Pathogenic Roles for RNASET2 in Clear Cell Renal Cell Carcinoma.

A specific splicing isoform of RNASET2 is associated with worse oncologic outcomes in clear cell renal cell carcinoma (ccRCC). However, the interplay between wild-type RNASET2 and its splice variant and how this might contribute to the pathogenesis of ccRCC remains poorly understood. We sought to better understand the relationship of RNASET2 in the pathogenesis of ccRCC and the interplay with a pathogenic splicing isoform (RNASET2-SV) and the tumor immune microenvironment. Using data from The Cancer Genome Atlas and Clinical Proteomic Tumor Analysis Consortium, we correlated clinical variables to RNASET2 expression and the presence of a specific RNASET2-SV. Immunohistochemical staining with matched RNA sequencing of ccRCC patients was then utilized to understand the spatial relationships of RNASET2 with immune cells. Finally, in vitro studies were performed to demonstrate the oncogenic role of RNASET2 and highlight its potential mechanisms. RNASET2 gene expression is associated with higher grade tumors and worse overall survival in The Cancer Genome Atlas cohort. The presence of the RNASET2-SV was associated with increased expression of the wild-type RNASET2 protein and epigenetic modifications of the gene. Immunohistochemical staining revealed increased intracellular accumulation of RNASET2 in patients with increased RNA expression of RNASET2-SV. In vitro experiments reveal that this accumulation results in increased cell proliferation, potentially from altered metabolic pathways. RNASET2 exhibits a tumor-promoting role in the pathogenesis of ccRCC that is increased in the presence of a specific RNASET2-SV and associated with changes in the cellular localization of the protein.

Tailer: a pipeline for sequencing-based analysis of nonpolyadenylated RNA 3' end processing.

Post-transcriptional trimming and tailing of RNA 3' ends play key roles in the processing and quality control of noncoding RNAs (ncRNAs). However, bioinformatic tools to examine changes in the RNA 3' "tailome" are sparse and not standardized. Here we present Tailer, a bioinformatic pipeline in two parts that allows for robust quantification and analysis of tail information from next-generation sequencing experiments that preserve RNA 3' end information. The first part of Tailer, Tailer-processing, uses genome annotation or reference FASTA gene sequences to quantify RNA 3' ends from SAM-formatted alignment files or FASTQ sequence read files produced from sequencing experiments. The second part, Tailer-analysis, uses the output of Tailer-processing to identify statistically significant RNA targets of trimming and tailing and create graphs for data exploration. We apply Tailer to RNA 3' end sequencing experiments from three published studies and find that it accurately and reproducibly recapitulates key findings. Thus, Tailer should be a useful and easily accessible tool to globally investigate tailing dynamics of nonpolyadenylated RNAs and conditions that perturb them.

A Taxonomy for Health Information Systems.

The health sector is highly digitized, which is enabling the collection of vast quantities of electronic data about health and well-being. These data are collected by a diverse array of information and communication technologies, including systems used by health care organizations, consumer and community sources such as information collected on the web, and passively collected data from technologies such as wearables and devices. Understanding the breadth of IT that collect these data and how it can be actioned is a challenge for the significant portion of the digital health workforce that interact with health data as part of their duties but are not for informatics experts. This viewpoint aims to present a taxonomy categorizing common information and communication technologies that collect electronic data. An initial classification of key information systems collecting electronic health data was undertaken via a rapid review of the literature. Subsequently, a purposeful search of the scholarly and gray literature was undertaken to extract key information about the systems within each category to generate definitions of the systems and describe the strengths and limitations of these systems.

Educating primary care physicians about eating disorders: Pilot data from a microlearning programme.

