A Case Report of Pulmonary Vein Stenosis Within the Labyrinth of Fibrosing Mediastinitis.

This case centers on a 76-year-old male experiencing exertional dyspnea and hemoptysis, with a medical history marked by recurrent pulmonary embolism and chronic obstructive pulmonary disease (COPD). Notably, he resides in a histoplasmosis-endemic area. A computed tomography (CT) pulmonary embolism scan revealed notable findings, including an enlarged right lower pulmonary artery, vascular congestion, atelectasis, and a mass exerting pressure on the right lower pulmonary vein. Biopsy results identified the mass as fibrosing mediastinitis, likely attributed to histoplasmosis. A transthoracic echocardiogram indicated right ventricular dilatation, impaired function, and a right ventricular systolic pressure of 63 mm Hg. During right heart catheterization, the patient displayed disparate pulmonary artery wedge pressures (PAWPs) between the right and left sides. This discrepancy was linked to a blunted back wave from the left atrium to the catheter, induced by pulmonary vein compression. Although an infrequent phenomenon, the recorded asymmetry in PAWPs played a crucial role in guiding accurate patient management. The absence of subsequent evaluation of PAWP on the left side could have altered the treatment plan, potentially delaying appropriate patient care. This case emphasizes the necessity of thorough exploration with right heart catheterization when clinical symptoms warrant, highlighting the importance of standardized practices in such procedures.

Protocol for the process evaluation of an intervention to improve antenatal smoking cessation support (MOHMQuit) in maternity services in New South Wales, Australia.

INTRODUCTION: Smoking cessation in pregnancy remains a public health priority. Our team used the Behaviour Change Wheel to develop the Midwives and Obstetricians Helping Mothers to Quit smoking (MOHMQuit) intervention with health system, leader (including managers and educators) and clinician components. MOHMQuit addresses a critical evidence to practice gap in the provision of smoking cessation support in antenatal care. It involves nine maternity services in New South Wales in a cluster randomised stepped-wedge controlled trial of effectiveness. This paper describes the design and rationale for the process evaluation of MOHMQuit. The process evaluation aims to assess to what extent and how MOHMQuit is being implemented (acceptability; adoption/uptake; appropriateness; feasibility; fidelity; penetration and sustainability), and the context in which it is implemented, in order to support further refinement of MOHMQuit throughout the trial, and aid understanding and interpretation of the results of the trial. METHODS AND ANALYSIS: The process evaluation is an integral part of the stepped-wedge trial. Its design is underpinned by implementation science frameworks and adopts a mixed methods approach. Quantitative evidence from participating leaders and clinicians in our study will be used to produce individual and site-level descriptive statistics. Qualitative evidence of leaders' perceptions about the implementation will be collected using semistructured interviews and will be analysed descriptively within-site and thematically across the dataset. The process evaluation will also use publicly available data and observations from the research team implementing MOHMQuit, for example, training logs. These data will be synthesised to provide site-level as well as individual-level implementation outcomes. ETHICS AND DISSEMINATION: The study received ethical approval from the Population Health Services Research Ethics Committee for NSW, Australia (Reference 2021/ETH00887). Results will be communicated via the study's steering committee and will also be published in peer-reviewed journals and presented at conferences. TRIAL REGISTRATION NUMBER: Australian New Zealand Trials Registry ACTRN12622000167763. https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12622000167763.

Establishing the sensitivity and specificity of the gynaecological cancer distress screen.

