On the receiving end: have patient perceptions of the side-effects of cancer chemotherapy changed since the twentieth century?

BACKGROUND: Studies in 1983 and 1993 identified and ranked symptoms experienced by cancer patients receiving chemotherapy. We repeated the studies to obtain updated information on patient perceptions of chemotherapy-associated symptoms. PATIENTS AND METHODS: A cross-sectional interview and patient-reported outcome questionnaires were administered to out-patients receiving chemotherapy. Patients selected from 124 cards to identify and rank the severity of physical and non-physical symptoms they had experienced and attributed to chemotherapy (primary endpoint). The patient's medical oncologist and primary chemotherapy nurse were invited to rank the five symptoms they believed the patient would rank as their most severe. We analysed the association of symptoms and their severity with patient demographics, chemotherapy regimen, and patient-reported outcomes. Results were compared to the earlier studies. RESULTS: Overall, 302 patients completed the interview: median age 58 years (range 17-85); 56% female; main tumour types colorectal 81 (27%), breast 67 (22%), lung 49 (16%); 45% treated with curative intent. Most common symptoms (reported by >50%) were: alopecia, general weakness, effects on family/partner, loss of taste, nausea, fatigue, difficulty sleeping, effects on work/home duties, and having to put life on hold. The most severe symptoms (ranked by >15% in top five) were: concern about effects on family/partner, nausea, fear of the future, fatigue, not knowing what will happen, putting my life on hold, and general weakness. Perceptions of doctors and nurses of patients' symptom severity closely matched patients' rankings. CONCLUSIONS: Compared to earlier studies, there was an increase in non-physical concerns such as effects on family and future, and a decrease in physical symptoms, particularly vomiting, but nausea, fatigue and general weakness remained bothersome. HIGHLIGHTS: • Symptoms related to chemotherapy have changed over time, likely due to less toxic regimens and improvements in supportive care. • Effects on family/partner, fear of the future, not knowing what will happen, and "life on hold" were major issues for patients. • Vomiting has decreased but nausea, fatigue and general weakness remain common symptoms for chemotherapy patients.

Understanding the Multidimensional Effects of Resident Duty Hours Restrictions: A Thematic Analysis of Published Viewpoints in Surgery.

PURPOSE: Individuals representing various surgical disciplines have expressed concerns with the impact of resident duty hours (RDH) restrictions on resident education and patient outcomes. This thematic review of published viewpoints aimed to describe the effects of these restrictions in surgery. METHOD: The authors conducted a qualitative systematic review of non-research-based literature published between 2003 and 2015. Articles were included if they focused on the RDH restrictions in surgery and resident wellness, health promotion, resident safety, resident education and/or training, patient safety, medical errors, and/or heterogeneity regarding training or disciplines. A thematic analysis approach guided data extraction. Contextual data were abstracted from the included articles to aid in framing the identified themes. RESULTS: Of 1,482 identified articles, 214 were included in the review. Most were from authors in the United States (144; 67%) and focused on the 80-hour workweek (164; 77%). The emerging themes were organized into three overarching categories: (1) impact of the RDH restrictions, (2) surgery has its own unique culture, and (3) strategies going forward. Published opinions suggested that RDH restrictions alone are insufficient to achieve the desired outcomes and that careful consideration of the surgical training model is needed to maintain the integrity of educational outcomes. CONCLUSIONS: Opinions from the surgical community highlight the complexity of issues surrounding the RDH restrictions and suggest that recent changes are not achieving all the desired outcomes and have resulted in unintended outcomes. From the perceptions of the various stakeholders in surgical education studied, areas for new policies were identified.

Trauma Non-Technical Training (TNT-2): the development, piloting and multilevel assessment of a simulation-based, interprofessional curriculum for team-based trauma resuscitation.

Medical error is common during trauma resuscitations. Most errors are nontechnical, stemming from ineffective team leadership, nonstandardized communication among team members, lack of global situational awareness, poor use of resources and inappropriate triage and prioritization. We developed an interprofessional, simulation-based trauma team training curriculum for Canadian surgical trainees. Here we discuss its piloting and evaluation.

A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes.

