Comprehensive geriatric assessment and decision-making in older men with incurable but manageable (chronic) cancer.

PURPOSE: In older cancer patients, treatment decision-making is often complex. A comprehensive geriatric assessment (CGA) is an established tool used in geriatric medicine to identify unmet need requiring intervention. This study aimed to assess whether using a CGA in older male cancer patients with incurable but manageable disease provides information that would alter a cancer clinician's intended management plan. Acceptability and feasibility were secondary aims. METHODS: Elderly men with incurable but manageable malignancies (advanced prostate cancer and multiple myeloma) who had previously received at least one line of treatment were recruited from hospital outpatient clinics. A CGA was undertaken. Additional parameters measuring pain, fatigue and disease-specific concerns were also recorded, at the recommendation of patient involvement groups. Results were made available to clinicians. Patient and clinician acceptability and changes in subsequent management were recorded. RESULTS: Forty-eight patients completed the study. The median ages were 70.8 years and 74 years for myeloma and prostate respectively. Most identified concerns are related to disease-specific concerns (93%), pain (91%), frailty (57%) and nutrition (52%). Results altered the clinician's oncological management plan in nine cases only. Patients found the format and content of CGA acceptable. CONCLUSIONS: Many unmet needs were identified in this population of elderly men with manageable but non curable cancer which led to supportive care referrals and interventions. The CGA, however, did not result in significant changes in clinical oncology treatment plans for the majority of patients. The application of the CGA and other assessments was viewed positively by participants and can feasibly be undertaken in the outpatient oncology setting.

Use of a Respiratory Volume Monitor to Assess Respiratory Competence in Cardiac Surgery Patients After Extubation.

BACKGROUND: Patients who have undergone cardiac surgery are generally mechanically ventilated postoperatively. Early postoperative extubation is currently recommended in anesthesia guidelines. No current technology can accurately, non-invasively, measure respiratory competence after extubation. Pulse oximetry has been helpful, but this is a late indicator of respiratory compromise. A novel, non-invasive, respiratory volume monitor (RVM) has been shown to deliver accurate continuous, real-time minute ventilation (MV), tidal volume (TV) and respiratory rate (RR) measurements and provide an objective measure of respiratory competence. The RVM will accurately reflect MV, TV and RR in cardiac surgery patients before and after extubation. METHODS: RVM traces were recorded from patients before and after cardiac surgery. Continuous monitoring began on admission to the unit and was ended at 24 h after extubation. RVM-based MV, TV and RR were calculated from 30-s segments. MV, TV and RR were also continuously recorded from the ventilator prior to extubation. The RVM was calibrated to each patient using the readings from the ventilator. RESULTS: During mechanical ventilation, the RVM measured TVs strongly correlated with the ventilator TVs (r = 0.97). Following extubation, the patient's breathing became more erratic and TVs and MVs decreased. Within 1 h, all patients studied showed a marked recovery of MV and TV. CONCLUSIONS: RVM-based MV, TV and RR correlated well with similar data collected from ventilators. After extubation, RVM shows promise as a means to monitor respiratory competence of non-intubated patients, and has implications for use in other settings and improving patient safety.

The evaluation of a non-invasive respiratory volume monitor in surgical patients undergoing elective surgery with general anesthesia.

Continuous respiratory assessment is especially important during post-operative care following extubation. Respiratory depression and subsequent adverse outcomes can arise due to opioid administration and/or residual anesthetics. A non-invasive respiratory volume monitor (RVM) has been developed that provides continuous, real-time, measurements of minute ventilation (MV), tidal volume (TV), and respiratory rate (RR) via a standardized set of thoracic electrodes. Previous work demonstrated accuracy of the RVM versus standard spirometry and its utility in demonstrating response to opioids in postoperative patients. This study evaluated the correlation between RVM measurements of MV, TV and RR to ventilator measurements during general anesthesia (GA). Continuous digital RVM and ventilator traces, as well as RVM measurements of MV, TV and RR, were analyzed from ten patients (mean 62.6±7.4 years; body mass index 28.6±5.2 kg/m2) undergoing surgery with GA. RVM data were compared to ventilator data and bias, precision and accuracy were calculated. The average MV difference between the RVM and ventilator was -0.10 L/min (bias: -1.3%, precision: 6.6%, accuracy: 9.0%. The average TV difference was 40 mL (bias: 0.4%, precision: 7.3%, accuracy: 9.1%). The average RR difference was -0.22 breaths/minute (bias: -1.8%, precision: 3.7% accuracy: 4.1%). Correlations between the RVM traces and the ventilator were compared at various points with correlations>0.90 throughout. Pairing the close correlation to ventilator measurements in intubated patients demonstrated by this study with previously described accuracy compared to spirometry in non-intubated patients, the RVM can be considered to have the capability to provide continuity of ventilation monitoring post-extubation This supports the use of real-time continuous RVM measurements to drive post-operative and post-extubation protocols, initiate therapeutic interventions and improve patient safety.