OBJECTIVE: Nuanced distress screening tools can help cancer care services manage specific cancer groups' concerns more efficiently. This study examines the sensitivity and specificity of a tool specifically for women with gynaecological cancers (called the Gynaecological Cancer Distress Screen or DT-Gyn). METHODS: This paper presents cross-sectional data from individuals recently treated for gynaecological cancer recruited through Australian cancer care services, partner organisations, and support/advocacy services. Receiver operating characteristics analyses were used to evaluate the diagnostic accuracy of the DT-Gyn against criterion measures for anxiety (GAD-7), depression (patient health questionnaire), and distress (IES-R and K10). RESULTS: Overall, 373 individuals aged 19-91 provided complete data for the study. Using the recognised distress thermometer (DT) cut-off of 4, 47% of participants were classified as distressed, while a cut-off of 5 suggested that 40% had clinically relevant distress. The DT-Gyn showed good discriminant ability across all measures (IES-R: area under the curve (AUC) = 0.86, 95% CI = 0.82-0.90; GAD-7: AUC = 0.89, 95% CI = 0.85-0.93; K10: AUC = 0.88, 95% CI = 0.85-0.92; PHQ-9: AUC = 0.85, 95% CI = 0.81-0.89) and the Youden Index suggested an optimum DT cut-point of 5. CONCLUSIONS: This study established the psychometric properties of the DT-Gyn, a tool designed to identify and manage the common sources of distress in women with gynaecological cancers. We suggest a DT cut point ≥5 is optimal in detecting 'clinically relevant' distress, anxiety, and depression in this population.

Integrating Palliative Care Into Self-management of Breast Cancer: A Pilot Randomized Controlled Trial.

BACKGROUND: Breast cancer patients may not be well-informed about palliative care, hindering its integration into cancer self-management. OBJECTIVE: The aim of this study was to test Managing Cancer Care: A Personal Guide (MCC-PT), an intervention to improve palliative care literacy and cancer self-management. METHODS: This was a single-blind pilot randomized controlled trial to evaluate the feasibility/acceptability and intervention effects of MCC-PT on palliative care literacy, self-management behaviors/emotions, and moderation by demographic/clinical characteristics. We enrolled 71 stages I to IV breast cancer patients aged at least 21 years, with >6-month prognosis at an academic cancer center. Patients were randomized to MCC-PT (n = 32) versus symptom management education as attention-control (n = 39). At baseline, 1 month, and 3 months, participants completed the Knowledge of Care Options Test (primary outcome), Control Preferences Scale, Goals of Care Form, Medical Communication Competence Scale, Measurement of Transitions in Cancer Scale, Chronic Disease Self-efficacy Scale, Hospital Anxiety and Depression Scale, and the Mishel Uncertainty in Illness Scale. RESULTS: Mean participant age was 51.5 years (range, 28-74 years); 53.5% were racial/ethnic minority patients, and 40.8% had stage III/IV cancer. After adjusting for race/ethnicity, MCC-PT users improved their palliative care literacy with a large effect size (partial η2 = 0.13). Patients at late stage of disease showed increased self-management (partial η2 = 0.05) and reduced anxiety (partial η2 = 0.05) and depression (partial η2 = 0.07) with medium effect sizes. CONCLUSIONS: Managing Cancer Care: A Personal Guide is feasible and appears most effective in late-stage cancer. Research is needed to elucidate relationships among cancer stage, race/ethnicity, and self-management outcomes. IMPLICATIONS FOR PRACTICE: Integration of palliative care into cancer care can assist in creation of appropriate self-management plans and improve emotional outcomes.

The MOHMQuit (Midwives and Obstetricians Helping Mothers to Quit Smoking) Trial: protocol for a stepped-wedge implementation trial to improve best practice smoking cessation support in public antenatal care services.

BACKGROUND: Smoking during pregnancy is the most important preventable cause of adverse pregnancy outcomes, yet smoking cessation support (SCS) is inconsistently provided. The MOMHQUIT intervention was developed to address this evidence-practice gap, using the Behaviour Change Wheel method by mapping barriers to intervention strategies. MOHMQuit includes systems, leadership and clinician elements. This implementation trial will determine the effectiveness and cost-effectiveness of MOHMQuit in improving smoking cessation rates in pregnant women in public maternity care services in Australia; test the mechanisms of action of the intervention strategies; and examine implementation outcomes. METHODS: A stepped-wedge cluster-randomised design will be used. Implementation of MOHMQuit will include reinforcing leadership investment in SCS as a clinical priority, strengthening maternity care clinicians' knowledge, skills, confidence and attitudes towards the provision of SCS, and clinicians' documentation of guideline-recommended SCS provided during antenatal care. Approximately, 4000 women who report smoking during pregnancy will be recruited across nine sites. The intervention and its implementation will be evaluated using a mixed methods approach. The primary outcome will be 7-day point prevalence abstinence at the end of pregnancy, among pregnant smokers, verified by salivary cotinine testing. Continuous data collection from electronic medical records and telephone interviews with postpartum women will occur throughout 32 months of the trial to assess changes in cessation rates reported by women, and SCS documented by clinicians and reported by women. Data collection to assess changes in clinicians' knowledge, skills, confidence and attitudes will occur prior to and immediately after the intervention at each site, and again 6 months later. Questionnaires at 3 months following the intervention, and semi-structured interviews at 6 months with maternity service leaders will explore leaders' perceptions of acceptability, adoption, appropriateness, feasibility, adaptations and fidelity of delivery of the MOHMQuit intervention. Structural equation modelling will examine causal linkages between the strategies, mediators and outcomes. Cost-effectiveness analyses will also be undertaken. DISCUSSION: This study will provide evidence of the effectiveness of a multi-level implementation intervention to support policy decisions; and evidence regarding mechanisms of action of the intervention strategies (how the strategies effected outcomes) to support further theoretical developments in implementation science. TRIAL REGISTRATION: ACTRN12622000167763, registered February 2nd 2022.

