients have similar risks of SAE, whereas IDDM (odds ratio 2.79; P < 0.001) patients have a greater risk of adverse events, particularly at BMIs greater than 40 kg/m2. Discussion: Consistent with previous reports, ND (odds ratio 1.65; P < 0.001) and NIDDM (odds ratio 1.75; P = 0.007) morbidly obese patients (BMI > 40 kg/m2) had an increased odds of SAEs after THA, but for IDDM (odds ratio 2.79; P < 0.001) patients this increased odds was notably higher. Although patients with IDDM have increased rates of adverse events compared with ND and NIDDM patients, these findings should not be used to establish strict BMI cutoffs in patients with IDDM. Nonetheless, the results suggest additional factors, such as patient medical history and diabetes control, should be considered when evaluating patients with IDDM for THA. Level of Significance: Level III

Reasons for Revision: Primary Total Hip Arthroplasty Mechanisms of Failure Background: This study aimed to examine the major reasons for total hip arthroplasty (THA) failure and temporal patterns in THA revisions. Methods: A retrospective chart review was conducted on 535 revisions performed on 444 THAs from January 2010 to May 2019 at our institution. Results: The average time to revision THA was 8.51 ± 8.38 years, with 136 cases (30.9%) occurring within 2 years after primary THA. The major mechanisms of failure that resulted in revision surgery were mechanical failure (162, 36.5%), metallosis (95, 21.4%), dislocation or instability (65, 14.6%), periprosthetic fracture (46, 10.4%), infection (44, 9.9%), hematoma or poor wound healing (15, 3.4%), and pain or other (17, 3.8%). Conclusion: Based on our institutional experience over the past decade, mechanical failure without dislocation, metallosis, dislocation, periprosthetic fracture, and infection are typical reasons patients present for primary THA revision. Revisions within 2 years after primary THA are more likely to be the result of infection and periprosthetic fracture. Mechanical failure is the most common reason for revision THA overall, and mechanical failure and metallosis are more likely to be the reason revision is necessary 2 or more years after primary THA.

Implications of Admission and Surgical Timing on Hospital Length of Stay in Patients with Hip Fractures Introduction: Hospital reimbursements for geriatric hip fractures are contingent on patient outcomes and hospital length of stay (LOS). This study examined if the day of the week (DOTW) and time of day (TOD) of both admission and surgery are associated with increased LOS. Methods: LOS, time from admission to surgery, DOTW of admission/surgery, TOD of admission/surgery, and demographics were retrospectively collected. The average LOS was 4.5 days. Patients were grouped into cohorts of LOS 1 to 4 days (short-stay) and 5 to 12 days (long-stay). The percentage of short-stay patients was compared with the percentage of long-stay patients for each DOTW/TOD of admission/surgery with chi square tests. Results: One hundred patients were included, 58 short stays and 42 long stays. Both groups were similar regarding demographics. Long-stay patients were 4.2 times more likely to have been admitted ([95% confidence interval 1.2 to 14.6], P = 0.02) and 4.8 times as likely to have undergone surgery ([95% confidence interval 1.0 to 5.6], P = 0.01) on a Thursday, respectively. TOD of admission/surgery did not demonstrate any association with LOS. Discussion: Thursday admission/surgery was associated with longer LOS. Delayed surgical optimization coupled with insurance companies' observance of regular business hours may delay admission to inpatient rehab or skilled nursing facilities, resulting in avoidable healthcare expenditures.

Demographics and Clinical Presentation of Early-Stage Legg-Calvé-Perthes Disease: A Prospective, Multicenter, International Study Background: Children with Legg-Calvé-Perthes disease (LCPD) are classically described as small, thin, high-energy children presenting with a painless limp. Epidemiologic studies have historically been retrospective and regional in nature. The purpose of this study was to determine the demographic and clinical features of children presenting in the early stages of LCPD in an international, multicenter cohort. Methods: Children (6 to 10 years) in the early stages of LCPD (modified Waldenström stage I to IIa) were enrolled in a prospective, multicenter study. Demographic and clinical data at presentation were analyzed. Body mass index percentiles were determined using country-specific growth charts for children in the United States and India, two countries with largest enrollment. Statistical analyses included t-tests and chi-square. Results: A total of 209 children (86% males; mean age 7.9 ± 1.2 years) from 25 centers (six countries) were included. Eight-four percent of children presented with pain with or without a limp. Average pain score at presentation was 3 ± 2 (range 0 to 9), and 63% of children (n = 105) used pain medications. Of these children 65% required medication more than once per week. Thirty percent of children missed school due to pain in the past month, and of those, 74% missed at least 1 day per week. Twenty-nine percent of children from the United States and 20% of children from India were overweight or obese. Nineteen percent reported household smoking. Discussion: This prospective study provides a new international multicenter representation of early LCPD. The frequency of pain and missed school highlights the substantial morbidity and potential social cost and burden for children and families. The prevalence of being overweight/obese in our LCPD cohort was comparable to rates within the pediatric cohort as a whole, and fewer children have a history of smoke exposure than in previous reports. Level of Evidence: Level II, prospective comparative study