BACKGROUND: Over two-thirds of people present to their primary care physician (or general practitioner; GP) as a first point of contact for mental health concerns. However, eating disorders (EDs) are often not identified in a primary care setting. A significant barrier to early detection and intervention is lack of primary care physician training in EDs; compounded by the significant time commitments required for training by already time-poor general practitioners. The aim of the current study was to pilot and evaluate a microlearning programme that can be delivered to general practitioners with high workloads to help support patients with, or at risk of, developing an ED. METHODS: Fifty-one Australian general practitioners aged between 25-to-60 years old were recruited. Participants completed a baseline questionnaire to ascertain their experience working in general practice and with EDs. Participants then completed an online programme consisting of a series of 10 case studies (vignettes) delivered over a 6-10 week period related to various facets of ED care. Following conclusion of the programme, participants were asked to complete an evaluative questionnaire related to the content of the programme; perceived knowledge, confidence, willingness-to-treat, skill change; and their overall experience of microlearning. RESULTS: All 51 GPs completed the programme and reached completion criteria for all vignettes, 40 of whom completed the programme evaluation. Participants indicated improved skill, confidence, willingness-to-treat, and knowledge following the completion of the pilot programme. Almost all (97.5%; n = 39) found microlearning to be an effective method to learn about EDs; with 87.5% (n = 35) of participants reporting they felt able to apply what was learnt in practice. Qualitative feedback highlighted the benefit of microlearning's flexibility to train general practitioners to work with complex health presentations, specifically EDs. CONCLUSIONS: Findings from the current study lend support to the use of microlearning in medical health professional training; notably around complex mental health concerns. Microlearning appears to be an acceptable and effective training method for GPs to learn about EDs. Given the significant time demands on GPs and the resulting challenges in designing appropriate training for this part of the workforce, this training method has promise. The pre-existing interest in EDs in the current study sample was high; future studies should sample more broadly to ensure that microlearning can be applied at scale.

Impact of initial therapy with upadacitinib or adalimumab on achievement of 48-week treatment goals in patients with rheumatoid arthritis: post hoc analysis of SELECT-COMPARE.

OBJECTIVES: Evaluate the importance of treatment sequencing in SELECT-COMPARE, assessing potential differences between starting upadacitinib or adalimumab therapy following inadequate MTX response. METHODS: Patients from SELECT-COMPARE were randomized to upadacitinib 15 mg once daily, placebo or adalimumab 40 mg. Per protocol, patients with <20% improvement in tender or swollen joint counts (weeks 14, 18, 22) or failure to achieve Clinical Disease Activity Index (CDAI) low disease activity (LDA) at week 26 were blindly switched from upadacitinib to adalimumab or vice versa. Treatment outcomes, including clinical remission/LDA, physical function, pain and a novel combined endpoint for deep response, were evaluated through 48 weeks and corresponding time-averaged response rates determined. Data were analysed by initial randomized group regardless of any subsequent switch in therapy. RESULTS: This post hoc analysis included 651 patients initially randomized to upadacitinib (of whom 252 switched to adalimumab) and 327 patients initially randomized to adalimumab (of whom 159 switched to upadacitinib). At week 48, patients randomized to either therapy demonstrated similar achievement of most treatment endpoints. Greater improvements in the total time spent in a lower disease state were observed for initial upadacitinib vs initial adalimumab therapy across most clinical and patient-reported outcomes through 48 weeks, and the median time to DAS28(CRP) <2.6/≤3.2 occurred 6-8 weeks earlier among those randomized to upadacitinib. CONCLUSION: Following a modified treat-to-target strategy, rates of CDAI remission/LDA and DAS28(CRP) <2.6/≤3.2 at 48 weeks were similar, regardless of starting therapy. However, patients initially receiving upadacitinib reached treatment targets more quickly and spent more time in clinical targets over the initial 48 weeks of treatment. TRIAL REGISTRATION: ClinicalTrials.gov, https://clinicaltrials.gov, NCT02629159.

Comprehensive molecular and clinical characterization of NUP98 fusions in pediatric acute myeloid leukemia.

NUP98 fusions comprise a family of rare recurrent alterations in AML, associated with adverse outcomes. In order to define the underlying biology and clinical implications of this family of fusions, we performed comprehensive transcriptome, epigenome, and immunophenotypic profiling of 2,235 children and young adults with AML and identified 160 NUP98 rearrangements (7.2%), including 108 NUP98-NSD1 (4.8%), 32 NUP98-KDM5A (1.4%) and 20 NUP98-X cases (0.9%) with 13 different fusion partners. Fusion partners defined disease characteristics and biology; patients with NUP98-NSD1 or NUP98-KDM5A had distinct immunophenotypic, transcriptomic, and epigenomic profiles. Unlike the two most prevalent NUP98 fusions, NUP98-X variants are typically not cryptic. Furthermore, NUP98-X cases are associated with WT1 mutations, and have epigenomic profiles that resemble either NUP98-NSD1 or NUP98-KDM5A. Cooperating FLT3-ITD and WT1 mutations define NUP98-NSD1, and chromosome 13 aberrations are highly enriched in NUP98-KDM5A. Importantly, we demonstrate that NUP98 fusions portend dismal overall survival, with the noteworthy exception of patients bearing abnormal chromosome 13 (clinicaltrials gov. Identifiers: NCT00002798, NCT00070174, NCT00372593, NCT01371981).