Continuous noninvasive respiratory volume monitoring for the identification of patients at risk for opioid-induced respiratory depression and obstructive breathing patterns.

BACKGROUND: Opioid-induced respiratory depression (OIRD) and postoperative apnea (POA) can lead to complications after surgery or traumatic injury. Previously, real-time monitoring of respiratory insufficiency and identification of apneic events have been difficult. A noninvasive respiratory volume monitor (RVM) that reports minute ventilation (MV), tidal volume, and respiratory rate is now available. The RVM was used to report the effect of opioids on respiratory status as well as demonstrate apneic breathing patterns in a hospital postanesthesia care unit. METHODS: RVM traces were collected from 132 patients. Predicted MV (MVPRED) for each patient was used to calculate and the "percent predicted" MV (MVMEASURED / MVPRED × 100%) before opioid administration. Patients were stratified patients into two categories: "at risk," MV of less than 80% MVPRED, and "not at risk," MV of 80% MVPRED or greater. After opioid dosing, patients with MV of less than 40% MVPRED were categorized as "unsafe." POA was defined as more than five apneic or hypopneic events per hour. RESULTS: Of the 132 patients, 50 received opioids. Baseline MV was 7.2 ± 0.5 L/min. The MV-based protocol classified 18 of 50 patients as at risk before opioid administration. After the first opioid dose administration, at-risk patients experienced an average MV decrease (36.7% ± 8.5% MVPRED) and 13 of 18 decreased into unsafe; the 32 not at-risk patients experienced a lesser average MV decrease (76.9% ± 6.3% MVPRED). Only 1 of 32 not at-risk patients had a decrease in MV to unsafe. The proposed protocol had a sensitivity of 93% and a specificity of 86%. Of the 132 patients, 26 displayed POA. Of the 26 patients, 12 experienced POA without receiving opioids. Of the 26 patients with POA, 14 also received opioids, and of those, 6 were classified as unsafe. CONCLUSION: This investigation indicates that at risk and unsafe respiratory patterns occur frequently after procedure. RVM provides continuous noninvasive objective measurements of OIRD and POA. The RVM may prove a useful tool in opioid dosing and in recognition and management of POA and strong potential value in the rapid detection of OIRD and apnea in the contemporary combat casualty environment. LEVEL OF EVIDENCE: Care management study, level V.

Preparing breast cancer patients for survivorship (PREP) - a pilot study of a patient-centred supportive group visit intervention.

PURPOSE: The process of breast cancer follow-up has psychosocial benefits for patients, notably reassurance, although attending hospital appointments can increase anxiety. Discharge from hospital follow-up can also invoke anxiety as many patients seek reassurance from continued specialist follow-up. Inevitably, due to increased survival and associated resource issues, opportunities for follow-up and support will be reduced. We delivered and evaluated an intervention which supported the transition from cancer patient to cancer survivor, for breast cancer patients being discharged to primary care. METHODS: We delivered and evaluated a pilot of a patient-centred group intervention 'Preparing Patients for Discharge', aimed at reducing distress. Between January and September 2008, 172 participants were recruited and 74 (43%) expressed an interest in participating in the intervention; 32 of 74 took part, and participated in its evaluation using a semi-structured evaluation questionnaire, standardized measures [Hospital Anxiety and Depression Scale (HADS) and Clinical Outcomes for Routine Evaluation (CORE)] and independent qualitative interviews. RESULTS: The qualitative analysis of questionnaire data indicated key factors were 1) shared experience, 2) support and reassurance, and 3) positive views about cancer and being discharged. The interview data revealed that the intervention enabled participants to: share experiences, focus on emotional needs, and have open discussions about recurrence, while increasing confidence in being discharged and using alternative support services. However, no significant differences were found in pre-post-interventions scores of HADS and CORE. CONCLUSIONS: Providing a structured group intervention approach for breast cancer patients offers an early opportunity to support cancer survivors and facilitate and encourage self-management.