Improving implementation of smoking cessation guidelines in pregnancy care: development of an intervention to address system, maternity service leader and clinician factors.

BACKGROUND: Smoking during pregnancy increases the risk of multiple serious adverse infant, child and maternal outcomes, yet nearly 10% of Australian women still smoke during pregnancy. Despite evidence-based guidelines that recommend routine and repeated smoking cessation support (SCS) for all pregnant women, the provision of recommended SCS remains poor. Guidance on developing complex interventions to improve health care recommends drawing on existing theories, reviewing evidence, undertaking primary data collection, attending to future real-world implementation and designing and refining interventions using iterative cycles with stakeholder input throughout. Here, we describe using the Behaviour Change Wheel (BCW) and the Theoretical Domains Framework to apply these principles in developing an intervention to improve the provision of SCS in Australian maternity services. METHODS: Working closely with key stakeholders in the New South Wales (NSW) health system, we applied the steps of the BCW method then undertook a small feasibility study in one service to further refine the intervention. Stakeholders were engaged in multiple ways-as a core research team member, through a project Advisory Group, targeted meetings with policymakers, a large workshop to review potential components and the feasibility study. RESULTS: Barriers to and enablers of providing SCS were identified in five of six components described in the BCW method (psychological capability, physical opportunity, social opportunity and reflective and automatic motivation). These were mapped to intervention types and we selected education, training, enablement, environmental restructuring, persuasion, incentivisation and modelling as suitable in our context. Through application of the APEASE criteria (Affordability, Practicability, Effectiveness, Acceptability, Side effects and Equity) in the stakeholder workshop, behaviour change techniques were selected and applied in developing the intervention which includes systems, clinician and leadership elements. The feasibility study confirmed the feasibility and acceptability of the midwifery component and the need to further strengthen the leadership component. CONCLUSIONS: Using the BCW method combined with strong stakeholder engagement from inception resulted in transparent development of the MOHMQuit intervention, which targets identified barriers to and enablers of the provision of SCS and is developed specifically for the context in which it will be implemented. The intervention is being trialled in eight public maternity services in NSW.

Improving Clinicians' Implementation of Guidelines to Help Women Stop Smoking in Pregnancy: Developing Evidence-Based Print and Video Materials.

Smoking in pregnancy remains a public health challenge. Our team developed a comprehensive intervention using the Behaviour Change Wheel to support clinicians' implementation of guidelines on supporting women to stop smoking in pregnancy. Integral to the intervention was a suite of evidence-based video and print materials. This paper describes the rationale and process for developing these materials. Comprehensive mixed methods research was undertaken to identify the key barriers and enablers for clinicians in implementing the guidelines. This research identified which behaviours required change, and which behaviour change techniques were best suited to effecting that change. Materials were developed based on this understanding, in a collaborative process with multiple stakeholders, and their feasibility and acceptability explored in a small trial. Materials developed included leadership, clinician and client resources. There are considerable advantages to systematically and collaboratively developing materials which are integral to a behaviour-change intervention even though it is resource intensive to do so.

Factors associated with provision of smoking cessation support to pregnant women - a cross-sectional survey of midwives in New South Wales, Australia.