Digital health competencies for the next generation of physicians.

As health care continues to change and evolve in a digital society, there is an escalating need for physicians who are skilled and enabled to deliver care using digital health technologies, while remaining able to successfully broker the triadic relationship among patients, computers and themselves. The focus needs to remain firmly on how technology can be leveraged and used to support good medical practice and quality health care, particularly around resolution of longstanding challenges in health care delivery, including equitable access in rural and remote areas, closing the gap on health outcomes and experiences for First Nations peoples and better support in aged care and those living with chronic disease and disability. We propose a set of requisite digital health competencies and recommend that the acquisition and evaluation of these competencies become embedded in physician training curricula and continuing professional development programmes.

A mixed methods study of Aboriginal health workers' and exercise physiologists' experiences of co-designing chronic lung disease 'yarning' education resources.

BACKGROUND: Despite the high incidence of chronic obstructive pulmonary disease (COPD) in Aboriginal communities in Australia, Aboriginal Health Workers (AHWs) have limited knowledge about effective management. AIM: To evaluate an online education program, co-designed with AHWs and exercise physiologists (EPs) or physiotherapists (PTs), to increase knowledge about COPD and its management. METHODS: AHWs and EPs from four Aboriginal Community Controlled Health Services (ACCHS) were recruited. An Aboriginal researcher and a physiotherapist experienced in COPD management and pulmonary rehabilitation (PR) delivered seven online education sessions. These sessions used co-design principles and an Aboriginal pedagogy framework '8 Ways of learning', which incorporates Aboriginal protocols and perspectives to realign teaching techniques and strengthen learning outcomes. Topics covered were: How the lungs work; What is COPD; Medications and how to use inhalers and COPD Action Plans; Why exercise is important; Managing breathlessness; Healthy eating; Managing anxiety and depression. After each session, AHWs with support from EPs, co-designed education 'yarning' resources using Aboriginal ways of learning to ensure topics were culturally safe for the local Aboriginal community and practiced delivering this at the following session. At the end of the program participants completed an anonymous online survey (5-point Likert scale) to assess satisfaction, and a semi-structured interview about their experience of the online education. RESULTS: Of the 12 participants, 11 completed the survey (7 AHWs, 4 EPs). Most (90%) participants strongly agreed or agreed that the online sessions increased knowledge and skills they needed to support Aboriginal patients with COPD. All (100%) participants felt: their cultural perspectives and opinions were valued and that they were encouraged to include cultural knowledge. Most (91%) reported that delivering their own co-designed yarning scripts during the online sessions improved their understanding of the topics. Eleven participants completed semi-structured interviews about participating in online education to co-design Aboriginal 'yarning' resources. Themes identified were: revealing the Aboriginal lung health landscape; participating in online learning; structuring the online education sessions; co-designing with the facilitators. CONCLUSIONS: Online education using co-design and 8 Ways of learning was rated highly by AHWs and EPs for improving COPD knowledge and valuing cultural perspectives. The use of co-design principles supported the cultural adaptation of COPD resources for Aboriginal people with COPD. TRIAL REGISTRATION: PROSPERO (registration number: CRD42019111405).

Thought Leader Perspectives on the Benefits, Barriers, and Enablers for Routinely Collected Electronic Health Data to Support Professional Development: Qualitative Study.

BACKGROUND: Hospitals routinely collect large amounts of administrative data such as length of stay, 28-day readmissions, and hospital-acquired complications; yet, these data are underused for continuing professional development (CPD). First, these clinical indicators are rarely reviewed outside of existing quality and safety reporting. Second, many medical specialists view their CPD requirements as time-consuming, having minimal impact on practice change and improving patient outcomes. There is an opportunity to build new user interfaces based on these data, designed to support individual and group reflection. Data-informed reflective practice has the potential to generate new insights about performance, bridging the gap between CPD and clinical practice. OBJECTIVE: This study aims to understand why routinely collected administrative data have not yet become widely used to support reflective practice and lifelong learning. METHODS: We conducted semistructured interviews (N=19) with thought leaders from a range of backgrounds, including clinicians, surgeons, chief medical officers, information and communications technology professionals, informaticians, researchers, and leaders from related industries. Interviews were thematically analyzed by 2 independent coders. RESULTS: Respondents identified visibility of outcomes, peer comparison, group reflective discussions, and practice change as potential benefits. The key barriers included legacy technology, distrust with data quality, privacy, data misinterpretation, and team culture. Respondents suggested recruiting local champions for co-design, presenting data for understanding rather than information, coaching by specialty group leaders, and timely reflection linked to CPD as enablers to successful implementation. CONCLUSIONS: Overall, there was consensus among thought leaders, bringing together insights from diverse backgrounds and medical jurisdictions. We found that clinicians are interested in repurposing administrative data for professional development despite concerns with underlying data quality, privacy, legacy technology, and visual presentation. They prefer group reflection led by supportive specialty group leaders, rather than individual reflection. Our findings provide novel insights into the specific benefits, barriers, and benefits of potential reflective practice interfaces based on these data sets. They can inform the design of new models of in-hospital reflection linked to the annual CPD planning-recording-reflection cycle.

