Bridging the gap between attitudes and action: A qualitative exploration of clinician and exercise professional’s perceptions to increase opportunities for exercise counselling and referral in cancer care

ObjectiveThis study aimed to 1) understand factors impacting the implementation of exercise communication and referral, and 2) explore integrated clinical approaches to exercise communication and referral in cancer care.MethodsSeven focus groups (N = 53) were conducted with clinicians and exercise professionals throughout Sydney, Australia. A sub-sample of participants (n = 9) attended a half-day workshop to identifying best practice approaches for moving forward. Data were analysed using thematic content analysis.ResultsTwo themes emerged: 1) Factors impacting the knowledge-to-action gap, inclusive of limited exercise specific knowledge and training opportunities, funding structure, and current referral process, and 2) Recommendations for a consistent and efficient way forward, detailing the need for oncologist-initiated communication, distribution of cancer-exercise resources, and access to exercise professionals with cancer expertise.ConclusionsThis study identified factors (e.g., cancer-exercise specific training, integration of exercise physiologists) influencing exercise counselling and referral. A potential implementation-referral approach accounting for these factors and how to incorporate exercise into a standard model of cancer care, is described. Future testing is required to determine feasibility and practicality of these approaches.Practical ImplicationsA pragmatic model is provided to guide implementation-referral, inclusive of oncologist-initiated communication exchange, relevant resources, and access to exercise professionals with cancer expertise.     

Epidemiology of Connectional Silence in specialist serious illness conversations

ContextHuman connection can reduce suffering and facilitate meaningful decision-making amid the often terrifying experience of hospitalization for advanced cancer. Some conversational pauses indicate human connection, but we know little about their prevalence, distribution or association with outcomes.PurposeTo describe the epidemiology of Connectional Silence during serious illness conversations in advanced cancer.MethodsWe audio-recorded 226 inpatient palliative care consultations at two academic centers. We identified pauses lasting 2+ seconds and distinguished Connectional Silences from other pauses, sub-categorized as either Invitational (ICS) or Emotional (ECS). We identified treatment decisional status pre-consultation from medical records and post-consultation via clinicians. Patients self-reported quality-of-life before and one day after consultation.ResultsAmong all 6769 two-second silences, we observed 328 (4.8%) ECS and 240 (3.5%) ICS. ECS prevalence was associated with decisions favoring fewer disease-focused treatments (OR_adj: 2.12; 95% CI: 1.12, 4.06). Earlier conversational ECS was associated with improved quality-of-life (p = 0.01). ICS prevalence was associated with clinicians' prognosis expectations.ConclusionsConnectional Silences during specialist serious illness conversations are associated with decision-making and improved patient quality-of-life. Further work is necessary to evaluate potential causal relationships.Practice implicationsPauses offer important opportunities to advance the science of human connection in serious illness decision-making.     

Evaluation of a Novel Multimodal Opioid-Free Postoperative Pain Management Pathway Following Robotic-Assisted Radical Prostatectomy: A Pilot Series in the Veteran Population

BackgroundVeterans have disproportionate risk of opioid misuse and abuse compared to the civilian population. Managing acute postoperative pain without opioids is of the utmost importance for the Veteran patient population. This pilot study evaluates a novel multimodal opioid-free pain control regimen by assessing postoperative pain in Veterans undergoing robotic-assisted radical prostatectomy (RARP).MethodsProspective data was collected from patients undergoing RARP at a Department of Veterans Affairs Medical Center. Patients in the opioid-cohort received tramadol, hydrocodone-acetaminophen, or oxycodone-acetaminophen postoperatively. The opioid-free novel multimodal approach consisted of 100 mg gabapentin TID, 15 mg ketorolac Q6 hours, and 1 mg scheduled IV acetaminophen Q6 hours. Pain scores were collected using a visual analogue pain scale on postoperative days 0 and 1.ResultsData was collected from 57 patients, 33 treated with opioids and 24 with the opioid-free pathway. There were no significant differences in demographics (P > .05) between cohorts. No significant differences were observed for preoperative and intraoperative variables (P > .05). Average postoperative day 0 pain scores for opioid-free (2.2 ± 3.1) and opioid treatments (3.1 ± 3.1) were not statistically different (P = .1321). Postoperative day 1 differences of average pain scores for opioid-free (0.9 ± 1.9) and opioid (1.6 ± 3.1) treatments were not statistically significant (P = .1647).ConclusionsThe novel multimodal opioid-free treatment in this study may be effectively utilized for postoperative pain during hospital recovery of Veterans undergoing RARP. Future directions include a randomized control clinical trial in the general population.     

Academy of Nutrition and Dietetics Nutrition Research Network: Validation of a Novel Nutrition Informatics Tool to Assess Agreement Between Documented Nutrition Care and Evidence-Based Recommendations