BACKGROUND: Smoking is the most important preventable cause of adverse pregnancy outcomes, but provision of smoking cessation support (SCS) to pregnant women is poor. We examined the association between midwives' implementation of SCS (5As - Ask, Advise, Assess, Assist, Arrange follow-up) and reported barriers/enablers to implementation. METHODS: On-line anonymous survey of midwives providing antenatal care in New South Wales (NSW), Australia, assessing provision of the 5As and barriers/enablers to their implementation, using the Theoretical Domains Framework (TDF). Factor analyses identified constructs underlying the 5As; and barriers/enablers. Multivariate general linear models examined relationships between the barrier/enabler factors and the 5As factors. RESULTS: Of 750 midwives invited, 150 (20%) participated. Respondents more commonly reported Asking and Assessing than Advising, Assisting, or Arranging follow-up (e.g. 77% always Ask smoking status; 17% always Arrange follow-up). Three 5As factors were identified- 'Helping', 'Assessing quitting' and 'Assessing dependence'. Responses to barrier/enabler items showed greater knowledge, skills, intentions, and confidence with Assessment than Assisting; endorsement for SCS as a priority and part of midwives' professional role; and gaps in training and organisational support for SCS. Nine barrier/enabler factors were identified. Of these, the factors of 'Capability' (knowledge, skills, confidence); 'Work Environment' (service has resources, capacity, champions and values SCS) and 'Personal priority' (part of role and a priority) predicted 'Helping'. CONCLUSION: The TDF enabled systematic identification of barriers to providing SCS, and the multivariate models identified key contributors to poor implementation. Combined with qualitative data, these results have been mapped to intervention components to develop a comprehensive intervention to improve SCS.

Tracheolaryngeal Squamous Cell Carcinoma with Extensive Mucosal Spread Without Metastasis in a Female.

Tracheal tumors remain one of the most interesting and challenging respiratory tumors. Usually, with the more invasive histologic subtypes, cancer has already invaded surrounding structures at the time of diagnosis. We present an unusual case of primary tracheal squamous cell carcinoma with an extensive mucosal spread at the time of diagnosis without any invasion of surrounding organs or distant metastasis. We discuss the unique features and our treatment approach to this unusual presentation. We also discuss the various epidemiologic, diagnostic and treatment aspects of upper airways tumors of the hypopharynx, larynx, and trachea that can help patients achieve more favorable outcomes.

Goals of Care in a Pandemic: Our Experience and Recommendations.

We propose that the palliative care team response will occur in two ways: first, communication and second, symptom management. Our experience with discussing goals of care with the family of a COVID-positive patient highlighted some expected and unexpected challenges. We describe these challenges along with recommendations for approaching these conversations. We also propose a framework for proactively mobilizing the palliative care workforce to aggressively address goals of care in all patients, with the aim of reducing the need for rationing of resources.

Diabetic macular oedema and diode subthreshold micropulse laser (DIAMONDS): study protocol for a randomised controlled trial.

BACKGROUND: In the UK, macular laser is the treatment of choice for people with diabetic macular oedema with central retinal subfield thickness (CST) < 400 µm, as per National Institute for Health and Care Excellence guidelines. It remains unclear whether subthreshold micropulse laser is superior and should replace standard threshold laser for the treatment of eligible patients. METHODS: DIAMONDS is a pragmatic, multicentre, allocation-concealed, randomised, equivalence, double-masked clinical trial that aims to determine the clinical effectiveness and cost-effectiveness of subthreshold micropulse laser compared with standard threshold laser, for the treatment of diabetic macular oedema with CST < 400 µm. The primary outcome is the mean change in best-corrected visual acuity in the study eye from baseline to month 24 post treatment. Secondary outcomes (at 24 months) include change in binocular best corrected visual acuity; CST; mean deviation of the Humphrey 10-2 visual field; change in percentage of people meeting driving standards; European Quality of Life-5 Dimensions, National Eye Institute Visual Functioning Questionnaire-25 and VisQoL scores; incremental cost per quality-adjusted life year gained; side effects; number of laser treatments and use of additional therapies. The primary statistical analysis will be per protocol rather than intention-to-treat analysis because the latter increases type I error in non-inferiority or equivalence trials. The difference between lasers for change in best-corrected visual acuity (using 95% CI) will be compared to the permitted maximum difference of five Early Treatment Diabetic Retinopathy Study (ETDRS) letters. Linear and logistic regression models will be used to compare outcomes between treatment groups. A Markov-model-based cost-utility analysis will extend beyond the trial period to estimate longer-term cost-effectiveness. DISCUSSION: This trial will determine the clinical effectiveness and cost-effectiveness of subthreshold micropulse laser, when compared with standard threshold laser, for the treatment of diabetic macular oedema, the main cause of sight loss in people with diabetes mellitus. TRIAL REGISTRATION: International Standard Randomised Controlled Trials, ISRCTN17742985 . Registered on 19 May 2017 (retrospectively registered).

