Purpose of study: To examine change in balance-related fall risk and daily functional abilities in the first 2 postoperative weeks and up to 6 weeks after gynecologic surgery. Materials and methods: Prospective cohort study in gynecologic surgery patients age 65 and older. Balance confidence (Activities-specific Balance Confidence Scale) and functional status (basic and instrumental activities of daily living) were recorded pre-and post-operatively daily for 1 week and twice the second week. Physical performance balance and functional mobility were measured pre-and 1 week post-operatively using the Tinetti Fall Risk Scale, Timed Up and Go, and 6-Minute Walk test. Measures were repeated 6 weeks after surgery. Nonparametric tests for paired data were used comparing scores baseline to post-operative (POD) 7 and to POD 42. Results: Median age was 72 years (range 65-88). Fall risk was elevated during the first 2 post-operative weeks, greatest on the median discharge day, POD 2 (p < 0.01). Balance performance and functional mobility at 1 week were significantly lower than baseline (p < 0.01). Functional abilities declined, including new dependence in medication management at home in 22% of these independent and cognitively intact women. Conclusions: After gynecologic surgery, older women's fall risk is highest on POD 2 and remains elevated from baseline for 2 weeks. Functional limitations in the early home recovery period include the anticipated (bathing, cooking, etc.) and some unanticipated (medication management) ones. This information may help with postoperative discharge planning.

BACKGROUND: Hysterectomies are one of the most frequently performed surgical procedures in the United States. There are a wide variety of diagnoses that require a patient to obtain this procedure, but the majority of hysterectomies are performed for benign indications. Currently, gynecologists do not follow a standardized protocol surrounding postoperative laboratory ordering, and healthcare professionals can order a wide range of tests as often as they choose. Extraneous laboratory orders are disruptive to the patients’ well-being and risk their health following surgery. These orders are costly for hospital systems, take up precious time of hospital employees, and influence the course of patient treatment only in extremely rare circumstances. There are few studies that develop exclusion criteria for patients who may not require a laboratory test following surgery. Though systems to predict postoperative hematocrit have been created, they are complicated and difficult to use. The few studies that were performed are yet to be accepted by the medical community, in part because of their limited scope. This study will be the first to incorporate the results of robotic surgery in the analysis. OBJECTIVE: The purpose of this study is to determine concrete parameters to indicate that a patient is in need of postoperative laboratory work and at risk for anemia or transfusion. We aim to develop two comprehensive models that guide surgical practitioners to identify the cases which do not require laboratory data. METHODS: A total of 1027 gynecologic surgeries were performed at Saint Francis Hospital and Medical Center between April 1, 2014 and May 31, 2016. This retrospective study extracted data from EPIC EMR according to 42 variables preconceived to be the leading indicators of postoperative hematocrit and overall healing. Five healthcare professionals were surveyed to identify the variables that influence their postsurgical patient assessments and their decisions to order blood testing. This information was developed into score sheets with differing levels of stringency. Correlation highlighted 14 of the initial 42 variables as contributors to postoperative hematocrit and an equation model was built. Stepwise linear regression was used for univariate and multivariate analyses, from which we created our equation to predict all patients’ postoperative hematocrit. RESULTS: Out of the 1027 initial cases, a total of 602 cases were identified as hysterectomies for benign indications. Survey data gave the highest value to urine output and heart rate as key indicators of postoperative anemia. From the survey data, two clinical scoring sheets with differing stringency were created to guide practitioner laboratory ordering. These sheets gave parameters of heart rate and urine output the largest correlative weight in determining postoperative hematocrit. However, based on regression analysis, parameters of age (AGE), body mass index (BMI), preoperative platelet count (PPC), estimated blood loss during surgery (IO EBL), preoperative hematocrit (PHCT) and postoperative fluid bolus orders (POSTOP FB) proved to be the key variables impacting postoperative hematocrit (POSTOP HCT). These items were translated into the equation: POSTOP HCT = 22.51 – 0.40*POSTOP FB – 0.01*IO EBL + 0.25 PHCT + 0.09*BMI + 0.06*AGE – 0.01*PPC (R-squared = 0.310). CONCLUSIONS: This study aims to decrease superfluous laboratory testing, as well as to contribute to a larger conversation considering the potential merits of clinical judgement in a data-driven healthcare system. We have created a number of comparable strategies in order to reduce the number of unnecessary blood draws: two clinical scoring sheets and an equation. The score sheets indicate when to order additional testing. These sheets are representative of a range of surgical practitioners’ conventional clinical judgement. The equation serves as an evidence-based guide for determining postoperative hematocrit following benign gynecologic surgery. These predictive mechanisms will be validated and a superior method determined as our research continues with prospective application. We eventually expect to use the most accurate mechanism to reduce postoperative blood testing following all surgeries.

