Prevalence of frailty and pain in hospitalised cancer patients: implications for older adult care.

A hospital-wide point prevalence study investigated frailty and pain in patients with a cancer-related admission. Modifiable factors associated with frailty in people with cancer were determined through logistic regression. Forty-eight patients (19%) with cancer-related admissions were 2.65 times more likely to be frail and 2.12 more likely to have moderate pain. Frailty and pain were highly prevalent among cancer-related admissions, reinforcing the need for frailty screening and importance of pain assessment for patients with cancer.

Facilitated case conferences on end-of-life care for persons with advanced dementia-a qualitative study of interactions between long-term care clinicians and family members.

BACKGROUND: Prognostic uncertainty and the need for proxy decision-making owing to cognitive impairment in advanced dementia, adds complexity to end-of-life care planning within the long-term care setting. Case conferences provide a structure to facilitate difficult conversations and an opportunity for family and clinicians to engage in prospective planning, and reach agreement on goals of end-of-life care. OBJECTIVE: To explore interactions between multidisciplinary healthcare clinicians and families during facilitated case conferences on end-of-life care for residents with advanced dementia. METHODS: A qualitative approach was used. Transcripts of audio-recorded case conferences facilitated by a trained registered nurse were coded by two independent researchers and analysed inductively. Transcripts were selected from an available pool until thematic saturation was reached. Emerging themes were confirmed with the wider research group. RESULTS: Thematic saturation was reached after 25 transcripts. An overarching theme concerned the ways in which clinicians and families bridged medical and person-centred perspectives. Subthemes included: details of day-to-day care versus establishing overall goals of care; expression of emotion versus retreat from emotion; and missed opportunities versus expressed cues. Successful facilitation served to 'bridge the gap' between family and clinicians. CONCLUSION: Facilitation of case conferences for residents with advanced dementia should focus on ensuring that: clinicians do not miss opportunities to discuss end-of-life care; discussions on the minutiae of care regularly return to the resident's broader goals of care; and information on dementia and treatments provided by clinicians is integrated with advice by family members regarding the resident's premorbid values and likely preferences.

'It is a journey of discovery': living with myeloma.

PURPOSE: Although multiple myeloma (MM) is incurable, many people live with the disease for a number of years. Thus, understanding the effect of the disease and its therapies on the lives of those with MM is important. This qualitative study explores the impact of MM and its treatments on patients. METHODS: People with newly diagnosed or relapsed MM were recruited from a tertiary institution. Participants were interviewed using a semi-structured approach. The questions were designed to obtain insight into how participants viewed their diagnosis, treatment, and symptoms and how these had impacted on their lives. Data were analysed using a phenomenological approach. RESULTS: Fifteen people with MM with a mean age of 62 were recruited. Participants' mean time since diagnosis was 2.7 years and they had received a mean of 1.7 lines of therapy. The first major theme to emerge was lifestyle changes. Interviewees described MM as causing changes to all aspects of their lives, including substantial functional changes, as well as changes to employment, relationships, and their sense of self. The second major theme was 'adjust, adjust, adjust'. Alongside challenging life changes, participants described a range of practical, psychological, and relational approaches to adjusting to living with MM. CONCLUSION: This study highlights the importance of and the need for improved supportive care in patients with MM, ideally with a multidisciplinary approach. It also identifies the potential for further investigation of patient approaches to adjusting to MM and development of support strategies.

The experiences of patients with advanced cancer and caregivers presenting to Emergency Departments: A qualitative study.