Incidence of Pseudotumors in a Dual Modular Stem Construct With and Without Metal-on-Metal Bearing Surface Background: The purpose of this study was to compare the incidence of pseudotumors in metal-on-metal (MoM) titanium modular neck hip arthroplasties to non-MoM modular neck hip arthroplasties. A secondary goal was to determine whether a correlation exists between elevated metal concentrations and pseudotumor incidence. Methods: The data were collected and evaluated from 49 MoM joints and 26 non-MoM joints between the years 2012 and 2017. Hip ultrasonography was done after a minimum of 5 years postimplantation. Whole serum metal (titanium, cobalt, and chromium) concentrations were measured at the hip ultrasonography study. Results: The average time elapsed between surgery and ultrasonography visit was 7.6 years. In the 49 patients with MoM joints, 22.4% (n = 11) had a pseudotumor. In the 26 patients with non-MoM joints, 9.1% of metal-on-polyethylene hips (n = 1) and 0% of ceramic-on-ceramic/polyethylene hips developed a pseudotumor. No significant statistical correlation was observed between serum metal concentrations and pseudotumor formation (P > 0.05). A significant correlation was observed of serum titanium concentration to pseudotumor size (P = 0.024). Conclusion: The incidence of pseudotumor formation in MoM total hip arthroplasties was more than five times the incidence associated with non-MoM bearings. The correlation between serum titanium concentration and pseudotumor size suggests that titanium levels may be a useful indicator for pseudotumor formation in patients with this particular titanium modular neck femoral implant. No notable correlation was observed between serum cobalt and chromium concentration and pseudotumor formation or size.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Translational Critical Care Medicine

Cerebral Venous Thrombosis in Air Travelers during COVID-19 Times: Is the Risk Higher? Luis Rafael Moscote-Salazar, Tariq Janjua, Pilar Bosque-Varela, Amit Agrawal Journal of Translational Critical Care Medicine 2020 2(3):47-48

Research Progress on Sepsis-Related Liver Injury Kai Kang, Na-Na Li, Yang Gao, Xue Du, Xin-Yu Zhang, Ming-Yan Zhao, Kai-Jiang Yu Journal of Translational Critical Care Medicine 2020 2(3):49-53 Liver injury is one of the most common critical clinical illnesses and is one of the manifestations of multiple organ dysfunction induced by sepsis. The liver plays a central role in the development of sepsis. The role of the liver in removing bacteria and regulating immune inflammation is crucial, and the liver is the target of sepsis-related injuries. However, the mechanism of liver injury in sepsis is still not clear. This review discusses the pathophysiology, clinical manifestations, and treatment of sepsis-related liver injury. Liver injury, pathophysiological mechanism, sepsis, sepsis-related liver injury

Endoplasmic Reticulum Stress and Critical Care Medicine Ying Shi, Tingting Wang, Xiangrong Zuo Journal of Translational Critical Care Medicine 2020 2(3):54-63 Many patients suffer from multiple organ dysfunction syndrome (MODS), which represents a dominant cause of death in the intensive care unit. Current theories about the mechanisms of MODS include inflammation, dysregulated immune response, reduced cellular oxygen utilization, cytopathic hypoxia, and apoptosis. Moreover, an increasing number of studies have shown that endoplasmic reticulum stress (ERS) is related to organ dysfunction. The endoplasmic reticulum is an organelle that is responsible for secretion and membrane protein synthesis and assembly as well as some other physiological activities. Under certain conditions, the homeostasis of ER can be lost, causing the accumulation of unfolded or misfolded protein, which is termed as ERS. During ERS, unfolded protein response (UPR) is activated. Once UPR fails to rebuilt cellular homeostasis, cell function will be impaired and apoptosis will be induced. To better understand the relationship between ERS and severe diseases, we summarize the current research in the context of ERS and UPR signaling associated with various organ dysfunction and severe diseases, including acute lung injury, hepatic injury, heart failure, hemorrhagic shock with multiple organ dysfunction, sepsis, and some other diseases. We also discuss ERS or UPR as a novel therapeutic target and their future directions.

D Vitamin, Coronavirus, and Neurological Injuries William Andres Florez Perdomo, Harold Enrique Vásquez Ucros, Luis Rafael Moscote-Salazar Journal of Translational Critical Care Medicine 2020 2(3):64-65

Patients Admitted to the Intensive Care Unit Should Receive Central Venous Pressure Monitoring: We Should Personalize Our Approach Patrick M Honore, Aude Mugisha, Luc Kugener, Sebastien Redant, Rachid Attou, Andrea Gallerani, David De Bels Journal of Translational Critical Care Medicine 2020 2(3):66-66

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Noncommunicable Diseases

Coronavirus disease 2019 and noncommunicable diseases: Lessons learned so far and implications for the future Kavumpurathu Raman Thankappan International Journal of Noncommunicable Diseases 2020 5(4):155-157

Awareness of patients regarding self-management of heart failure attending a tertiary care hospital of North India Bandna Kumari, Sukhpal Kaur, Monika Dutta, Ajay Bahl, Parag Barwad International Journal of Noncommunicable Diseases 2020 5(4):158-164 Background: Heart failure is a rampant health problem affecting millions of people worldwide. Patients' knowledge about this complex disease contributes toward its self-management at home thereby, reduction in frequent hospitalizations and increased health-care cost. Aim: This study aims to assess the awareness of patients regarding self-management of heart failure. Methods and Results: A cross-sectional study was conducted on diagnosed patients having heart failure for at least 6 months with left ventricular ejection fraction <40% from functional class New York Heart Association II–IV ambulatory. One hundred and one participants were interviewed individually during routine visit. A prevalidated questionnaire was used to collect demographic characteristics, status of illness and knowledge of patients. Data were analyzed using descriptive and inferential statistics. 66.3% of the patients had insufficient knowledge about heart failure. Acceptable level of knowledge was found in 11.9% of the participants. Weak linear correlation (r = -0.232, P = 0.019) was found between education and mean knowledge score. Significant association of education and habitat with higher knowledge was seen in binomial logistic regression model. Conclusion: Lack of awareness regarding self-management of disease was found in majority of the patients. Structured teaching programs with special emphasis on nature of illness, lifestyle modifications, identifying worsening symptoms and their management at home were needed. Heart failure, knowledge, self-management