Assessment of the effect of addition of 24 hours of oral tranexamic acid post-operatively to a single intraoperative intravenous dose of tranexamic acid on calculated blood loss following primary hip and knee arthroplasty (TRAC-24): a study protocol for a randomised controlled trial.

BACKGROUND: While it is has been proven that tranexamic acid (TXA) reduces blood loss in primary total hip and knee arthroplasty (THA and TKA), there is little published evidence on the use of TXA beyond 3 h post-operatively. Most blood loss occurs after wound closure and the primary aim of this study is to determine if the use of oral TXA post-operatively for up to 24 h will reduce calculated blood loss at 48 h beyond an intra-operative intravenous bolus alone following primary THA and TKA. To date, most TXA studies have excluded patients with a history of thromboembolic disease. METHODS/DESIGN: This is a phase IV, single-centred, open-label, parallel-group, randomised controlled trial. Participants are randomised to one of three groups: group 1, an intravenous (IV) bolus of TXA peri-operatively plus oral TXA post-operatively for 24 h; group 2, an IV bolus of TXA peri-operatively or group 3, standard care (no TXA). Eligible participants, including those with a history of thromboembolic disease, are allocated to these groups with a 2:2:1 allocation ratio. The primary outcome is the indirectly calculated blood loss 48 h after surgery. Researchers and patients are not blinded to the treatment; however, staff processing blood samples are. Originally 1166 participants were required to complete this study, 583 THA and 583 TKA. However, following an interim analysis after 100 THA and 100 TKA participants had been recruited to the study, the data monitoring ethics committee recommended stopping group 3 (standard care). DISCUSSION: TRAC-24 will help to determine whether an extended TXA dosing regimen can further reduce blood loss following primary THA and TKA. By including patients with a history of thromboembolic disease, this study will add to our understanding of the safety profile of TXA in this clinical situation. TRIAL REGISTRATION: ISRCTN registry, ISRCTN58790500 . Registered on 3 June 2016, EudraCT: 2015-002661-36.

Improving implementation of the smoking cessation guidelines with pregnant women: How to support clinicians?

OBJECTIVE: this study aimed to explore the enablers and barriers to implementation of the Australian smoking cessation in pregnancy guidelines. These guidelines direct clinicians to follow the 5As of cessation: Ask, Advise, Assess, Assist and Arrange follow-up. DESIGN: semi-structured interviews based on the Theoretical Domains Framework (TDF) elicited clinicians' views and experiences of implementing the guidelines. SETTING: antenatal care in the NSW public health system. PARTICIPANTS: 27 maternity service managers, obstetricians and midwives. FINDINGS: participants confirmed that implementation of the smoking cessation guidelines was sub-optimal. This was particularly the case with Assist and Arrange follow up at the initial visit, and with following any of the 5As at subsequent visits. Key barriers included systems which did not support implementation or monitoring, lack of knowledge, skills and training, perceived time restrictions, 'difficult conversations' and perceiving smoking as a social activity. Enablers included clinicians' knowledge of the harms of smoking in pregnancy, clinicians' skills in communicating with pregnant women, positive emotions, professional role and identity, the potential of training and of champions to influence practice, and systems that regulated behaviour. KEY CONCLUSIONS: these findings will contribute to the development of a multifaceted intervention to support clinicians in implementing the guidelines. IMPLICATIONS FOR PRACTICE: Building on existing strengths, antenatal care providers may be supported in implementing the guidelines by working with systems which remind and support implementation, the clear reframing of smoking as an addiction, knowledge and skills development and by realizing the potential of leadership to maximise the impact of reinforcement and social influence.