Patient Use, Experience, and Satisfaction With Telehealth in an Australian Population (Reimagining Health Care): Web-Based Survey Study.

BACKGROUND: The COVID-19 pandemic triggered a rapid scale-up of telehealth services in Australia as a means to provide continued care through periods of physical restrictions. The factors that influence engagement in telehealth remain unclear. OBJECTIVE: The purpose of this study is to understand the experience of Australian people who engaged in a telehealth consultation during the pandemic period (2020-2021) and the demographic factors that influence engagement. METHODS: A web-based survey was distributed to Australians aged over 18 years that included 4 questions on frequency and type of clinical consultation, including with a general practitioner (GP), specialist, allied health, or nurse; 1 question on the experience of telehealth; and 2 questions on the quality of and satisfaction with telehealth. Statistical analysis included proportion of responses (of positive responses where a Likert scale was used) and regression analyses to determine the effect of demographic variables. RESULTS: Of the 1820 participants who completed the survey, 88.3% (1607/1820) had engaged in a health care consultation of some type in the previous 12 months, and 69.3% (1114/1607) of those had used telehealth. The most common type of consultation was with a GP (959/1114, 86.1%). Older people were more likely to have had a health care consultation but less likely to have had a telehealth consultation. There was no difference in use of telehealth between metropolitan and nonmetropolitan regions; however, people with a bachelor's degree or above were more likely to have used telehealth and to report a positive experience. A total of 87% (977/1114) of participants agreed or strongly agreed that they had received the information they required from their consultation, 71% (797/1114) agreed or strongly agreed that the outcome of their consultation was the same as it would have been face-to-face, 84% (931/1114) agreed or strongly agreed that the doctor or health care provider made them feel comfortable, 83% (924/1114) agreed or strongly agreed that the doctor or health care provider was equally as knowledgeable as providers they have seen in person; 57% (629/1114) of respondents reported that they would not have been able to access their health consultation if it were not for telehealth; 69% (765/1114) of respondents reported that they were satisfied with their telehealth consultation, and 60% (671/1114) reported that they would choose to continue to use telehealth in the future. CONCLUSIONS: There was a relatively high level of engagement with telehealth over the 12 months leading up to the study period, and the majority of participants reported a positive experience and satisfaction with their telehealth consultation. While there was no indication that remoteness influenced telehealth usage, there remains work to be done to improve access to older people and those with less than a bachelor's degree.

Feasibility of Microlearning for Improving the Self-Efficacy of Cancer Patients Managing Side Effects of Chemotherapy.

Lung cancer patients have a high symptom burden that negatively affects their quality of life. Increasing patient self-efficacy to deal with treatment side effects can ameliorate their symptom burden. Education programs can help enhance patient self-efficacy by giving patients more control over their condition through increased disease literacy. This study aimed to evaluate the feasibility of microlearning for delivering lung cancer patients' information on side effects of chemotherapy. Secondary objectives of the program are to understand the acceptability of microlearning for delivery this type of education to lung cancer patients and the potential impact of microlearning on patient self-efficacy, knowledge and confidence managing side effects of chemotherapy. A mixed-methods prepost test (or quasi-experimental) study design was used to better enable patients to identify and manage the side effects of their condition and chemotherapy. Participants were patients diagnosed with stage II to stage IV lung cancer, who had a life expectancy of greater than 3 months and were aged 18 years or older. Multiple validated scales were used to assess patient self-efficacy pre- and post-intervention. The online program was evaluated using quantitative data of completion rates extracted from the online platform. Semi-structured interviews were used to explore the impact of the online program on perceived self-efficacy and quality of life. Twenty-three participants agreed to participate in the study and five agreed to complete a semi-structured interview. Participants found the content comprehensive, relevant and engaging. The program improved perceived disease literacy and helped participants develop coping strategies to manage side effects. Participants also found the platform easy to use and navigate. Additional courses and features were requested. Patients with a diagnosis of cancer receive a large amount of information about the side effects of chemotherapy and how to manage them. This information is often provided soon after diagnosis or upon commencement of therapy, which can be overwhelming for some patients. Microlearning, a method of online learning that spaces distributing of content over several weeks, may be a useful tool for supporting delivering of health information to this group of patients.