Syftet med denna litteraturstudie var att beskriva hur patienter upplever information inför gynekologiska ingrepp och undersökningar. Metoden som användes för att belysa syftet var beskrivande litteraturstudie. Data insamlades via två databaser, Medline och Cinahl. Andra sökstrategier var manuell sökning i valda källor. 15 vetenskapliga artiklar inkluderades i resultatet, dessa kvalitetsgranskades, analyserades och sammanställdes. Huvudresultat: Resultatet visade att vissa kvinnor saknade information om olika behandlingsalternativ, information om förberedelser samt information om postoperativa perioden. Många kvinnor tyckte dock att denna information varit bra. Många tyckte information angående indikationer för operation som bra, många ville inte ha för detaljerad information, vissa saknade information för att kunna ställa följdfrågor och kvinnor tyckte information om bl.a. kirurgisk teknik var bra. Kvinnorna var ofta nöjda med informationen och att lita till vårdpersonalen. Kvinnorna upplevde oftast den givna informationen som tillräcklig. Slutsats: Författarna anser att vidare forskning bör bedrivas inom området då det i studien framkommit att kvinnor många gånger saknar information kring sin undersökning samt ingrepp. Då upplevd informationsbrist kan göra att hela vårdupplevelsen blir lidande behövs vidare studier och då främst om hur informationen når patienten bäst då vi sett att information som finns hos personalen inte kommer patienten till nytta alla gånger. / The purpose of this study was to describe how patients perceive information prior gynecological surgery and examinations. Method: The method used to illuminate the purpose was descriptive literature. Data were collected via two databases, Medline and Cinahl. Other search strategies were manual search of selected sources. 15 numbers of articles were included in the result. Quality was reviewed, analyzed then summarized. Main results: Results showed that some women lacked information about treatment options, information about preparation and information about the postoperative period. Many felt that this information was good. Many thought that the information about indications for surgery were good, many women didn´t want the information to detailed, some lacked information to come up with additional questions and women thought that the information about such as surgical technique was good. Women were often satisfied with the information and with trusting the caregivers. Women usually experienced the given information to be adequate. Conlusion: The authors believe that further research should be conducted in the area where the study found that women often lack information about their investigation and intervention. This perceived lack of information can make the entire health care experience suffer, therefore further studies are needed, mainly on how to reach the patient with the information as we have seen that information given by the staff is not always received or recognized by the patient.

La chimiothérapie systémique par voie intraveineuse, essentiellement réservée aux cancers avancés, n'est pas ciblée sur la tumeur, il est très difficile d’atteindre des niveaux thérapeutiques en intra tumoral, et ses effets secondaires et sa toxicité sont doses-limitantes.La chimiothérapie localisée pourrait permettre :1) la stabilisation des molécules médicamenteuses incorporées une seule administration médicamenteuse,2) une libération prolongée et contrôlée du médicament pour assurer une diffusion adéquate et l'absorption par les cellules cancéreuses sur plusieurs cycles de division cellulaire 3) le chargement de molécules de chimiothérapie insolubles dans l’eau, 4) l’apport direct au site de la maladie, 6) des effets secondaires diminués en évitant la circulation systémique,7) des résections chirurgicales moindres en traitant les marges de la tumeur. Nous nous sommes plus particulièrement intéressés aux cancers gynécologiques. Nous avons étudié les effets pharmacologiques et cliniques de microsphères chargées en doxorubicine (Doxo) sur un modèle de carcinose péritonéale et de tumeur de glande mammaire, et étudié le profil de diffusion ganglionnaire de divers implants non chargés. 12 jours après injection laparoscopique de tumeurs VX2 sur les ligaments larges droits et gauches de lapines WNZ 12 une injection laparoscopique de 0,5 ml de microsphères chargées ou non de Doxo (respectivement DM, groupe 1 et BM, groupe 2) a été réalisée de façon aléatoire d’un côté ou de l’autre, en sous péritonéal, au site tumoral. 