Insights into preferences for psycho-oncology services among women with gynecologic cancer following distress screening.

Much attention has been given to implementing routine screening programs in cancer care to improve the management of distress following diagnosis. Although patients might screen positive for distress, several studies have found that most then refuse additional psychosocial support. To inform the development of successful models of distress screening, this qualitative study explored preferences for psychosocial care among 18 women diagnosed with a gynecologic cancer who scored at least 4 on the Distress Thermometer (DT). Participants were recruited from a gynecologic oncology outpatient clinic in Newcastle, Australia, and interviewed. Unanimously, participants felt that completing the DT was an integral part of their cancer care. However, half then refused the referral to see a psychologist. These women typically reported that a referral was not needed, because their rating on the DT reflected transient stressors or physical distress. Many also spoke about their need to cope with the challenges they were facing on their own and the extensive social support they already had in place to help them overcome these challenges. In contrast, women who accepted referral to the psychologist often struggled to cope with several losses they felt had existential and long-term effects. Commonly, these women reported not having the social support they needed, managing several concurrent life stressors, and/or not having the repertoire of coping skills they required to "remain afloat." Findings from this study begin to bridge the gap between clinicians' and patients' expectations of how psychosocial services should be used in response to distress screening.

Do high frequency ultrasound images support clinical skin assessment?

High frequency ultrasound imaging has been reported as a potential method of identifying the suspected tissue damage in patients "at risk" of pressure ulceration. The aim of this study was to explore whether ultrasound images supported the clinical skin assessment in an inpatient population through identification of subcutaneous tissue damage. Skin on the heels and/or sacral coccygeal area of fifty vascular surgery inpatients was assessed clinically by tissue viability nurses and with ultrasound pre operatively and at least every other day until discharge. Images were compared to routine clinical skin assessment outcomes. Qualitative classification of ultrasound images did not match outcomes yielded through the clinical skin assessment. Images corresponding to 16 participants were classified as subgroup 3 damage at the heels (equivalent to grade 2 pressure ulceration); clinical skin assessment rated no heels as greater than grade 1a (blanching erythema). Conversely, all images captured of the sacral coccygeal area were classified as normal; the clinical skin assessment rated two participants as grade 1b (non-blanching erythema). Ultrasound imaging is a potentially useful adjunct to the clinical skin assessment in providing information about the underlying tissue. However, further longitudinal clinical assessment is required to characterise images against actual and "staged" pressure ulceration.

Expression of immune genes on chromosome 6p21.3-22.1 in schizophrenia.

Schizophrenia is a common mental illness with a large genetic component. Three genome-wide association studies have implicated the major histocompatibility complex gene region on chromosome 6p21.3-22.1 in schizophrenia. In addition, nicotine, which is commonly abused in schizophrenia, affects the expression of central nervous system immune genes. Messenger RNA levels for genes in the 6p21.3-22.1 region were measured in human postmortem hippocampus of 89 subjects. The effects of schizophrenia diagnosis, smoking and systemic inflammatory illness were compared. Cell-specific expression patterns for the class I major histocompatibility complex gene HLA-A were explored utilizing in situ hybridization. Expression of five genes was altered in schizophrenic subjects. Messenger RNA levels for the class I major histocompatibility complex antigen HLA-B were increased in schizophrenic nonsmokers, while levels for smokers were indistinguishable from those of controls. ß2 microglobulin, HLA-A and Notch4 were all expressed in a pattern where inflammatory illness was associated with increased expression in controls but not in subjects with schizophrenia. Schizophrenia was also associated with increased expression of Butyrophilin 2A2. HLA-A was expressed in glutamatergic and GABAergic neurons in the dentate gyrus, hilus, and the stratum pyramidale of the CA1-CA4 regions of the hippocampus, but not in astrocytes. In conclusion, the expression of genes from the major histocompatibility complex region of chromosome 6 with likely roles in synaptic development is altered in schizophrenia. There were also significant interactions between schizophrenia diagnosis and both inflammatory illness and smoking.