Role of anti-HBs in functional cure of HBeAg+ chronic hepatitis B patients infected with HBV genotype A.

BACKGROUND & AIMS: HBsAg-specific antibody responses are difficult to detect during chronic hepatitis B infection (CHB) and are often overlooked. The aim of this study was to examine whether anti-HBs may be involved in functional cure (FC) by profiling anti-HBs responses in patients with CHB using a panel of specific assays. METHODS: Longitudinal serum samples were obtained from 25 patients with CHB who were infected with HBV genotype A and were undergoing nucleos(t)ide analogue (NA) treatment: 14 achieved FC while 11 remained infected (non-FC). Anti-HBs immune complexes (HBsAg-IC), FcγRIIIa dimer binding, epitope specificity and neutralisation efficacy were measured. RESULTS: HBsAg-IC peaks were detected prior to HBsAg loss in 10/14 FC patients. These HBsAg-IC peaks overlapped with either an alanine aminotransferase (ALT) flare (8/10 patients), or a rise in ALT (2/10 patients). HBsAg-IC peaks were detected in 7/11 non-FC patients, but were not associated with an ALT flare. FCγRIIIa binding was detected in 9/14 FC patients, independent from detection of overlapping HBsAg-IC/ALT peaks. FC patients had stable HBsAg epitope occupancy across the study, whereas non-FC patients had a reduction in HBsAg epitope occupancy within the first 12-24 weeks of NA treatment. Convalescent sera from FC patients recognised more HBsAg epitopes and neutralised HBV infection more potently than anti-HBs derived from vaccinees. Neutralisation potency appeared to increase post-HBsAg loss in 4/5 FC patients examined. CONCLUSIONS: Using these assays, we confirm that anti-HBs responses are present and fluctuate over time in this cohort of patients with HBeAg+ CHB, who were infected with HBV genotype A and treated with NAs. Key anti-HBs profiles associated with either FC or failure to achieve FC were also identified, suggesting a role for anti-HBs responses in FC. LAY SUMMARY: Using a panel of assays to characterise hepatitis B surface antibody (anti-HBs) responses in a group of patients with chronic hepatitis B, we identified anti-HBs profiles associated with either functional cure, or failure to achieve functional cure. Functional cure was associated with immune complex peaks which overlapped with alanine aminotransferase flares. Conversely, in those who did not achieve functional cure, immune complex peaks were present, but were not associated with alanine aminotransferase flares, and a decline in anti-HBs diversity was observed early during treatment.

Inhibition of structural joint damage progression with upadacitinib in rheumatoid arthritis: 1-year outcomes from the SELECT phase 3 program.

OBJECTIVES: To evaluate the inhibition of progression of structural joint damage through week 48 in patients with moderately to severely active RA receiving upadacitinib as monotherapy or in combination with MTX. METHODS: Radiographic progression was assessed in two phase 3 randomized controlled trials. MTX-naïve patients were randomized to upadacitinib 15 or 30 mg once daily or MTX monotherapy (SELECT-EARLY, n = 945), while MTX inadequate responders (IRs) were randomized to upadacitinib 15 mg once daily or adalimumab 40 mg every other week or placebo added to background MTX (SELECT-COMPARE, n = 1629). The mean changes from baseline in modified total Sharp score (mTSS), joint space narrowing and erosion scores were determined. Data were analysed both by linear extrapolation for missing data imputation and treatment switching and as observed. RESULTS: In patients naïve or with limited exposure to MTX (SELECT-EARLY), mean changes from baseline to week 48 in mTSS were 0.03 for upadacitinib 15 mg, 0.14 for upadacitinib 30 mg and 1.00 for MTX based on linear extrapolation (P < 0.001 for both upadacitinib doses vs MTX). Among patients with an inadequate response to MTX (SELECT-COMPARE), the mean change from baseline in mTSS was significantly reduced in the upadacitinib 15 mg plus MTX group vs placebo plus MTX (0.28 vs 1.73; P < 0.001). The mean change from baseline in the adalimumab plus MTX group was 0.39. CONCLUSION: Upadacitinib monotherapy or in combination with background MTX was effective in inhibiting the progression of structural joint damage through week 48 in MTX-naïve and MTX-IR patients with RA. TRIAL REGISTRATION: ClinicalTrials.gov (https://clinicaltrials.gov), NCT02706873 and NCT02629159.