Relationship between diabetes mellitus and indoor air pollution: An exploratory analysis Sandeep Mishra, Leslie A McClure, Vijay Golla, Vasudeva Guddattu, Claudiu Lungu, Nalini Sathiakumar International Journal of Noncommunicable Diseases 2020 5(4):165-170 Context: Diabetes is one of the leading causes of morbidity and mortality worldwide. India has the second highest number of individuals with diabetes in the world and these numbers are predicted to reach 120 million by 2045. Environmental exposure to particulate matter and nitrogen dioxide has been identified as a risk factor for diabetes However, to date, no published studies have examined the association of indoor air pollution (IAP) and diabetes in developing countries such as India, where traditional biomass fuels are still used for cooking and heating. Aims: To evaluate the association between IAP and diabetes mellitus. Settings and Design: The data collected through India's third National Family Health Survey (NFHS-3) in 2005–2006 were queried and analyzed. Materials and Methods: This study examined the association between IAP and diabetes among women aged 45 years and above using data from the NFHS-3. Statistical Analysis: Multivariable regression analysis was used to determine the relationship between diabetes and type of fuel, calculate adjusted odds ratios (OR) and the 95% confidence interval (CI) after adjusting for confounders. Results: Less than 1/3 of the 9,502 (28%) participants were overweight or obese and 304 women reported having diabetes. A statistically significant association between solid fuel use and diabetes in women >45 years of age was observed (OR: 1.59; 95% CI: 1.08–2.34). Conclusions: This study is the first attempt to determine the relationship between diabetes and IAP; more robust population-based cohort studies are needed to further explore this association.

Situational analysis of practice patterns and challenges in cardiovascular disease management: A qualitative study Farah Naaz Fathima, Twinkle Agrawal, Padmini Nidhin, Denis Xavier International Journal of Noncommunicable Diseases 2020 5(4):171-177 Background: Optimal management of cardiovascular diseases (CVDs) in developing countries is hindered by challenges among patients, caregivers, and health-care providers, understanding which is critical for CVD control. Objective: To explore the perspectives of patients with CVD, their caregivers, and health-care providers on the burden of the disease and challenges in management and to evolve strategies for improvement of care. Methods: A qualitative study using focus group discussions (FGDs) with patients and caregivers and in-depth interviews (IDIs) with care providers was conducted. Thematic analysis of data from FGDs and IDIs was done by inductive examination of textual information. Key subthemes and themes that emerged were recorded. Results: A total of 12 FGDs and 13 IDIs were conducted. Participants perceived CVDs as a big problem in both urban and rural areas. Lack of resources and time, lengthy and tedious procedures, high patient load, lack of awareness about standard treatment guidelines among private practitioners, and inadequate involvement of family members emerged as the key challenges in the control of CVDs. Training of private practitioners, nurse educators, and doctors in the public health system; strengthening of the existing national program; and greater involvement of family members in care of patients were the key strategic suggestions for improvement of care in CVD. Conclusion: Control of CVDs is laced with many challenges which involve multiple stakeholders. Addressing this issue demands a multipronged approach with interventions directed at empowering the patient and the caregivers and enhancing their involvement in care along with strengthening the health system.

Assessment of 5-year risk of cardiovascular events among adults residing in an urban underprivileged area of Bangalore city: A community-based cross-sectional study Nancy Angeline Gnanaselvam, Avita Rose Johnson, Somya Andrea Gomes, JV Jeskezia, Niresh Chandran, Suchitra Bajaj International Journal of Noncommunicable Diseases 2020 5(4):178-183 Background: Cardiovascular disease (CVD) is the major cause of premature morbidity and mortality in India and is undergoing an epidemiological transition, now affecting the urban poor. It is important to assess patients for CVD risk and mitigate risk factors as a primary mode of prevention of CVD accordingly. Objective: The objective of the study was to assess the 5-year risk of cardiovascular events and the prevalence of CVD risk factors in an underprivileged area of Bangalore City. Methods: Community-based house-to-house survey of all adults aged 30 years and above, using an interview schedule on Epicollect mobile application, capturing sociodemographic details and CVD risk factors based on the INTERHEART risk assessment which included dietary risk factors, smoking and alcohol, physical activity, and central obesity. Blood pressure, random blood sugar, height, weight, and waist circumference measurement were done. The National Health and Nutrition Examination Survey CVD risk assessment charts were used to calculate the 5-year risk of a cardiovascular event. Results: Of 1184 study participants, 23% had moderate risk (10%–20%) and 30% had high risk (>20%) of a cardiovascular event in the next 5 years. Factors such as being not currently married, belonging to a religious minority, lower education, not being gainfully employed, belonging to a joint family, and salty food consumption were significantly associated with higher CVD risk. Conclusion: Urban underprivileged areas with undermined social determinants of health have significantly high burden of CVD risk and hence require a holistic approach to CVD risk assessment and noncommunicable diseases care starting with easy to use CVD risk assessment charts by community level health workers. Cardiovascular diseases risk assessment, diabetes, hypertension, noncommunicable diseases, urban health

