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Background: Symptom management in conjunction with proton beam therapy (PBT) from patient's perspective has not been explored. Such knowledge is essential to optimize the care in this relatively new treatment modality. Objective: The aim of this study was to explore the process of symptom management in patients with brain tumor receiving PBT. Methods: Participants were 22 patients with primary brain tumor who received PBT, recruited in collaboration with a national center for proton therapy and 2 oncology clinics at 2 university hospitals in Sweden. Interviews using open-ended questions were conducted before, during, and/or after treatment. Verbatim interview transcripts were analyzed using classic Grounded Theory. Results: "The art of living with symptoms" emerged as the core concept. This encompassed 3 interconnected symptom management concepts: "Adapting to limited ability," "Learning about oneself," and "Creating new routines." These concepts were summarized in a substantive theoretical model of symptom management. Despite the struggle to manage symptoms, participants lived a satisfactory life. Conclusions: Symptom management in conjunction with PBT comprises a process of action, thoughts, and emotions. The concepts that emerged indicated patients' symptom management strategies were based on their own resources. Implications for Practice: It is important that PBT facilities develop an approach that facilitates the symptom management process based on patients' experiences of symptoms, as well as their actions and available resources.

May Bazzi,1 Solveig M Lundgren,1 Mikael Hellström,2 Isabell Fridh,3 Karin Ahlberg,1 Ingegerd Bergbom11Institute of Health and Care Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; 2Department of Radiology, Sahlgrenska University Hospital and Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden; 3Faculty of Caring Sciences, Work Life & Social Welfare, University of Borås, Borås, SwedenIntroduction: A hybrid operating room (OR) is a surgical OR with integrated imaging equipment and the possibility to serve both open surgery and image-guided interventions.Aim: This study aimed to investigate the work processes and types of collaboration in a hybrid OR during endovascular aortic repair (EVAR).Methods: Data consisted of video recordings from nine procedures, with a total recording time of 48 hrs 39 mins. The procedures were divided into four episodes (Acts). A qualitative cross-case analysis was conducted, resulting in a typical case. The type of collaboration during specific tasks was discussed and determined based on Thylefors´ team typology.Results: An extensive amount of safety activities occurred in the preparation phase (Acts 1 and 2), involving a number of staff categories. After the skin incision (Act 3), the main activities were performed by fewer staff categories, while some persons had a standby position and there were persons who were not at all involved in the procedure.Discussion: The different specialist staff in the hybrid OR worked through different types of collaboration: multi-, inter- and transprofessional. The level of needed collaboration depended on the activity performed, but it was largely multiprofessional and took place largely in separate groups of specialties: anesthesiology, surgery and radiology. Waiting time and overlapping tasks indicate that the procedures could be more efficient and safe for the patient.Conclusion: This study highlights that the three expertise specialties were required for safe treatment in the hybrid OR, but the extent of interprofessional activities was limited. Our results provide a basis for the development of more effective procedures with closer and more efficient interprofessional collaboration and reduction of overlapping roles. Considerable waiting times, traffic flow and presence of people who were not involved in the patient care are areas of further investigation.Keywords: hybrid operating room, work processes, collaboration, tasks, video recording, cross case analysis

Background The peroxisome biogenesis disorders, which are caused by mutations in any of 13 different PEX genes, include the Zellweger spectrum disorders. Severe defects in one of these PEX genes result in the absence of functional peroxisomes which is seen in classical Zellweger syndrome. These patients present with hypotonia and seizures shortly after birth. Other typical symptoms are dysmorphic features, liver disease, retinal degeneration, sensorineural deafness, polycystic kidneys, and the patient does not reach any developmental milestones. Case presentation We report a case of a patient with Zellweger spectrum disorder due to a novel mutation in the PEX10 gene, presenting with a mild late-onset neurological phenotype. The patient, an Assyrian girl originating from Iraq, presented with sensorineural hearing impairment at the age of 5 followed by sensorimotor polyneuropathy, cognitive delay, impaired gross and fine motor skills, and tremor and muscle weakness in her teens. Analyses of biochemical markers for peroxisomal disease suggested a mild peroxisomal defect and functional studies in fibroblasts confirmed the existence of a peroxisome biogenesis disorder. Diagnosis was confirmed by next generation sequencing analysis, which showed a novel homozygous mutation (c.530 T > G (p.Leu177Arg) (NM_153818.1)) in the PEX10 gene predicted to be pathogenic. Conclusions This case highlights the importance of performing biochemical, functional, and genetic peroxisomal screening in patients with clinical presentations milder than those usually observed in Zellweger spectrum disorders.