Can existing electronic medical records be used to quantify cardiovascular risk at point of care?

BACKGROUND: Using electronic data for cardiovascular risk stratification could help in prioritising healthcare access and optimise cardiovascular prevention. AIMS: To determine whether assessment of absolute cardiovascular risk (Australian absolute cardiovascular disease risk (ACVDR)) and short-term ischaemic risk (History, ECG, Age, Risk factors, and Troponin (HEART) score) is possible from available data in Electronic Medical Record (EMR) and My Health Record (MHR) of patients presenting with acute cardiac symptoms to a Rapid Access Cardiology Clinic (RACC). METHODS: Audit of EMR and MHR on 200 randomly selected adults who presented to RACC between 1 March 2017 and 4 February 2020. The main outcomes were the proportion of patients for which ACVDR score and HEART score could be calculated. RESULTS: Mean age was 55.2 ± 17.8 years and 43% were female. Most (85%) were referred from emergency for chest pain (52%). Forty-six percent had hypertension, 35% obesity, 20% diabetes mellitus, 17% ischaemic heart disease and 18% were current smokers. There was no significant difference in MHR accessibility with age, gender and number of comorbidities. An ACVDR score could be estimated for 17.5% (EMR) and 0% (MHR) of patients. None had complete data to estimate HEART score in either EMR or MHR. Most commonly missing variables for ACVDR score were blood pressure (MHR) and high-density lipoprotein cholesterol (EMR), and for HEART score the missing variables were body mass index and comorbidities (MHR and EMR). CONCLUSIONS: Significant gaps are apparent in electronic medical data capture of key variables to perform cardiovascular risk assessment. Medical data capture should prioritise the collection of clinically important data to help address gaps in cardiovascular management.

Implementing evidence into practice to improve chronic lung disease management in Indigenous Australians: the breathe easy, walk easy, lungs for life (BE WELL) project (protocol).

BACKGROUND: Strong evidence exists for the benefits of pulmonary rehabilitation (PR) for people with chronic obstructive pulmonary disease (COPD), however the availability of culturally safe PR for Aboriginal and Torres Strait Islander (Indigenous) Peoples is limited. The study aims to determine whether PR can be implemented within Aboriginal Community Controlled Health Services (ACCHS) to improve outcomes for Indigenous people with COPD. METHODS: Multi-centre cohort study using participatory action research guided by the Knowledge-to-Action Framework. ACCHS supportive of enhancing services for chronic lung disease will be recruited. Aboriginal Health Workers (AHW) and the exercise physiologist (EP) or physiotherapist (PT) within these ACCHS will attend a workshop aimed at increasing knowledge and skills related to management of COPD and the provision of PR. Indigenous people with COPD will be invited to attend an 8-week, twice weekly, supervised PR program. OUTCOMES: AHW, EP/PT knowledge, skills and confidence in the assessment and management of COPD will be measured before and immediately after the BE WELL workshop and at 3, 6 and 12 months using a survey. PR participant measures will be exercise capacity (6-minute walk test (6MWT), health-related quality of life and health status at commencement and completion of an 8-week PR program. Secondary outcomes will include: number, length and cost of hospitalisations for a COPD exacerbation in 12-months prior and 12-months post PR; local contextual factors influencing implementation of PR; specific respiratory services provided by ACCHS to manage COPD prior to project commencement and at project completion. Repeated measures ANOVA will be used to evaluate changes in knowledge and confidence over time of AHWs and EP/PTs. Paired t-tests will be used to evaluate change in patient outcomes from pre- to post-PR. Number of hospital admissions in the 12 months before and after the PR will be compared using unpaired t-tests. DISCUSSION: Pulmonary rehabilitation is an essential component of best-practice management of COPD and is recommended in COPD guidelines. Indigenous peoples have limited access to culturally safe PR programs. This study will evaluate whether PR can be implemented within ACCHS and improve outcomes for Indigenous people with COPD. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001337369, Registered 2nd September 2017 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373585&isClinicalTrial=False.

Development, acceptability and uptake of an on-line communication skills education program targeting challenging conversations for oncology health professionals related to identifying and responding to anxiety and depression.