Predictors of bovine TB risk behaviour amongst meat handlers in Nigeria: a cross-sectional study guided by the health belief model.

BACKGROUND: Bovine Tuberculosis (bTB) is still a serious public health threat in developing countries. The aim of this study is to determine the social and cognitive factors predicting one of the risk behaviours amongst meat handlers in Nigeria, namely, eating Fuku Elegusi. This is the practice of eating the visibly infected parts of the lung in-order to convince customers to buy meat. The study is guided by the health belief model (HBM). METHODS: This is a cross-sectional study of 349 randomly selected meat handlers in Oko-Oba Abattoir, in Lagos State. Descriptive statistics and multiple logistic regression analysis were employed to determine perceptions and prevalence of risk behaviours and to identify predictors of eating Fuku Elegusi. RESULTS: Just over a quarter (28.1%) of the study participants knew that eating Fuku Elegusi could be a source of bTB in humans. The prevalence of eating Fuku Elegusi was found to be 22%. Across all knowledge indicators related to bTB, those who don't eat Fuku Elegusi exhibited better knowledge. Strong predictors of eating Fuku Elegusi were: being male (OR: 2.39, 95% CI: 1.10 to 5.19; p = 0.03), not knowing that eating Fuku Elegusi exposes to bTB (OR: 3.72, 95% CI: 1.69 to 8.22; p = 0.001), and the perception that one cannot sell meat without tasting it (perceived barrier) (OR: 1.35, 95% CI: 1.13 to 1.60; p = 0.001). Lower risk of eating Fuku Elegusi was predicted by perceived susceptibility to bTB due to another risk behaviour, namely, not washing hands after handling meat (OR: 0.78, 95% CI: 0.64 to 0.96; p-value = 0.021). Television and radio were the most acceptable media for TB prevention messages (78.5% and 75.6% respectively). CONCLUSION: Meat handlers in developing countries bear high risk to bTB owing to prevailing social and cognition determinants. Findings were largely consistent with the propositions of HBM.

Does an intensive self-management structured education course improve outcomes for children and young people with type 1 diabetes? The Kids In Control OF Food (KICk-OFF) cluster-randomised controlled trial protocol.

INTRODUCTION: The Kids In Control OF Food (KICk-OFF) is a cluster-randomised controlled trial, which aims to determine the efficacy of a 5 day structured education course for 11-year-olds to 16-year-olds with type 1 diabetes (T1DM) when compared with standard care, and its cost effectiveness. Less than 15% of children and young people with T1DM in the UK meet the recommended glycaemic target. Self-management education programmes for adults with T1DM improve clinical and psychological outcomes, but none have been evaluated in the paediatric population. KICk-OFF is a 5-day structured education course for 11-year-olds to 16- year-olds with T1DM. It was developed with input from young people, parents, teachers and educationalists. METHODS AND ANALYSIS: 36 paediatric diabetes centres across the UK randomised into intervention and control arms. Up to 560 participants were recruited prior to centre randomisation. KICk-OFF courses are delivered in the intervention centres, with standard care continued in the control arm. Primary outcomes are change in glycaemic control (HbA1c) and quality of life between baseline and 6 months postintervention, and the incidence of severe hypoglycaemia. Sustained change in self-management behaviour is assessed by follow-up at 12 and 24 months. Health economic analysis will be undertaken. Data will be reported according to the CONSORT statement for cluster-randomised clinical trials. All analyses will be by intention-to-treat with a two-sided p value of <0.05 being regarded as statistically significant. The study commenced in 2008. Data collection from participants is ongoing and the study will be completed in 2013. ETHICS: The study has been approved by the Sheffield Research Ethics Committee. DISSEMINATION: Results will be reported in peer reviewed journals and conferences. TRIAL REGISTRATION: Current Controlled Trials ISRCTN37042683.

Emerging nursing roles for late effects care for children and young adults with cancer.