BACKGROUND: Despite being a common event in the course of an advanced cancer illness, there is little understanding of patients' perceptions of hospital Emergency Department presentations. AIM: To explore the experiences and perceptions of Emergency Departments held by patients with advanced cancer and their informal caregivers. DESIGN: Cross-sectional study involving semi-structured interviews with advanced cancer patients and their informal caregivers. Qualitative data analysis was underpinned by a phenomenological approach utilising a data-driven inductive thematic frame. SETTING/PARTICIPANTS: In total, 19 patients with advanced cancer who presented to Emergency Departments in the previous 6 months and 10 informal caregivers from an Australian public hospital and community palliative care service were interviewed. RESULTS: Patients reported that Emergency Department presentations were largely prompted by worsening symptoms or were a means to expedite hospital admission, with many instructed to attend by their health care provider. The experience in the Emergency Department was described as a time of anxiety and uncertainty with concerns over communication, the general environment and delays in the symptom management highlighted. Long waits were common. Despite this, patients described relief at receiving care. While the Emergency Department was viewed as a safety net for the health system, many believed advanced cancer patients should have alternative options. CONCLUSION: Relatively simple changes of regular communication updates and early symptom relief would improve patient experience of Emergency Department care. However, since an Emergency Department presentation is frequently serving as a default to access medical care, a significant re-orientation of the health care system is required to meet patient needs.

Canine oral papillomavirus outbreak at a dog daycare facility.

This report describes an outbreak at a dog daycare facility where 13 of 52 dogs developed suspected canine papillomavirus (CPV) infection. Based on contact tracing, subclinical CPV shedding was speculated. Active surveillance, exclusion of animals with active or recent infection and cohort formation may have been effective in stopping the outbreak.

Éclosion du papillomavirus oral canin dans une garderie canine. Ce rapport décrit l'éclosion dans une garderie canine où 13 des 52 chiens ont développé une infection suspectée par le virus du papillome canin (VPC). En se basant sur le retraçage des contacts, on a émis la supposition d'une excrétion subclinique du VPC. Une surveillance active, l'exclusion des animaux avec une infection active ou récente et la formation d'une cohorte ont pu être efficaces pour freiner l'éclosion.(Traduit par Isabelle Vallières).

Presentation patterns and outcomes of patients with cancer accessing care in emergency departments in Victoria, Australia.

PURPOSE: People with cancer attend emergency departments (EDs) for many reasons. Improved understanding of the specific needs of these patients may assist in optimizing health service delivery. ED presentation and hospital utilization characteristics were explored for people with cancer and compared with those patients without cancer. METHODS: This descriptive, retrospective, multicentre cohort study used hospital administrative data. Descriptive and inferential statistics were used to summarise and compare ED presentation characteristics amongst cancer and non-cancer groups. Predictive analyses were used to identify ED presentation features predictive of hospital admission for cancer patients. Outcomes of interest were level of acuity, ED and inpatient length of stay, re-presentation rates and admission rates amongst cancer patients and non-cancer patients. RESULTS: ED (529,377) presentations occurred over the 36 months, of which 2.4% (n = 12,489) were cancer-related. Compared with all other attendances, cancer-related attendances had a higher level of acuity, requiring longer management time and length of stay in ED. Re-presentation rates for people with cancer were nearly double those of others (64 vs 33%, p < 0.001), with twice the rate of hospital admission (90 vs 46%, p < 0.001), longer inpatient length of stay (5.6 vs 2.8 days, p < 0.001) and had higher inpatient mortality (7.9 vs 1.0%, p < 0.001). Acuity and arriving by ambulance were significant predictors of hospital admission, with cancer-related attendances having ten times the odds of admission compared to other attendances (OR = 10.4, 95% CI 9.8-11.1). CONCLUSIONS: ED presentations by people with cancer represent a more urgent, complex caseload frequently requiring hospital admission when compared to other presentations, suggesting that for optimal cancer care, close collaboration and integration of oncology, palliative care and emergency medicine providers are needed to improve pathways of care.

What's in a name? A qualitative exploration of what is understood by "palliative care" in the emergency department.