Glycemic efficacy and safety of hydroxychloroquine in type 2 diabetes mellitus: A systematic review and meta.analysis of relevance amid the COVID-19 pandemic Rimesh Pal, Mainak Banerjee, Ashok Kumar, Sanjay Kumar Bhadada International Journal of Noncommunicable Diseases 2020 5(4):184-193 Aims: Hydroxychloroquine (HCQ) is approved for use as an oral anti-diabetic drug (OAD) in patients with uncontrolled type 2 diabetes mellitus (T2DM); however, robust data are lacking. The present meta-analysis was conducted to provide precise effect estimates regarding the efficacy and safety of HCQ in patients with T2DM. Methods: PubMed/Cochrane Library and grey literature were systematically searched till August 25, 2020, to identify randomized controlled trials (RCTs) with duration =12 weeks, evaluating the efficacy and safety of HCQ (400 mg/day) in patients with T2DM and glycated hemoglobin (HbA1c) =7.0%–7.5% already on a combination of metformin/sulfonylurea compared to either placebo or another OAD. Results: We identified eight eligible RCTs, pooling data retrieved from 1763 patients with T2DM. HCQ resulted in significant decrease in HbA1c by 0.88% (95% confidence interval [CI]: -1.01 to - 0.75) compared to placebo and by 0.32% (95% CI: -0.37 to -0.26) compared to an OAD. Besides, there were significant reductions in fasting blood glucose, postprandial blood glucose, body weight, triglycerides, and low-density lipoprotein. A small but significant increase in high-density lipoprotein was also noted. An increase in the risk of any episode of symptomatic hypoglycemia (whether documented or not) was observed (risk ratio = 1.34 [95% CI: 1.10–1.63]). No other safety issues were identified. Conclusions: The meta-analysis suggests that HCQ, used as an add-on drug in patients with T2DM exerts significant beneficial effects on glycemic control, body weight, and lipid profile, however, increasing the risk for symptomatic hypoglycemia. HCQ might be useful amid the ongoing pandemic, as the drug has also been found to be beneficial in COVID-19.

Availability of oral liquid formulations: Dilemmas in managing children with nephrotic syndrome Chakrant Mothsara, Karalanglin Tiewsoh, Avaneesh Kumar Pandey, Samir Malhotra, Nusrat Shafiq International Journal of Noncommunicable Diseases 2020 5(4):194-200 Conditions such as nephrotic syndrome (NS), which require administration of drugs for a protracted period, present a difficult situation for pediatricians to treat due to lack of appropriate formulations. In the present study, we explored the issue of availability of pediatric oral formulations and suggested solutions with NS as an example. We searched PubMed, Embase and Ovid, Google, Google Scholar, Current Index of Medical Specialties-Monthly Index of Medical Specialties, and standard textbooks for data acquisition. We found that many drugs used in NS are either not available in suitable pediatric formulation or are not specifically approved for use in pediatric population. Most of these drugs have high pharmacokinetic variability, which further necessitates the availability of proper formulation. Standardized compounding vehicles are also not available in our country. Manipulation of existing adult dosage forms for administering to pediatric patients is often arbitrary and may be associated with either underdosing or overdosing. There is an urgent need for development and standardization of compounding vehicles so that required dose delivery can be ensured in children with NS.

Dietary recommendation in diabetes care: Carbohydrate counting and caloric content of Nigerian foods Taoreed Adegoke Azeez, Patience Chimah, Abdul Fattah Hassan, Adedeji Moradeyo, Ubong Umoren, Emmanuel Eguzozie International Journal of Noncommunicable Diseases 2020 5(4):201-206 The prevalence of diabetes mellitus is rising globally and even more in low- and middle-income countries such as Nigeria. Optimal management of the disease is important to improve survival and prevent or delay its complications. Lifestyle management is a standard universal approach in optimizing the care given to diabetic patients. Dietary management is the central link in lifestyle modifications of individuals living with diabetes. Medical nutrition therapy (MNT) is a systematic therapeutic approach of assessing the nutritional needs of an individual, determining nutritional goals, counseling the clients on how to achieve the goals, prescribing and monitoring meal plans to achieve the goals. It is evidence-based, effective, and highly recommended. All carers of the diabetes patient, including the health workers and the family members of the patients need to have basic understanding of MNT but the efforts should be coordinated by licensed dietitians. There are evidences that adherence to prescribed calories is effective in the control of cardiovascular risk factors such as blood glucose, weight, lipid profile, and blood pressure. However, prescription of calories should be based on thoughtful consideration of the nutritional needs, weight goal, personal preferences and tastes and cultural practices of individuals living with diabetes mellitus. Food pyramids give a graphical illustration on the recommended classes and servings of food. Six to eleven servings per day of carbohydrates, 3–5 servings per day of vegetables, 2–4 servings per day of fruit, 2–3 servings per day of dairy products, and 2–3 servings per day of fish are the recommended proportions of the different classes of foods for an adult on an average of 2000 calories. Carbohydrate counting, taken with appropriate insulin dosing and physical activity, has been demonstrated to be effective in optimizing the glycemic control of patients on multiple daily insulin injections. There are challenges in doing this in Nigeria due to lack of food labels. The caloric contents of common Nigerian foods are highlighted so as to help in achieving dietary goals.

Development and validation of composite risk score to assess risks of major noncommunicable diseases in Northern Indian populations: A research protocol Ria Nangia, JS Thakur, Anil Kumar Bhalla, Ajay Duseja International Journal of Noncommunicable Diseases 2020 5(4):207-210 Background: Noncommunicable diseases (NCDs) which mainly consist of cardiovascular diseases, diabetes, cancer, and chronic respiratory diseases account for 38 million deaths out of the 56 million deaths globally and 54% of healthy life years lost in 2012. Risk scores predict the risk of the disease efficiently, and an important strategy to prevent or delay the occurrence of chronic diseases is the early identification of those with undiagnosed NCDs. Methods: Two different population-based studies will be used for the development of the score and its validation. Secondary data from WHO STEPS Survey Haryana of 5250 individuals will be used to develop the predictive score and will be validated using STEPS Punjab data. Risk predictors will be used as the independent factors in the multivariate logistic regression and the dependent variable will be the disease. The regression coefficient will be used to assign each variable category a score. Risk score will be derived from receiver operating characteristic curve and the optimal cut-off will be determined using Youden's Index. Measures of overall predictive accuracy, discrimination and calibration will be used to assess predictive performance. Discussion: The present study is an attempt to develop a composite risk score for major NCDs so that effective preventive and control measures can be initiated once the risk is known. The developed tool will help in risk assessment and the successful implementation of NCD programs.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Nursing Science