BACKGROUND: In 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated 80-hour resident duty limits. In 2011 the ACGME mandated 16-hour duty maximums for PGY1 (post graduate year) residents. The stated goals were to improve patient safety, resident well-being, and education. A systematic review and meta-analysis were performed to evaluate the impact of resident duty hours (RDH) on clinical and educational outcomes in surgery. METHODS: A systematic review (1980-2013) was executed on CINAHL, Cochrane Database, Embase, Medline, and Scopus. Quality of articles was assessed using the GRADE guidelines. Sixteen-hour shifts and night float systems were analyzed separately. Articles that examined mortality data were combined in a random-effects meta-analysis to evaluate the impact of RDH on patient mortality. RESULTS: A total of 135 articles met the inclusion criteria. Among these, 42% (N = 57) were considered moderate-high quality. There was no overall improvement in patient outcomes as a result of RDH; however, some studies suggest increased complication rates in high-acuity patients. There was no improvement in education related to RDH restrictions, and performance on certification examinations has declined in some specialties. Survey studies revealed a perception of worsened education and patient safety. There were improvements in resident wellness after the 80-hour workweek, but there was little improvement or negative effects on wellness after 16-hour duty maximums were implemented. CONCLUSIONS: Recent RDH changes are not consistently associated with improvements in resident well-being, and have negative impacts on patient outcomes and performance on certification examinations. Greater flexibility to accommodate resident training needs is required. Further erosion of training time should be considered with great caution.

Venous and arterial base deficits: do these agree in occult shock and in the elderly? A Bland-Altman analysis.

BACKGROUND: Trauma centers are increasingly advocating the replacement of arterial blood gas measurements with venous blood gas measurements for simplification of base deficit (BD) determination. These values have never been demonstrated to agree in important trauma populations, such as for patients in occult shock (OS) or the elderly. The goal of this study was to investigate the level of agreement between venous and arterial BDs from blood gases in critically ill or injured patients, specifically in OS and the elderly. METHODS: This is a retrospective, consecutive, cohort study using matched pairs of venous and arterial blood gases from patients admitted to the Trauma and Neurosurgery Intensive Care Unit in a Level I trauma center in Toronto, Ontario, Canada. Agreement between near simultaneous arterial and venous BD was calculated using the Bland-Altman method. McNemar's test was used for differences in BDs in the presence or absence of OS and in elderly patients. RESULTS: BDs for 466 arterial and venous samples from 72 patients were compared pairwise. There was no significant difference between samples (p = 0.88). Ninety-eight percent of samples were within 3.0 mmol/L of each other. No significant differences were detected between venous and arterial BD in the presence of OS or in the elderly (p = 0.72 and p = 0.25, respectively). CONCLUSION: Arterial and venous BDs agree, including in the presence of OS and in the elderly. Consideration may be given to venous sampling both in the intensive care unit or in other areas of care, such as the trauma bay. LEVEL OF EVIDENCE: Diagnostic study, level III.

A crisis of faith? A review of simulation in teaching team-based, crisis management skills to surgical trainees.

BACKGROUND: Team-based training using crisis resource management (CRM) has gained popularity as a strategy to minimize the impact of medical error during critical events. The purpose of this review was to appraise and summarize the design, implementation, and efficacy of peer-reviewed, simulation-based CRM training programs for postgraduate trainees (residents). METHODS: Two independent reviewers conducted a structured literature review, querying multiple medical and allied health databases from 1950 to May 2010 (MEDLINE, EMBASE, CINAHL, EBM, and PsycINFO). We included articles that (1) were written in English, (2) were published in peer-reviewed journals, (3) included residents, (4) contained a simulation component, and (5) included a team-based component. Peer-reviewed articles describing the implementation of CRM instruction were critically appraised using the Kirkpatrick framework for evaluating training programs. RESULTS: Fifteen studies involving a total of 404 residents met inclusion criteria; most studies reported high resident satisfaction for CRM training. In several CRM domains, residents demonstrated significant improvements after training, which did not decay over time. With regard to design, oral feedback may be equivalent to video feedback and single-day interventions may be as efficacious as multiple-day interventions for residents. No studies demonstrated a link between simulation-based CRM training and performance during real-life critical events. CONCLUSIONS: The findings support the utility of CRM programs for residents. A high degree of satisfaction and perceived value reflect robust resident engagement. The iteration of themes from our review provides the basis for the development of best practices in curricula design. A dearth of well-designed, randomized studies preclude the quantification of impact of simulation-based training in the clinical environment.