BACKGROUND: The understanding of what palliative care is, and which patients may benefit from palliative care, has important implications for optimal patient care in all areas of health provision. AIM: To explore the understanding of palliative care by healthcare professionals caring for patients with advanced cancer attending emergency departments. DESIGN: Qualitative study, with two phases: the first, a series of focus groups with healthcare professionals from various disciplines and settings caring for patients with advanced cancer presenting to emergency departments; the second, semi-structured telephone interviews with emergency healthcare professionals across Australian States and Territories, including outside metropolitan centers. The data were audio-recorded and transcribed, with analysis undertaken using a qualitative thematic analysis. SETTING/PARTICIPANTS: Saturation of themes was reached after 8 focus groups (22 emergency nurses, 21 emergency physicians, 6 oncologists, 6 hospital palliative care clinicians, and 28 community palliative care clinicians) and 11 telephone interviews (8 emergency physicians and 3 emergency nurses), a total of 94 participants. RESULTS: The overarching theme was that healthcare professionals held contradictory understandings of palliative care and its application in the emergency department; subthemes highlighted these inconsistencies when the term "palliative" is used, in understandings of and engagement with palliative care services and in perceptions about the practical utility of palliative care. CONCLUSION: There are entrenched contradictions and tensions surrounding the term "palliative care"; confronting these is likely to require more than re-branding, and will promote better care for this vulnerable patient group in the emergency department.

"Better pathways of care": suggested improvements to the emergency department management of people with advanced cancer.

OBJECTIVE: It is difficult to provide optimal care to people with advanced cancer presenting to emergency departments (EDs). Recent data suggest that the ED environment, the skills and priorities of treating staff, and the lack of clear communication related to goals of care contribute to the difficulty. By exploring the views of emergency, palliative care (PC), and oncology clinicians on the care of these patients, this study aimed to describe potential solutions. METHODS: This qualitative study involved focus groups with clinicians at two major hospitals and two community PC services in Melbourne, Australia, and semistructured telephone interviews with emergency clinicians from all other Australian states and territories. Discussions were recorded and transcribed verbatim. Thematic analysis identified ways to improve or enhance care. RESULTS: Throughout discussions with 94 clinicians, a number of possible improvements to care were raised; these were broadly grouped into service areas: clinical care, pathways, information access, and education. CONCLUSION: The provision of care to patients with advanced cancer in the ED occurs across sites, across disciplines, and across teams. To make improvements to care, we must address these complexities. The improvements suggested in this study place the patient (and the patient's family) at the centre of care.

Leave no one behind: A global survey of the current state of geriatric oncology practice by SIOG national representatives.

INTRODUCTION: The Sustainable Development Goals of the United Nations include a commitment to "leave no one behind" as a universal goal. To achieve this in geriatric oncology (GO) worldwide, it is important to understand the current state of GO at an international level. The International Society of Geriatric Oncology (SIOG) has several National Representatives (NRs) who act as SIOG's delegates in their respective countries. The NRs took part in this international survey exploring the state of GO practice, identifying barriers and solutions. MATERIALS AND METHODS: The NRs answered open-ended questions by email from February 2020 to October 2022. The questionnaire domains included the demographic information of older adults for their countries, and the NRs' opinions on whether GO is developing, what the barriers are to developing GO, and proposed actions to remove these barriers. The demographic data of each country reported in the survey was adjusted using literature and database searches. RESULTS: Twenty-one of thirty countries with NRs (70%) participated in this questionnaire study: 12 European, four Asian, two North American, two South American, and one Oceanian. The proportion of the population aged ≥75 years varied from 2.2% to 15.8%, and the average life expectancy also varied from 70 years to 86 years. All NRs reported that GO was developing in their country; four NRs (18%) reported that GO was well developed. Although all NRs agreed that geriatric assessment was useful, only three reported that it was used day-to-day in their countries' clinical practice (14%). The major barriers identified were the lack of (i) evidence to support GO use, (ii) awareness and interest in GO, and (iii) resources (time, manpower, and funding). The major proposed actions were to (i) provide new evidence through clinical trials specific for GO patients, (ii) stimulate awareness through networking, and (iii) deliver educational materials and information to healthcare providers and medical students. DISCUSSION: This current survey has identified the barriers to GO and proposed actions that could remove them. Broader awareness seems to be essential to implementing GO. Additional actions are needed to develop GO within countries and can be supported through international partnerships.

The war against dementia: are we battle weary yet?