Secondary Traumatic Stress in Nursing: A Walker and Avant Concept Analysis Nurses on the front lines of health care are impacted psychologically by their work and may experience secondary traumatic stress. The literature contains several different terms to explore concepts that describe the impact of traumatic patient experiences on the nurse, making it difficult to differentiate the concepts. Using the Walker and Avant method of analysis, the author reviewed nursing-specific publications within the last 10 years and seminal works to develop a purer meaning of secondary traumatic stress and distinguish it from other related terms. A more precise definition of secondary traumatic stress will allow for the advancement of research related to awareness and prevention in nursing. Correspondence: Marni B. Kellogg, PhD, RN, CPN, CNE, University of Massachusetts Dartmouth, 285 Old Westport Rd, Dartmouth, MA, 02747 (mkellogg@umassd.edu). The author has no acknowledgments or disclosures. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Symptom Management Theory: Analysis, Evaluation, and Implications for Caring for Adults With Cancer A detailed analysis of Symptom Management Theory (SMT) along with its extent of use and implications for adults with cancer as demonstrated in 20 oncology research studies is reported. SMT provides useful guidance for adult oncology research and nursing practice. Theory dimension most researched in cancer was symptom experience. Although theory assertions were demonstrated in 80% of the studies, it was used to an adequate extent only in 35% of them. Comparisons between cancer-related clinical outcomes with and without use of SMT, certain theory modifications, and future SMT-based studies involving longitudinal designs in this population are warranted. Correspondence: Asha Mathew, MBA, MSN, RN, RM, Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois at Chicago, 845 S. Damen Ave, Room 1024, Chicago, IL 60612 (asolom8@uic.edu). This article was supported by the National Institute of Nursing Research of the National Institutes of Health under award no. K24NR015340. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors declare that they have no conflicts of interest. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Exploring Nurses' Perceptions of Safety: A Phenomenological Study The purpose of the study is to explore the lived experiences of nurses with regard to their personal safety and to identify the fundamental structures underlying nurse safety. A qualitative descriptive phenomenological design, using the data analysis method proposed by Colaizzi, was used. Eleven nurses participated in the study between March and July 2019. The research findings indicated the fundamental structure of nurse safety encompasses 3 categories: "nurses' personal protection systems," "safety support systems," and "risk factors." The fundamental structure identified in this study can contribute to better understanding and insight regarding the safety of nurses. Correspondence: Seung Wan Kang, PhD, MD, Associate Professor, College of Nursing, Research Institute of Nursing Science, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul 03080, South Korea (drdemian@snu.ac.kr). Immeasurable appreciation for their support is extended to the nurses who participated and shared their stories and Dr Hack Sun Kim, who reviewed the results of the study. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.advancesinnursingscience.com). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

A Critical Analysis of the American Nurses Association Position Statement on Workplace Violence: Ethical Implications In 2015, the American Nurses Association issued a position statement on workplace violence. An authoritative, disciplinary position is critically important to inform policies and recommendations addressing this significant issue in nursing. Position statements and policies should reflect disciplinary values. A discourse analysis of this position statement was performed through the lens of nursing ethics. The position statement endorses a zero-tolerance response, which is moralist, punitive, and questionably effective. It problematically presents patient and coworker violence as equivalent. Promotion of this position has the potential to erode public trust and lead us down a path of criminalizing illness behaviors. Correspondence: Darcy Copeland, PhD, RN, University of Northern Colorado, Campus Box 125, Gunter Hall, Greeley, CO 80639 (Darcy.copeland@unco.edu). The author would like to thank Dr Lorna Hutchison for reviewing this article. The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Integrity of Databases for Literature Searches in Nursing: Avoiding Predatory Journals The quality of literature used as the foundation to any research or scholarly project is critical. The purpose of this study was to analyze the extent to which predatory nursing journals were included in credible databases, MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus, commonly used by nurse scholars when searching for information. Findings indicated that no predatory nursing journals were currently indexed in MEDLINE or CINAHL, and only one journal was in Scopus. Citations to articles published in predatory nursing journals are not likely found in a search using these curated databases but rather through Google or Google Scholar search engines. Correspondence: Marilyn H. Oermann, PhD, RN, ANEF, FAAN, Duke University School of Nursing, DUMC 3322, 307 Trent Dr, Durham, NC 27710 (marilyn.oermann@duke.edu). Peggy L. Chinn, PhD, RN, FAAN, Editor, Advances in Nursing Science, is a member of our research team and contributed to the study and preparation of the manuscript. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