7 jours après les ligaments larges, l’utérus, les ovaires, les orifices de trocarts, les intestins, la vessie, le foie et les poumons ont été examinés en macroscopie et microscopie. Le volume tumoral était plus faible dans le groupe 1 (3,6 ± 3,2 cm) par rapport au groupe 2 (8,9 ± 5,4 cm) (MW, p = 0,0179). La nécrose a été observée autour de toutes les DM, sans nécrose autour des BM. La concentration de Doxo était de 2,1 ± 2,7 uM aux limites tumorales, au-dessus du niveau thérapeutique de 1,0 uM. Sur un autre modèle, 19 jours après injection locale de suspensions tumorales de VX2 sur la deuxième glande mammaire de lapines WNZ chaque glande a été aléatoirement traitée par injection locale de 0,5 ml de microsphères chargées ou non de Doxo (HSDOXO, Groupe1, et HS, groupe 2).Pour les tumeurs de moins de 5 cm3 ou 2 cm de diamètre avant traitement, le volume final était plus faible dans le groupe 1 par rapport à groupe2 (respectivement p<0.008 et p<0.3, MW)et la croissance tumorale a été diminuée après injection de HSDOXO par rapport à HS. En microscopie une nécrose tissulaire a été observée autour des HSDOXO en extratumoral, sans nécrose autour des HS.Nous avons enfin étudié la diffusion de particules de diverses tailles, non chargées, au ganglion sentinelle d’une tumeur de glande mammaire . Les animaux ont été répartis en trois groupes de trois, chacun d'eux recevant des particules de 100 nM, 1 uM ou 10 uM. Cinq jours après traitement, l'intensité de fluorescence a été évaluée par lampe UV. Le ganglion sentinelle a été disséqué selon la technique du bleu, avant curage complet. Les premiers résultats montrent la capture de particules de 1 et 100µm par les ganglions tumoraux mais aussi dans les ganglions sains, ce qui permettrait d’envisager un traitement ganglionnaire préventif et curatif.De plus en plus de tumeurs seront décelées au stade local. Par ailleurs l'identification des phénotypes génomiques permettra un traitement personnalisé « à la carte ». On pourrait envisager un dispositif de délivrance programmable traitant tous les aspects de la maladie, de l'inhibition de la croissance tumorale et de l'angiogenèse à la promotion de la cicatrisation des tissus normaux. / Systemic chemotherapy is mainly reserved for advanced cancers, is not targeted to the tumor, it is very difficult to achieve intratumoral therapeutic levels and its side effects and toxicity are dose-limiting.Local chemotherapy may have several advantages:1) stabilization of embedded drug molecules and preservation of anticancer activity,2) controlled and prolonged drug release to ensure adequate diffusion and uptake into cancer cells over many cycles of tumor cell division, 3) loading and release of water-insoluble chemotherapeutics, 4) direct delivery to the site of disease, 5) one-time administration of the drug, 6) diminished side effects due to the avoidance of systemic circulation of chemotherapeutic drugs.We were particularly interested in gynecological cancers. We studied the pharmacological and clinical effects of doxorubicin-loaded microspheres (Doxo) in a model of peritoneal carcinomatosis,a model of mammary gland tumor, and studied the diffusion profile of various micro and nanoparticles in tumoral and non tumoral lymph nodes.12 days after laparoscopic injection of VX2 tumors on the right and left broad ligament of WNZ rabbits laparoscopic injection of 0.5 ml of microspheres loaded or not with Doxo (DM or Group 1, BM Group 2 respectively) was conducted randomly to one side or another, at the sub peritoneal tumor site. 7 days after the broad ligaments, uterus, ovaries, trocars, bowels, bladder, liver and lungs were examined macroscopically and microscopically. The tumor volume was lower in group 1 (3.6 ± 3.2 cm) compared with group 2 (8.9 ± 5.4 cm) (MW, p = 0.0179). Necrosis was observed around all DM without necrosis around the BM. Doxo concentration was 2.1 ± 2.7 µM at the tumor margins, above the therapeutic level of 1.0 uM.On another model, 19 days after local injection of VX2 tumor suspensions in the second mammary gland of WNZ rabbits each gland was randomly treated by local injection of 0.5 ml of microspheres loaded or not with Doxo (HSDOXO, Group1, and HS Group 2).For tumors less than 5 cm3 or 2 cm in diameter before treatment, the final volume was lower in group 1 compared to Group 2 (p <0.008 and p <0.3, MW) and tumor growth was reduced after HSDOXO injection compared to HS. Microscopic tissue necrosis was observed around extratumoral HSDOXO without necrosis around the HS.We finally studied the diffusion of unloaded particles of various sizes on the lymph nodes of a mammary gland tumor. The animals were divided into three groups of three, each receiving particles of 100 nm, 1 µm or 10 µm. Five days after treatment, the fluorescence intensity was measured by UV lamp. The sentinel lymph node was dissected according to the technique of blue dye.The first results show the capture of 1 μm and 100μm particles by the tumoral and non tumoral lymph nodes, which would consider a preventive and curative treatment of the nodes.Since more and more tumors are detected at the local stage and with the identification of genomic phenotypes, a personalized local chemotherapy could be the next step of cancer therapy. One could imagine a programmable controlled drug delivery device dealing with all aspects of the disease, inhibition of tumor growth and angiogenesis, while promoting the healing of normal tissues.