INTRODUCTION: Annually around 3500 children and young adults are diagnosed with cancer in the UK. While five year childhood cancer survival rates are high, many will experience long-term health problems as a result of their illness and its treatment. Providing late effects services is vital for this group of patients. The skills and expertise needed for nurses working within these services has not been systematically clarified or agreed. PURPOSE OF THE RESEARCH: To identify and compare the views of managers and nurses on the ideal and existing role of nurses in the provision of late effects care. METHODS AND SAMPLE: Structured questionnaires were utilised to collect data in two phases. Phase 1 captured the views of 80 health service managers and clinicians on ideal roles; Phase 2 captured the perspectives of 36 nurses in existing roles. Questionnaires were distributed via children, teenage and young adult treatment centres across England, UK. The data were tabulated using descriptive statistics while differences were analysed using chi-squared tests. KEY RESULTS: The findings identified ideal and actual roles from the perspectives of managers and nurses. Differences were identified in a number of domains. The nurses' role was clinically and patient-care focused, containing fewer elements relating to service development, research or education. CONCLUSION: Our work has identified existing and ideal roles for nurses providing late effects services. This information has provided the foundation for the development of a nurse competence framework which has been ratified by the Royal College of Nursing, UK.

Levels of distress in breast cancer survivors approaching discharge from routine hospital follow-up.

BACKGROUND: Hospital-based breast cancer follow-up provides reassurance to patients despite limited evidence for clinical efficacy. Although alternative models of hospital/community-based follow-up have yielded encouraging results, traditional hospital follow-up continues to be offered to all patients. Survival rates continue to rise; consequently, more patients are likely to require support, as many have a limited understanding of the long-term physical and emotional consequences of cancer and its treatment. We examine levels of psychological distress in breast cancer patients in follow-up 2 years or more from diagnosis. METHODS: This prospective study measured psychological distress levels using standardized measures [Hospital Anxiety and Depression Scale (HADS), Clinical Outcomes for Routine Evaluation (CORE) and Measure Yourself Medical Outcomes Profile (MYMOP)]. Between January and September 2008, 323 consecutive patients were approached in outpatient clinics. Ninety-six patients declined to participate. RESULTS: Two hundred twenty-seven patients took home patient information sheets; 172 (75%) returned completed questionnaires to assess levels of distress (HADS, CORE). MYMOP provided self-reported data on patient symptoms. Patients reported low levels of distress in hospital-based follow-up, which were comparable or better than general population norms, although there was a significant minority of patients reporting high scores (n = 27, 15.7%) on HADS or CORE. There was good agreement between these two measures. All sub-scales of CORE (except risk) correlated well with HADS for anxiety/depression. No significant changes were detected in the standardized measures. MYMOP results showed that 23.8% of respondents reported both physical and emotional symptoms. CONCLUSIONS: Breast cancer survivors reported good psychological outcomes 2 years on from diagnosis. Screening for psychological/emotional distress is a vital part of follow-up care, which should be incorporated into UK policy.

The impact of the 4 h target on patient care and outcomes in the Emergency Department: an analysis of hospital incidence data.

BACKGROUND: Recent government initiatives in the NHS have seen patient care becoming increasingly target-driven. However, the impact of targets, particularly those based on a timeframe, have not been extensively studied, and concerns remain about unintended consequences for patients. The aim of this study was to evaluate the effect of a 4 h target in the Emergency Department (ED) on patient care and outcomes. METHODS: The study comprised an interrupted time-series regression analysis of anonymised patient-level data from 580,000 new patient episodes in the ED between April 2000 and Feb 2006. Outcomes were time in ED, time to clinician, mortality, admission and reattendance rates, and number of investigations. RESULTS: 90% target was associated with reductions in time in department and fewer patients admitted for less than 24 and 48 h, and a slight increase in the number reattending within 7 days. 98% target was associated with levelling-off of time in department and reductions in numbers admitted and reattending within 7 days. Neither target was associated with change in time to clinician. The introduction of a minor injuries unit (MIU) was associated with reductions in time to clinician and percentage not waiting, and increases in number of investigations, percentages admitted, admitted for 24 h and reattendances within 7 days. Mortality was unaffected by either target or MIU. CONCLUSION: Although time target introduction is associated with changes in patient care, the introduction of a co-located MIU had greater impact.

Looking inside the black box of community rehabilitation and intermediate care teams in the United Kingdom: an audit of service and staffing.