End-of-Life Care Terminology: A Scoping Review The purpose of this scoping review is to present an overview of terms found in publications associated with end-of-life care management that can impact decision making by patients, health care providers, and researchers. Connotative terminology and syntax can influence the decision-making approach and process. We examined 49 publications for positive, negative, and neutral connotations. We consistently found negative terminology in the publications. To advance the development of nursing knowledge regarding end-of-life care, researchers should be aware of their biases of terminology and syntax use. We propose modifications to language used in end-of-life care planning models and literature can improve care congruency. Correspondence: Zahra Rahemi, PhD, RN, College of Behavioral, Social and Health Sciences, School of Nursing, Clemson University, 116 Edwards Hall, Clemson, SC 29634 (zrahemi@clemson.edu). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Black Female Sexuality: Intersectional Identities and Historical Contexts Black females experience significant sexual health disparities. Intersectionality theory offers nurses a framework to address health disparities. Intersectionality theory examines how categorical identities of difference confer power or oppression, affect social interactions, and influence individuals' engagement with institutional structures. This secondary analysis of qualitative data details the damaging effects that power, oppression, and disadvantaged identities have on the sexual health of Black women. Twenty participants explained how the intersection of race, gender, age, education, and sexuality influences sexual health risk. Our expanded model of intersectionality theory emphasizes historical context with implications for research, practice, and education to promote health equity. Correspondence: Natasha Crooks, PhD, RN, Department of Human Development Nursing Science, University of Illinois Chicago College of Nursing, 845 S. Damen Ave, Room 816, Chicago, IL 60612 (ncrooks@uic.edu). This study was funded by the National Institute of Nursing Research, Pre-doctoral Fellowship Ruth L. Kirschstein National Research Service Award (F31NR016624), principal investigator Natasha Crooks. We would like to acknowledge and thank the participants who shared their personal stories. We would also like to acknowledge the support from the University of Wisconsin-Madison, Public Health and Dane County, and the Allied Wellness Center. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

A Conceptual Framework of Self-advocacy in Women With Cancer Researchers define self-advocacy as the ability of an individual with cancer to overcome challenges in getting their preferences, needs, and values met. While imperative in all health care settings, self-advocacy is especially important in cancer care. The goal of this article is to present a conceptual framework for self-advocacy in cancer. We review foundational studies in self-advocacy, define the elements of the conceptual framework, discuss underlying assumptions of the framework, and suggest future directions in this research area. This framework provides an empirical and conceptual basis for studies designed to understand and improve self-advocacy among women with cancer. Correspondence: Teresa H. Thomas, PhD, RN, University of Pittsburgh School of Nursing, 3500 Victoria St, Ste 440, Pittsburgh, PA 15261 (t.thomas@pitt.edu). The authors want to dedicate this article to the late Susan M. Cohen, PhD, APRN, FAAN. She was a dedicated member of our research team and brought clarity of thought, enthusiasm, and reassurance to each of our studies described in this article. As a mentor, she endlessly supported this work and the development of all of her mentees. Without her guidance, along with that of our entire team of mentors and collaborators, this work would never have reached fruition. The following funding supported this article: American Cancer Society Mentored Research Scholar Grant MSRG-18-051-51 (Thomas), National Palliative Care Research Center Career Development Award (Thomas), American Cancer Society, Doctoral Degree Scholarship in Cancer Nursing DSCN-14-077-01-SCN (Thomas), National Institute of Nursing Research/National Institute of Health F31NR014066 (Thomas), National Institute of Nursing Research/National Institute of Health T32NR0111972 (Bender), National Institute of Nursing Research/National Institute of Health R01NR010735 (Donovan), Judith A. Erlen Nursing PhD Student Research Award (Thomas), Nightingale Awards of Pennsylvania, Doctoral Student Research Award (Thomas), Oncology Nursing Foundation, Doctoral Student Award (Thomas), Sigma Theta Tau International, Rosemary Berkel Crisp Research Award (Thomas), The Rockefeller University's Heilbrunn Family Center for Research Nursing, Heilbrunn Nurse Scholar (Thomas) Award, and Palliative Research Center (PaRC) at the University of Pittsburgh (Schenker). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Advancing Nursing Policy Advocacy Knowledge: A Theoretical Exploration Nursing policy advocacy continues to be recognized as a key part of a nurse's role by educators, professional associations, and regulators. Despite normative calls on nurses to engage in political action and advocacy, limited theories, models, and frameworks exist to support this practice within nursing. Using Walt and Gilson's Health Policy Triangle Framework, this article explores the theoretical underpinnings of policy advocacy to enhance nursing's contemporary role in advancing social justice. Specific consideration is placed on the type of nursing and policy knowledge and perspectives required to understand policy content, contexts, processes, and actors. Correspondence: Patrick Chiu, RN, MPH, Faculty of Nursing, 4-171 Edmonton Clinic Health Academy, University of Alberta, Edmonton, AB T6G 1C9, Canada (pakcheon@ualberta.ca). The author acknowledges the valuable feedback provided by Professor Jill White, PhD, MEd, MHPol, RN, RM, FAAN, Professor Emerita, University of Sydney, Australia, and the University of Technology Sydney; and Joanne Olson, PhD, RN, FAAN, Professor, Faculty of Nursing, University of Alberta. The author has disclosed that he has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Properties of Situation-Specific Theories and Neo-pragmatism The purpose of this article is to discuss whether the properties of existing situation-specific theories are congruent with the philosophical stance of neo-pragmatism. A literature review was conducted using PubMed, CINAHL, and PsycInfo with keywords of "situation-specific theory" and "nursing." Fifteen situation-specific theories were included in the analysis. The properties of existing situation-specific theories included "high specificity and low level of abstraction," "context understanding," "direct linkages to research and practice," and "reflecting diversities and complexities with limited generalizability." Finally, the findings are discussed in terms of their linkages to the major tenets of neo-pragmatism. Correspondence: Eun-Ok Im, PhD, MPH, RN, CNS, FAAN, Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Rd, Atlanta GA 30322 (eun.ok.im@emory.edu). The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Peritoneal Dialysis

History of peritoneal dialysis Sabina Yusuf Indian Journal of Peritoneal Dialysis 2020 38(1):1-5 >Peritoneal Dialysis is now an accepted mode of renal replacement therapy. The story of its development is a fascinating scientific journey of pioneers who have worked tirelessly to develop and extend the application of this technique which now plays such an important part in the treatment of patients with ESKD. This article reviews the milestones in the history of innovation of this life saving treatment in an attempt to understand to the hopes and ideas of our predecessors and build on them into the future to make peritoneal dialysis a more effective, safer, and inexpensive therapy for ESKD.