BACKGROUND: Anxiety and depression screening and management in cancer settings occurs inconsistently in Australia. We developed a clinical pathway (ADAPT CP) to promote standardized assessment and response to affected patients and enhance uptake of psychosocial interventions. Health professional education is a common strategy utilised to support implementation of practice change interventions. We developed an interactive on-line education program to support staff communication and confidence with anxiety/depression screening and referral prior to the ADAPT CP being implemented in 12 oncology services participating in the ADAPT CP cluster randomised controlled trial (CRCT). The aim of this research was to assess acceptability and uptake of the education program. Patient Involvement: Although the wider ADAPT Program included patient consumers on the Steering Committee, in the context of this research consumer engagement included health professionals working in oncology. These consumers contributed to resource development. METHODS: Development was informed by oncology and communication literature. The five online modules were pilot tested with 12 oncology nurses who participated in standardised medical simulations. Acceptability and uptake were assessed across the 12 Oncology services participating in the ADAPT CRCT. RESULTS: During pilot testing the online training was reported to be acceptable and overall communication and confidence improved for all participants post training. However, during the ADAPT CRCT uptake was low (7%; n = 20). Although those who accessed the training reported it to be valuable, competing demands and the online format reportedly limited HPs' capacity and willingness to undertake training. CONCLUSIONS: This interactive on-line training provides strategies and communication skills for front-line staff to guide important conversations about psychosocial screening and referral. Building workforce skills, knowledge and confidence is crucial for the successful implementation of practice change interventions. However, despite being acceptable during pilot testing, low uptake in real world settings highlights that organisational support and incentivisation for frontline staff to undertake training are critical for wider engagement. A multimodal approach to delivery of training to cater for staff preferences for face to face and/or online training may maximise uptake and increase effectiveness of training interventions. TRIAL REGISTRATION: Pilot study ACTRN12616001490460 (27/10/2016). ADAPT RCT ACTRN12617000411347(22/03/2017).

"There's a lot of talent in the room but it's only really the medical talent that gets heard": a qualitative exploration of multidisciplinary clinicians' perspectives of optimal nutrition care of patients with head and neck cancer.

BACKGROUND: The high prevalence of malnutrition in patients with head and neck cancer (HNC) negatively impacts outcomes. The best-available evidence has been published in clinical nutrition guidelines; however, translation into practice has lagged. AIM: This project aimed to explore multidisciplinary team (MDT) clinicians' perspectives regarding barriers and enablers to best-practice nutrition care in order to inform the design of a new model of care. METHOD: Qualitative interviews were conducted with clinicians who were purposively sampled from a major HNC tertiary referral centre in Sydney, Australia. To elicit information regarding barriers and facilitators to change, a semi-structured interview schedule was developed, interviews were transcribed verbatim and analyzed employing an inductive thematic approach. The Consolidated Framework for Implementation Research (CFIR) was used to guide data analysis and interpretation of key themes identified. RESULTS: Nineteen participants (11 supportive care and eight medical clinicians) representing allied health, medical, and nursing disciplines participated. Five key themes were identified: (1) acknowledgement of dietetics expertise and access to resources to deliver nutrition care; (2) proactive versus reactive nutrition care; (3) integrated and coordinated care-"The One Stop Shop"; (4) MDT favours the medical model; and (5) leadership-within disciplines, within the MDT. CONCLUSIONS: MDT clinicians expressed similar views regarding delivering optimal nutrition care to this high nutritional risk patient group. However, perspectives differed at times between medical and supportive care clinicians, attributable to perceptions that current service structure favours the medical model. In order to design and deliver an evidence-based model of care, specific strategies will be required to ensure: early and ongoing access to expert nutrition care; nutrition care processes are proactive; integrated and coordinated care; and leadership, both intra- and inter-disciplinary. This novel exploration of MDT clinicians' views provides supporting evidence that multi-component implementation strategies comprising individual, team and system-level approaches will be essential to leverage sustainable change.

Electronic medical record implementation in tertiary care: factors influencing adoption of an electronic medical record in a cancer centre.