Recently, the use of military metaphors when discussing dementia and in particular Alzheimer's disease has increased, both in medical literature and mainstream media. While military metaphors are a recent adoption when used to describe dementia, in oncology there has been longstanding debate about the usefulness of such metaphors. This article reviews the history of military metaphors in medicine, literature discussing their use, and considers their use in describing dementia. While military metaphors are widely used in medicine, consideration should be taken in their use as they have the potential to influence the way we and our patients conceptualise and experience illness and treatment.

A systematic review of the evidence: the effects of portion size manipulation with children and portion education/training interventions on dietary intake with adults.

BACKGROUND: Evidence shows that 3-5-year-old children undergo important physical and behavioral changes that include being affected by the amount of food they are served, with larger portions of food served resulting in greater dietary intake. This may be a key finding as researchers continue to identify effective treatments for the growing number of preschool children who are overweight or obese. Knowledge of the effects of varying portion sizes on young children's dietary intake is important; however, because parents of young children control the manner in which children are fed, educating parents regarding the estimation of portion sizes is an approach worth exploring as a way to affect the trajectory of their young child's weight gain. AIMS: The purposes of this systematic review were to determine (1) findings regarding the effect of varying portion sizes with young children and (2) the evidence regarding the effects of educating adults to estimate portion sizes. Evidence from this review may guide clinical practice and future research efforts. METHODS: A comprehensive literature search was conducted with multiple databases using MeSH Headings and keywords. This search strategy was supplemented by ancestry searches of all relevant articles. Two independent, trained pediatric practitioners determined quality of the studies using established criteria. RESULTS: Nine studies met the inclusion criteria as portion-manipulation interventions or portion-education/training interventions and were appraised. Evidence showed the positive effect of portion sizes on the energy intake of children. In addition, the ability of adults to accurately estimate portion size improved following education/training. CONCLUSIONS: Although many studies have focused on a variety of portion-related interventions, the influence of portion education with parents of young children has not been well researched. More research is needed to understand the effect of parent-focused, portion-education interventions that encourage appropriate energy intake and healthy weight attainment in young children.

Virtual and online learning during COVID-19: the experience of community children's nursing students.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic resulted in significant changes to education delivery. For many university programmes this has included a move from face-to-face to virtual and online learning and teaching. AIM: To gain insight into the experiences of students undertaking the community children's nursing specialist practitioner programme during the academic year 2020-21, when most learning and teaching was delivered using virtual and online methods as a consequence of the COVID-19 pandemic. METHOD: A survey questionnaire containing qualitative and quantitative questions was distributed to 28 students by programme leaders at three universities in England. Seven questionnaires were returned, yielding a 25% response rate. FINDINGS: Respondents' experience of online and virtual learning was generally positive, with benefits for work-life balance and the opportunity to revisit recorded lectures being particularly well regarded. Loss of opportunity for face-to-face engagement with fellow students and the teaching team were identified as disadvantages. CONCLUSION: There was strong student support for the provision of more flexible approaches to learning and teaching. Universities should recognise that failure to offer such flexibility could potentially affect recruitment and the viability of courses in the future.

'Everyone's nice, but ': A qualitative exploration of trainees' experiences of postgraduate geriatric medicine training in Australia.

OBJECTIVE: To understand the experiences of trainees who undertake geriatric medicine advanced training in Australia. METHODS: In this qualitative study, data were collected through semi-structured interviews with geriatric medicine advanced trainees. Data were analysed using a thematic analysis approach and data collection ceased when thematic saturation was achieved. RESULTS: Thirteen trainees participated. Trainees enjoyed the training program, supported each other and felt prepared for independent practice as a geriatrician. However, they noted the variability of supervision and feedback practices, and educational opportunities afforded to them across different clinical learning environments. They felt unable to give feedback on their training. The research project and concerns about employment after training were also substantial sources of stress. CONCLUSIONS: While geriatric medicine advanced trainees reported positively on much of their training, areas for improvement could include improved training for supervisors, improved support for research projects and more robust mechanisms for providing feedback.

An International Expert Delphi Consensus to Develop Dedicated Geriatric Radiation Oncology Curriculum Learning Outcomes.