Valacyclovir toxicity in peritoneal dialysis P Ravi Kumar Indian Journal of Peritoneal Dialysis 2020 38(1):6-10 Valacyclovir (Prodrug) an antiviral agent is not well cleared by peritoneal dialysis and can cause neuropsychiatric manifestations in patient with renal failure on peritoneal dialysis and having Herpes Zoster infection being treated with this drug. Methodology followed for the collection of data and literature review was by using a medline search using the terms Acyclovir, nervous system effects, Valacyclovir, neurotoxicity and peritoneal dialysis. The representative case discussed is about an elderly gentleman with chronic renal failure on CCPD presenting with hallucinations, altered sensorium and restlessness following treatment with Valacyclovir 1000 mg three times per oral daily who was admitted and evaluated. It is of vital importance to consider the differential diagnosis of Herpes zoster encephalitis in the differential diagnosis of these patients as it is difficult to rule it out. The mechanism of this drug induced neurotoxicity is thought to be probably, the accumulation of serum carboxymethoxymethyl guanidine (CMMG), a toxic metabolite of valacyclovir.As peritoneal dialysis is not very effective in removal of this drug, it is thought to be beneficial to change to Hemodialysis for short duration so as to clear the drug from the system as shown in the case and in the discussion. Safe doses in peritoneal dialysis are not clearly delineated. Extreme precaution must be exercised while prescribing these group of anti-viral drugs in patients with CKD and especially those on peritoneal dialysis. If such a patient does manifest neuropsychiatric symptoms it is necessary to immediately stop the drug concerned. Methods to increase the excretion of the drug must be employed immediately or to remove it by intensification of PD or ideally to aggressively remove it by means of hemodialysis. Moreover there is a paucity of similar reports in the literature.

Peritoneal dialysis – ideal renal replacement therapy during coronavirus (COVID-19) pandemic Jeethu Joseph Eapen Indian Journal of Peritoneal Dialysis 2020 38(1):11-12 Peritoneal dialysis has an important role to play in the ongoing coronavirus pandemic. It can help in maintaining social distancing goals in dialysis patients and hence should be considered as first line renal replacement therapy (RRT) in all incident ESRD patients. There is emerging interest in the role of PD for the treatment of Acute Kidney Injury especially in the setting of overburdened hemodialysis/CRRT services in the ICU. This article discusses the role of PD in managing critically ill COVID patients.

Peritonitis profile in a cohort of extreme poverty patients on continuous ambulatory peritoneal dialysis-5 year experience from a South Indian public private partnership model PD programme Mayoor V Prabhu, KN Sanman, Ranjit Shetty, GG Laxman Prabhu, BH Santhosh Pai Indian Journal of Peritoneal Dialysis 2020 38(1):13-15 Introduction Limitations in finance and education is thought to translate into poor technique , understanding and thereby into higher incidence of peritonitis and ultimately poor patient and technique survival. This notion sometimes leads to such patients being denied Continuous Ambulatory Peritoneal Dialysis (CAPD). Methods: In 2013, 20 patients were initiated on CAPD under a Public Private Partnership (PPP) model project in Karnataka province, India. By regulation, they were required to belong to Below Poverty Line (BPL ) category which is a measure of extreme poverty. BPL is the equivalent of earning less than a dollar per day. They were followed up for peritonitis, technique and patient survival besides overall performance. Results: 20 patients were included ( Male: 60%, Mean age 56.7 years, Diabetic Nephropathy 48%). Peritonitis rate was 1 in 33.8 patient –months, with 3 episodes of Fungal Peritonitis (FP) including one of Candida Hemolunii. All FP led to termination of CAPD. Coagulase-Negative Staphylococcus (CoNS) was the most common pathogen isolated , accounting for 60% of the episodes. Technique survival was 15% and patient survival was 20% at 5 years. Cardiovascular disease, sepsis, and malignancy accounted for majority of the deaths. Conclusions: Patients with background of extreme poverty had peritonitis rates comparable to good centres, however patient survival at 5 years was lower. Educational or economic considerations did not seem to be an impediment to successful CAPD.

Randomized controlled trial to compare the tolerability and efficacy of treatment with Icodextrin 7.5% versus Dextrose 2.5% in chronic peritoneal dialysis patients with high/high average solute transport characteristics and low residual renal function Vivek Sood, Rahul Grover, Vivek Kumar, Shravan Kumar Singh, Krishan Lal Gupta Indian Journal of Peritoneal Dialysis 2020 38(1):16-24 Aim: Comparison of tolerability and efficacy of treatment with icodextrin vs. dextrose 2.5% amongst high risk cohort of chronic peritoneal dialysis patients (high/high average solute transport characteristics and low residual renal function) over 3 months. Study Design and Methodology: The study was an open-label, comparative, prospective, randomized controlled trial, conducted at department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. A total of 349 end stage renal disease patients on chronic peritoneal dialysis were screened for eligibility over a period of 6 months and 41 patients with high / high average solute transport characteristics and low residual renal function were randomized to receive either icodextrin 7.5% solution or 2.5% dextrose solution in long dwell. Patients were assessed for adequacy of peritoneal dialysis (creatinine & urea clearance), peritoneal membrane transport characteristics including solute clearance (standard peritoneal equilibration test), body composition, total body water, fat mass and fat free mass (using whole body tetrapolar bioimpedance analyzer) at baseline and at the end of 3 months. Statistical Analysis: Continuous variables were compared with independent samples paired t test if normally distributed, or with Mann–Whitney U test if the distribution was skewed. Categorical variables were analyzed with Chi-square test or Fisher exact test as appropriate. Pearson's correlation coefficient was calculated between different quantitative variables. Paired t test and Wilcoxon signed-rank test were used for within-group comparisons. Repeated measure ANOVA was used to compare bioelectrical impedance between intervention groups. Results: The study has shown that use of icodextrin based continuous ambulatory peritoneal dialysis resulted in better ultrafiltration and improved solute clearance when compared to 2.5% dextrose based peritoneal dialysis in a select cohort of patients having high/high average transporter characteristics with poor residual renal function, however, it didn't significantly alter total body water and failed to translate into improvements in either patient's or physician's assessment of global health of response to therapy atleast at 3 months. Conclusions: Although use of icodextrin based peritoneal dialysis solution for long dwell resulted in significant improvement in solute clearance and ultrafiltration nevertheless failed to translate into better hydration status or subjective improvement scores atleast at 3 months.