BACKGROUND: Electronic Medical Records (EMRs) are one of a range of digital health solutions that are key enablers of the data revolution transforming the health sector. They offer a wide range of benefits to health professionals, patients, researchers and other key stakeholders. However, effective implementation has proved challenging. METHODS: A qualitative methodology was used in the study. Interviews were conducted with 12 clinical and administrative staff of a cancer centre at one-month pre-launch and eight clinical and administrative staff at 12-months post-launch of an EMR. Data from the interviews was collected via audio recording. Audio recordings were transcribed, de-identified and analysed to identify staff experiences with the EMR. RESULTS: Data from the pre-implementation interviews were grouped into four categories: 1) Awareness and understanding of EMR; 2) Engagement in launch process; 3) Standardisation and completeness of data; 4) Effect on workload. Data from the post-launch interviews were grouped into six categories: 1) Standardisation and completeness of data; 2) Effect on workload; 3) Feature completeness and functionality; 4) Interaction with technical support; 5) Learning curve; 6) Buy-in from staff. Two categories: Standardisation and completeness of data and effect on workload were common across pre and post-implementation interviews. CONCLUSION: Findings from this study contribute new knowledge on barriers and enablers to the implementation of EMRs in complex clinical settings. Barriers to successful implementation include lack of technical support once the EMR has launched, health professional perception the EMR increases workload, and the learning curve for staff adequately familiarize themselves with using the EMR.

Supportive Care Interventions for People With Cancer Assisted by Digital Technology: Systematic Review.

BACKGROUND: Although relatively new, digital health interventions are demonstrating rapid growth because of their ability to facilitate access and overcome issues of location, time, health status, and most recently, the impact of a major pandemic. With the increased uptake of digital technologies, digital health has the potential to improve the provision of supportive cancer care. OBJECTIVE: This systematic review aims to evaluate digital health interventions for supportive cancer care. METHODS: Published literature between 2000 and 2020 was systematically searched in MEDLINE, PubMed, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, and Scopus. Eligible publications were randomized controlled trials of clinician-led digital health interventions to support adult cancer patients. The interventions included were determined by applying a digital health conceptual model. Studies were appraised for quality using the revised Cochrane risk of bias tool. RESULTS: Twenty randomized controlled trials met the inclusion criteria for the analysis. Interventions varied by duration, frequency, degree of technology use, and applied outcome measures. Interventions targeting a single tumor stream, predominantly breast cancer, and studies involving the implementation of remote symptom monitoring have dominated the results. In most studies, digital intervention resulted in significant positive outcomes in patient-reported symptoms, levels of fatigue and pain, health-related quality of life, functional capacity, and depression levels compared with the control. CONCLUSIONS: Digital health interventions are helpful and effective for supportive care of patients with cancer. There is a need for high-quality research. Future endeavors could focus on the use of valid, standardized outcome measures, maintenance of methodological rigor, and strategies to improve patient and health professional engagement in the design and delivery of supportive digital health interventions. TRIAL REGISTRATION: PROSPERO CRD42020149730; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=149730.

"Completely and utterly flummoxed and out of my depth": patient and caregiver experiences during and after treatment for head and neck cancer-a qualitative evaluation of barriers and facilitators to best-practice nutrition care.

BACKGROUND: Malnutrition is prevalent in patients with head and neck cancer (HNC), impacting on outcomes. Despite publication of best-practice nutrition care clinical guidelines, evidence-practice gaps persist. AIM: This project aimed to understand the perspectives of patients and their caregivers about nutritional care and how their unmet supportive care needs can be better addressed in designing a new model of care (MOC). The results will contribute to documenting the barriers and enablers to implementing best practice nutrition care for patients with HNC. METHOD: Qualitative interviews were conducted with patients who had completed radiotherapy with or without (+/-) other treatment modality (surgery and/or systematic therapy) of curative intent for HNC. Patients were purposively sampled from a major tertiary referral centre in Sydney, Australia. Patients' primary caregivers were also invited to participate if both parties consented. A semi-structured interview schedule was developed to elicit information about barriers and facilitators to change and inform development of the new MOC. Interviews were transcribed verbatim then analysed using an inductive thematic approach. This study was one component of a mixed methods design to explore the barriers and facilitators to best-practice nutrition care in a head and neck oncology unit. RESULTS: Eleven participants (seven patients, four caregivers) took part in the interviews. Four key themes were identified with branching themes within each: (1) being ill-prepared for the impact of treatment, even when advised; (2) navigating complex systems to meet significant care needs; (3) depleted by overwhelming and prolonged suffering; and (4) information lost in translation. CONCLUSIONS: This study highlights the unique and complex care needs of people with HNC and those caring for them. To design and successfully deliver a patient-centred MOC, specific strategies will be required to address: early and ongoing access to expert supportive care clinicians; integrated and coordinated care; individual information, education and support needs and; and education of MDT staff in accurate and consistent messaging, ensuring nutrition care is a collective responsibility. Nutrition care did not appear to be viewed separately to overall care from the patient perspective as the importance of nutrition ultimately became viewed as vital treatment.