OBJECTIVE: To generate a picture of the range, configuration and staffing of community and intermediate care services in the United Kingdom (UK) and to ascertain whether any relationships exist between service configuration and staffing models. METHOD: A service audit tool was sent to members of the Community Therapist's Network (CTN) and to chief executives of primary care and National Health Service trusts in the UK. Data were collected from the CTN and chief executives of primary care trusts (PCTs) and NHS trusts between late 2005 and early 2006. RESULTS: The overall response rate to the two audits was 37% (n = 243), with 77% of these responses (n = 186) useable. Services varied greatly in terms of their organisation and staffing configurations. Skill mix varied according to the location of service delivery, with home-based services utilising more therapy and support staff than inpatient services. Two clusters of service emerged, based on the number of referrals per year, support staff in the team and the level of care provided by the service. CONCLUSION: There are no clear patterns to the structure and organisation of community and intermediate care services in relation to their purpose, and it remains unclear how different staffing configurations impact on service costs and patient outcomes. The amount of variation observed indicates that there is likely to be considerable variability in service costs and outcomes for the teams. Further evidence is required to determine the impact of different staffing models, and to identify approaches that optimise both effectiveness and efficiency.

Can type 2 diabetes be prevented in UK general practice? A lifestyle-change feasibility study (ISAIAH).

BACKGROUND: The increasing incidence of type 2 diabetes mellitus is attributed to increasing weight, reduced physical activity, and poor diet quality. Lifestyle change in patients with pre-diabetes can reduce progression to diabetes but this is difficult to achieve in practice. AIM: To study the effectiveness of a lifestyle-change intervention for pre-diabetes in general practice. DESIGN OF THE STUDY: A feasibility study. SETTING: A medium-sized general practice in Sheffield. METHOD: Participants were 33 patients with pre-diabetes. The intervention was a 6-month delayed entry comparison of usual treatment with a lifestyle-change programme: increased exercise and diet change, either reduction in glycaemic load, or reduced-fat diet. The main outcome measures were weight, body mass index (BMI), waist circumference, fasting glucose, lipid profile, and nutrition. RESULTS: A statistically significant difference was observed between control and intervention groups in three markers for risk of progression to diabetes (weight (P<0.03), BMI (P<0.03), and waist circumference (P<0.001)). No significant differences in fasting glucose or lipid profiles were seen. Aggregated data showed a statistically non-significant improvement in all the measures of metabolic risk of progression to diabetes in the low-glycaemic-load group when compared with a low-fat-diet group (P>0.05). Significant total energy, fat, and carbohydrate intake reduction was achieved and maintained in both groups. CONCLUSION: A lifestyle-change intervention feasibility programme for pre-diabetic patients was implemented in general clinical practice. The potential of a low-glycaemic-load diet to be more effective than a low-fat diet in promoting change in the features associated with progression to diabetes is worthy of further investigation.

Medical hyperspectral imaging to facilitate residual tumor identification during surgery.

INTRODUCTION: Adequate evaluation of breast tumor resection at surgery continues to be an important issue in surgical care, as over 30% of postoperative tumors recur locally unless radiation is used to destroy remaining tumor cells in the field. Medical Hyperspectral Imaging (MHSI) delivers near-real time images of biomarkers in tissue, providing an assessment of pathophysiology and the potential to distinguish different tissues based on spectral characteristics. METHODS: We have used an experimental DMBA-induced rat breast tumor model to examine the intraoperative utility of MHSI, in distinguishing tumor from normal breast and other tissues. Rats bearing tumors underwent surgical exposure and MHSI imaging, followed by partial resection of the tumors, then MHSI imaging of the resection bed, and finally total resection of tumors and of grossly normal-appearing glands. Resected tissue underwent gross examination, MHSI imaging, and histopathological evaluation. RESULTS: An algorithm based on spectral characteristics of tissue types was developed to distinguish between tumor and normal tissues. Tissues including tumor, blood vessels, muscle, and connective tissue were clearly identified and differentiated by MHSI. Fragments of residual tumor 0.5-1 mm in size intentionally left in the operative bed were readily identified. MHSI demonstrated a sensitivity of 89% and a specificity of 94% for detection of residual tumor, comparable to that of histopathological examination of the tumor bed (85% and 92%, respectively). CONCLUSION: We conclude that MHSI may be useful in identifying small residual tumor in a tumor resection bed and for indicating areas requiring more extensive resection and more effective biopsy locations to the surgeon.