Life threatening hyperkalemia necessitating temporary cardiac pacing and dialysis in elderly patients Ajaz A Lone, Tariq A Bhat, Khalid P Sofi, Imtiyaz A Wani, Muzafar M Wani, Mohd Ashraf Bhat Indian Journal of Peritoneal Dialysis 2020 38(1):25-29 Background Many elderly hypertensive patients are on cardio/reno protective medications (ACEIs, ARBs, β blockers & K sparing diuretics), which may precipitate or worsen hyperkalemia in them. Given its potential life threatening nature, identifying such patients is imperative. Rarely emergency temporary cardiac pacing may be required to thwart cardiac arrest while K is being lowered by extracorporeal removal. In many resource-constrained settings HD to lower K quickly is not always available. Materials and Methods We describe the profile of 26 patients over a three year period who besides medications & dialysis needed temporary cardiac pacing because of severe hyperkalemia. Results: The mean age of these 26 patients (17 males, 9 females) was 64+/-11 years. 12 (46%) had diabetes mellitus. On admission, the mean serum K was 6.7 ± 1.4 mmol/L, mean serum creatinine was 2.8 ± 1.6 mg/dL, mean arterial pH was 7.1 ± 0.5 and the mean plasma bicarbonate was 12 ± 4 mmol/L. The main causes for acute kidney injury (AKI) and hyperkalemia were dehydration (n = 14) and worsening heart failure (n = 7) with concomitant use of ACEIs, ARBs, β blockers, K sparing diuretics either alone or in combination. 22 patients received PD, two HD, while two received both. Six patients were admitted to the ICU, two of whom died. The duration of hospitalization ranged from 1-12 with a mean of 7 days. The patients in the drug induced hyperkalemia group who required pacing were elderly, had been on a combination of K elevating medications, were more likely to have DM and had a longer hospital stay compared to those who had hyperkalemia but did not require cardiac pacing. Conclusion: A combination of ACEIs, ARBs, β blockers & K sparing diuretics should be used with caution in patients who are elderly, have renal insufficiency, DM or heart failure or are at risk for dehydration. In places with limited availability of emergency HD, PD is an effective alternative for lowering serum K.

Unusual organisms causing continuous ambulatory peritoneal dialysis peritonitis SankaraKumar GaneshAravind, Anusha Rohit, N Gopalakrishnan, J Dhanapriya, T Dineshkumar, R Sakthirajan, N Malathy, T Balasubramaniyan, AT Maasila Indian Journal of Peritoneal Dialysis 2020 38(1):30-33 Peritonitis is an important cause for morbidity and mortality in Continuous Ambulatory Peritoneal Dialysis (CAPD) patients. There is an emerging trend towards unusual organism causing CAPD peritonitis. We report our experience with unusual organisms and its impact on survival. We had 43 CAPD peritonitis episodes, out of which, six were due to unusual organisms. Although five patients responded to antibiotic therapy, one lost her CAPD access (catheter). Clinically, peritonitis caused by unusual organism is similar to that caused by other pathogens. Adherence to diligent hygienic practices while handling catheter and bag is most important in avoiding such peritonitis episodes.

An unusual complication of CAPD technique: Lesson to be learnt Muzamil Ahmed, Manjusha Yadla Indian Journal of Peritoneal Dialysis 2020 38(1):34-35 Continuous Ambulatory Peritoneal Dialysis is a recommended mode of renal replacement therapy in those with vascular access failures. Complications of Surgical placement of catheter and Percutaneous technique by Nephrologist are well described. Complications may occur during the procedure or after the procedure. During the placement of the catheter, hollow viscus perforation is known to occur. Patients are given instructions of using laxative , emptying bladder before surgery in order to avoid bladder or bowel injury. Bladder perforation is one of the rare complication of CAPD technique.It is expected to occur commonly with rigid catheters than the soft catheters used in CAPD. Herein we report a case of bladder perforation during the procedure of placement of percutaneous CAPD catheterization.

A rare case of early Burkholderia cepacia peritonitis in a chronic ambulatory peritoneal dialysis patient Sambit Sahoo, Arvind Achra, B Muthukumar, Shiwangi Sharma Indian Journal of Peritoneal Dialysis 2020 38(1):36-38 Continuous ambulatory peritoneal dialysis (CAPD) is one of the preferred forms of renal replacement therapy. However, peritonitis is the leading cause of morbidity and mortality associated with CAPD. Here, we report a case of Burkholderia cepacia peritonitis which required combination of antibiotics and catheter removal for its treatment.

Literature Review Indian Journal of Peritoneal Dialysis 2020 38(1):39-41

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