Survivors of gynecological cancer experience physical, psychological and existential consequences. Late gastrointestinal and urinary bladder symptoms, sexual dysfunction, including underlying physical and relational aspects, as well as lymphedema and fatigue, are common complaints. This may lead to reduced quality of life and social functioning and cancer rehabilitation is needed. Cancer rehabilitation, focusing on the individual cancer survivor and her specific needs, starting at diagnosis and continuing throughout cancer treatment and at follow-ups, is necessary.

Cancer-related fatigue (CRF) is one of the most common and distressing symptoms in cancer patients and it may interfere with everyday aspects of life. Despite the recent significant increase in the literature on CRF it is nevertheless understudied, and several important questions involving experience, aetiology, assessment and interventions remain unanswered. The primary aim of this thesis was to advance the science of cancer-related fatigue and extend prior work by describing CRF over time and the relationship of fatigue to health-related quality of life in patients with uterine cancer who are receiving radiotherapy. Secondary aims were 1) to gain an understanding of the relationships between fatigue, other symptoms and selected physiological mechanisms associated with fatigue, and 2) to identify predictors of fatigue. The Conceptual Model of Symptom Management (Larson et al 1994; Dodd et al 2001) constituted the major theoretical framework for this dissertation. Both quantitative and qualitative methods have been used. In the qualitative study 15 respondents were included before data saturation was achieved. The data collection and data analysis took place in one simultaneous process in accordance with Grounded Theory. In the quantitative studies 60 patients with uterine cancer who were going to receive treatment with radiotherapy were included. Data was collected before start of radiotherapy, during radiotherapy and after completed radiotherapy mainly through self-rating instruments. The quantitative data was analysed with descriptive and non-parametric statistical methods.The results of the studies indicated that fatigue is an experience of the whole person. The patients had a low level of experienced fatigue before starting radiotherapy. The fatigue level increased significantly during the course of radiation therapy and after completed treatment. During the period of treatment, between 77 and 89% experienced fatigue. Other symptoms (loss of appetite, nausea/vomiting, diarrhoea, pain) also increased significantly during treatment and the increases were significantly correlated with general fatigue. The patients psychological distress (anxiety, depression) was low before start of treatment. Although the scores for depression had increased significantly after completed therapy, the levels were still within normal limits. The levels of coping resources, here defined as sense of coherence, were stable throughout the studies. The patients health-related quality of life was high before start of treatment. The scores for global quality of life and social function decreased significantly over time. There was a significant relationship between general fatigue and global quality of life over time when measured at baseline, after 3 weeks of therapy, and after completed therapy. There was also a significant correlation over time between general fatigue and physical function, role function and cognitive function. There was no significant correlation between general fatigue and IL-1, TNF-alpha or haemoglobin. There was a significant negative correlation between the change in IL-6 and general fatigue.The variation in the level of general fatigue after completed therapy was explained mainly by the level of experienced general fatigue at baseline. The knowledge obtained in this thesis should lead to better understanding of the cancer-related fatigue experience, including influencing variables, responses and outcomes, in women with uterine cancer who are receiving radiotherapy. Nursing interventions to help patients with CRF may include careful assessment, identification of patients at risk, and management of problems before the initiation of therapy.