PURPOSE: The management of older adults with cancer is rapidly becoming a significant challenge in radiation oncology (RO) practice. The education of future radiation oncologists in geriatric oncology is fundamental to ensuring that older adults receive high-quality care. Currently RO trainees receive little training and education in geriatric oncology. The objective of this study was to define core geriatric RO curriculum learning outcomes relevant to RO trainees worldwide. METHODS AND MATERIALS: A 2-stage modified Delphi consensus was conducted. Stage 1 involved the formation of an expert reference panel (ERP) of multiprofessional experts in geriatric oncology and/or RO and the compilation of a potential geriatric RO learning outcomes set. Stage 2 involved 3 iterative rounds: round 1 and round 2 (both online surveys), and an intervening ERP round. These aimed at identifying and refining ideal geriatric RO learning outcomes. Invited participants for round 1 and 2 included oncology health care professionals with expertise across RO, geriatric oncology, and/or education and consumers. Predefined Delphi consensus definitions were applied to the results of rounds 1 and 2. RESULTS: An ERP of 11 experts in geriatric oncology and/or RO was formed. Seventy potential knowledge- and skill-based learning outcomes were identified. In round 1, 103 of 179 invited eligible Delphi participants completed the survey (58% response rate). The ERP round was conducted, resulting in the exclusion of 28 learning outcomes. In round 2, 54 of 103 completed the survey (52% response rate). This identified a final total of 33 geriatric RO learning outcomes. CONCLUSIONS: The geriatric RO learning outcomes described in this study form an international consensus that can inform RO training bodies worldwide. This represents the first fundamental step in developing a global educational framework aimed at improving RO trainee knowledge and skills in geriatric oncology.

Cognitive Assessment Tools Recommended in Geriatric Oncology Guidelines: A Rapid Review.

Cognitive assessment is a cornerstone of geriatric care. Cognitive impairment has the potential to significantly impact multiple phases of a person's cancer care experience. Accurately identifying this vulnerability is a challenge for many cancer care clinicians, thus the use of validated cognitive assessment tools are recommended. As international cancer guidelines for older adults recommend Geriatric Assessment (GA) which includes an evaluation of cognition, clinicians need to be familiar with the overall interpretation of the commonly used cognitive assessment tools. This rapid review investigated the cognitive assessment tools that were most frequently recommended by Geriatric Oncology guidelines: Blessed Orientation-Memory-Concentration test (BOMC), Clock Drawing Test (CDT), Mini-Cog, Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and Short Portable Mental Status Questionnaire (SPMSQ). A detailed appraisal of the strengths and limitations of each tool was conducted, with a focus on practical aspects of implementing cognitive assessment tools into real-world clinical settings. Finally, recommendations on choosing an assessment tool and the additional considerations beyond screening are discussed.

Machine Learning Methods Predict Individual Upper-Limb Motor Impairment Following Therapy in Chronic Stroke.

Background. Accurate prediction of clinical impairment in upper-extremity motor function following therapy in chronic stroke patients is a difficult task for clinicians but is key in prescribing appropriate therapeutic strategies. Machine learning is a highly promising avenue with which to improve prediction accuracy in clinical practice. Objectives. The objective was to evaluate the performance of 5 machine learning methods in predicting postintervention upper-extremity motor impairment in chronic stroke patients using demographic, clinical, neurophysiological, and imaging input variables. Methods. A total of 102 patients (female: 31%, age 61 ± 11 years) were included. The upper-extremity Fugl-Meyer Assessment (UE-FMA) was used to assess motor impairment of the upper limb before and after intervention. Elastic net (EN), support vector machines, artificial neural networks, classification and regression trees, and random forest were used to predict postintervention UE-FMA. The performances of methods were compared using cross-validated R2. Results. EN performed significantly better than other methods in predicting postintervention UE-FMA using demographic and baseline clinical data (median REN2=0.91,RRF2=0.88,RANN2=0.83,RSVM2=0.79,RCART2=0.70;P < .05). Preintervention UE-FMA and the difference in motor threshold (MT) between the affected and unaffected hemispheres were the strongest predictors. The difference in MT had greater importance than the absence or presence of a motor-evoked potential (MEP) in the affected hemisphere. Conclusion. Machine learning methods may enable clinicians to accurately predict a chronic stroke patient's postintervention UE-FMA. Interhemispheric difference in the MT is an important predictor of chronic stroke patients' response to therapy and, therefore, could be included in prospective studies.