More evidence regarding registered dietitian nutritionist implementation of evidence-based nutrition practice guidelines (EBNPGs) is needed. We assessed the utility of an automated informatics tool to evaluate congruence of documented nutrition care with 13 individual recommendations in the diabetes mellitus (DM) EBNPG and with the guideline overall. A concurrent validation study was conducted using Nutrition Care Process Terminology documentation entered in the Academy of Nutrition and Dietetics Health Informatics Infrastructure by registered dietitian nutritionists caring for patients with DM. A 15% subset (n = 115) of the 790 patient encounters recorded were selected randomly, and the documented care was evaluated using the automated DM Expected Care Plan (ECP) Analyzer and expert audit. Recommendation-level congruence, as determined by each method, was compared using Cohen’s κ analysis, and the accuracy, sensitivity, and specificity of the DM ECP Analyzer for assessing overall guideline-level congruence was calculated with expert audits as the “gold standard.” For recommendation-level congruence, the DM ECP Analyzer identified more instances of recommendation implementation in the patient encounters, and classified more encounters as including partial or full recommendation implementation for 10 of the 13 recommendations, compared with the expert audit. There was slight to fair agreement between the DM ECP and the expert audit for most individual recommendations, with a mean ± standard deviation level of agreement of κ = .17 ± .19 across all eligible recommendations. At the guideline level, the DM Analyzer had high accuracy (98.3%) and sensitivity (99.1%) and low specificity (0%; no true negatives detected). The DM ECP Analyzer is acceptable for conducting automated audits of nutrition documentation to assess congruence of documented care with recommendations for evidence-based care. Future changes to the EBNPG, Nutrition Care Process Terminology, Academy of Nutrition and Dietetics Health Informatics Infrastructure, and the DM ECP Analyzer could potentially improve recommendation-level performance. The DM ECP Analyzer can be modified for other EBNPGs to facilitate automated assessment of guideline implementation.     

Medical error disclosure in the Italian healthcare context: A delicate balance between ethical obligations and the principle of non-self-incrimination

Surprisingly, Italian legal doctrine and jurisprudence never systematically address the medical error disclosure issue. The topic of medical error communication represents a non-negligible profile of interest, relating to the possible detrimental effects on doctors who accuse themselves of conduct that does not comply with the lex artis. The effects of error disclosure on the effectiveness of insurance guarantees in civil and administrative liability are particularly relevant, as are the implications for ethical liability. Although the burden of reporting an error falls within the wide range of informative duties doctors hold, it still seems far from having found a factual statement in clinical practice, especially in Italy. This applies whether the error has a marginal or significant impact on the patient’s health. The reasons lay in a very contradictory legal framework. Doctors tend with increasing ease not to comply with their information obligation – especially in cases where fulfilling this duty means admitting a personal, professional error – to preserve the integrity of their professional images. This article aims to offer a brief overview of that topic in the context of Italian healthcare.     

Safety and pharmacokinetics of Roscovitine (Seliciclib) in cystic fibrosis patients chronically infected with Pseudomonas aeruginosa,a randomized,placebo-controlled study

BackgroundThe orally available kinase inhibitor R-roscovitine has undergone clinical trials against various cancers and is currently under clinical evaluation against Cushing disease and rheumatoid arthritis. Roscovitine displays biological properties suggesting potential benefits in CF: it partially corrects F508del-CFTR trafficking, stimulates the bactericidal properties of CF alveolar macrophages, and displays anti-inflammatory properties and analgesic effects.MethodsA phase 2 trial study (ROSCO-CF) was launched to evaluate the safety and effects of roscovitine in Pseudomonas aeruginosa infected adult CF patients carrying two CF causing mutations (at least one F508del-CFTR mutation) and harboring a FEV1 ≥40%. ROSCO-CF was a multicenter, double-blind, placebo-controlled, dose-ranging study (200, 400, 800 mg roscovitine, orally administered daily for 4 days/week/4 weeks).ResultsAmong the 34 volunteers enrolled, randomization assigned 11/8/8/7 to receive the 0 (placebo)/ 200/400/800 mg roscovitine doses, respectively. In these subjects with polypharmacy, roscovitine was relatively safe and well-tolerated, with no significant adverse effects (AEs) other than five serious AEs (SAEs) possibly related to roscovitine. Pharmacokinetics of roscovitine were rather variable among subjects. No significant efficacy, at the levels of inflammation, infection, spirometry, sweat chloride, pain and quality of life, was detected in roscovitine-treated groups compared to the placebo-treated group.ConclusionRoscovitine was relatively safe and well-tolerated in CF patients especially at the 200 and 400 mg doses. However, there were 5 subject withdrawals due to SAEs in the roscovitine group and none in the placebo group. The lack of evidence for efficacy of roscovitine (despite encouraging cellular and animal results) may be due to high pharmacokinetics variability, short duration of treatment, and/or inappropriate dosing protocol.     

Evaluation of a delineation software for cardiac atlas-based autosegmentation: An example of the use of artificial intelligence in modern radiotherapy

PurposeThe primary objective of this work was to implement and evaluate a cardiac atlas-based autosegmentation technique based on the “Workflow Box” software (Mirada Medical, Oxford UK), in order to delineate cardiac substructures according to European Society of Therapeutic Radiation Oncology (ESTRO) guidelines; review and comparison with other cardiac atlas-based autosegmentation algorithms published to date.Materials and MethodsOf an atlas of data set from 20 breast cancer patients’ CT scans with recontoured cardiac substructures creation according to the ESTRO guidelines. Performance evaluation on a validation data set consisting of 20 others CT scans acquired in the same treatment position: cardiac substructure were automatically contoured by the Mirada system, using the implemented cardiac atlas, and simultaneously manually contoured by a radiation oncologist. The Dice similarity coefficient was used to evaluate the concordance level between the manual and the automatic segmentations.ResultsDice similarity coefficient value was 0.95 for the whole heart and 0.80 for the four cardiac chambers. Average Dice similarity coefficient value for the left ventricle walls was 0.50, ranging between 0.34 for the apical wall and 0.70 for the lateral wall. Compared to manual contours, autosegmented substructure volumes were significantly smaller, with the exception of the left ventricle. Coronary artery segmentation was unsuccessful. Performances were overall similar to other published cardiac atlas-based autosegmentation algorithms.ConclusionThe evaluated cardiac atlas-based autosegmentation technique, using the Mirada software, demonstrated acceptable performance for cardiac cavities delineation. However, algorithm improvement is still needed in order to develop efficient and trusted cardiac autosegmentation working tools for daily practice.