Dose and staffing comparison study of upper limb device-assisted therapy.

BACKGROUND: Neurological injuries cause persistent upper extremity motor deficits. Device-assisted therapy is an emerging trend in neuro-rehabilitation as it offers high intensity, repetitive practice in a standardized setting. OBJECTIVE: To investigate the effects of therapy duration and staff-participant configuration on device-assisted upper limb therapy outcomes in individuals with chronic paresis. METHODS: Forty-seven participants with chronic upper extremity weakness due to neurological injury were assigned to a therapy duration (30 or 60 min) and a staff-participant configuration (1-to-1 or 1-to-2). Therapy consisted of 3 sessions a week for 6 weeks using the Armeo®Spring device. Clinical assessments were performed at three timepoints (Pre, Post, and 3 month Follow up). RESULTS: Improvements in upper limb impairment, measured by change in Fugl-Meyer score (FM), were observed following therapy in all groups. FM improvement was comparable between 30 and 60 min sessions, but participants in the 1-to-2 group had significantly greater improvement in FM from Pre-to-Post and from Pre-to-Follow up than the 1-to-1 group. CONCLUSIONS: Device-assisted therapy can reduce upper limb impairment to a similar degree whether participants received 30 or 60 min per session. Our results suggest that delivering therapy in a 1-to-2 configuration is a feasible and more effective approach than traditional 1-to-1 staffing.

Evaluation of a Web-Based Training Model for Family Peer Advocates in Children's Mental Health.

OBJECTIVE: The aim of this study was to compare knowledge gains from a new online training program with gains from an existing in-person training program for family peer advocates. METHODS: Data were used from a pre-post study of individuals who enrolled in the Web-based Parent Empowerment Program training; 144 participants completed the training and pre-post tests, and 140 were admitted to the analyses. Knowledge was assessed with 34 questions, 29 of which were common to the online and in-person trainings. Pre-post knowledge scores were available from the in-person training. RESULTS: Statistically significant gains in knowledge were found with both the 34 questions and the 29 questions common to both trainings. Knowledge gains across the two training models did not differ. CONCLUSIONS: Data on knowledge gains from this accessible, affordable online model show promise for training the growing and important workforce of family peer advocates.

'Pretty fit and healthy': The discussion of older people in cancer multidisciplinary meetings.

INTRODUCTION: Cancer multidisciplinary meetings (MDMs) are central to treatment decision making. The language used in MDMs may influence treatment decisions, yet has received little research attention. This study aimed to examine the terminology used to describe non-cancer items in the discussion of older people within cancer MDMs. METHODS: MDMs of four tumour streams were attended over twelve weeks. For each person aged 70 or older discussed, the following was hand recorded: age, gender, and phrases describing non-cancer items and patient views. A qualitative thematic analysis was employed to examine the text. RESULTS: Twenty cancer MDMs were attended, at which 71 people aged 70 or older were discussed. Age, comorbid medical conditions, and general descriptors emerged as the areas in which non-cancer information was presented. In contrast to the medical terminology used to describe comorbid medical conditions, non-specific general descriptors, such as 'fit', 'well', and 'good', were used to describe other aspects of older people. Adverbs, including 'very', 'pretty', and 'quite', often accompanied general descriptors. The, often subtle, intonation and context associated with these adverbs resulted in markedly different meanings. CONCLUSION: Non-objective, potentially ambiguous general descriptors were commonly used to encompass non-disease aspects of older people in cancer MDMs. These descriptors may have the potential to sway treatment recommendations. However, their frequent use suggests team members recognise that non-disease aspects of a person, aside from chronological age, are considerations in treatment recommendations. Therefore, strategies to increase discussion of non-cancer items in a more objective manner may be acceptable to MDM attendees.