Effectiveness of QUICATOUCH: a computerised touch screen evaluation for pain and distress in ambulatory oncology patients in Newcastle, Australia.

OBJECTIVE: To describe the change in pain and distress over time to demonstrate the effectiveness of the QUICATOUCH program in an outpatient oncology population. METHODS: Descriptive study of the first 29 months of the QUICATOUCH program (13 736 assessments for 5775 patients). A longitudinal cohort design was used to examine the patients with three or more assessments (8129 assessments for 1778 patients). Effectiveness of this complex intervention (repeated assessment, clinician report and referral to speciality psycho-oncology service) was examined using: reduction in proportion over threshold for pain and distress, predictors of mean pain and distress scores and comparison of the number of new patients treated by the psycho-oncology service during the study and in the preceding 29 months. RESULTS: Pain and distress declined during the study. The risk of being over threshold at endpoint was reduced for pain (odds ratio (OR) 0.70, confidence interval (CI) 95% 0.60-0.81) and for distress (OR 0.58 CI 95% 0.49-0.68) with baseline as referent level. Three variables predicted the mean pain: clinic type, current radiotherapy treatment and distress score; and five predicted mean distress: time, gender, clinic type, age and pain score. There was an increase of 40% (533v747) in new patients treated by the psycho-oncology service. CONCLUSIONS: The QUICATOUCH assessment for pain and distress was implemented into usual clinical practice with reasonable coverage of patients for modest cost. It was effective in monitoring the patients over time, contributed to a reduction in pain and distress, whilst appropriately increasing the number of new patients reaching psychological treatment as part of the clinical service.

Natural but not inducible regulatory T cells require TNF-alpha signaling for in vivo function.

TNF-α has a multifunctional role in autoimmune diseases as reflected in the variable responses of different human diseases to anti-TNF-α therapy. Recent studies have suggested that TNF-α modulates autoimmunity partially via effects on regulatory T cells (Tregs) and that these effects are mediated through the type II TNFR (TNFR2). We have investigated the requirement for TNFR2-expression on murine natural Tregs (nTregs) and induced Tregs (iTregs) in mediating suppression of colitis. Surprisingly, we find that TNFR2-expression is required for both spleen- and thymus-derived nTreg-mediated suppression, but is not required for iTreg-mediated suppression. Abnormal TNFR2(-/-) nTreg function was not associated with an in vivo decrease in accumulation, stability, or expression of markers known to be relevant in Treg function. Because iTregs are generated in the presence of TGF-ß, we investigated whether activation in the presence of TGF-ß could overcome the functional defect in TNFR2(-/-) nTregs. Although preactivation alone did not restore suppressive function of nTregs, preactivation in the presence of TGF-ß did. These results identify potentially critical differences in activation requirements for nTregs versus iTregs. Furthermore, our findings are consistent with reports suggesting that nTregs are activated in sites of inflammation while iTregs are activated in lymph nodes. Finally, by demonstrating that nTregs require TNF-α for optimal function whereas iTregs do not, our results suggest that the enigma of variable responses of different human diseases to anti-TNF-α therapy may relate to whether nTregs or iTregs have the predominant regulatory role in a given disease.

Disruption to radiation therapy sessions due to anxiety among patients receiving radiation therapy to the head and neck area can be predicted using patient self-report measures.

OBJECTIVE: This analysis sought to determine whether patient self-report measures were associated with disruption to radiation therapy sessions due to anxiety among cancer patients undergoing radiation therapy to the head and neck region. METHOD: A cohort of patients undergoing radiation therapy to the head and neck region at a major regional radiation oncology treatment centre (ROTC) in Australia completed self-report measures of anxiety, history of panic and fears relevant to use of an immobilising mask. The treating Radiation Therapist (RT) rated the level of session disruption due to patient anxiety during the Computerised Tomography/Simulation (CT/Sim) (baseline) session and first treatment session. RESULTS: Complete data were obtained for 90 patients. RTs rated 11 and 24% of patients as having some level of session disruption session due to anxiety at baseline and Treatment 1, respectively. Five factors were significantly associated with session disruption at baseline in bivariate analyses: currently taking psycho-active medication (p=0.008); fear of enclosed spaces (p=0.006); fear of face being covered up (p=0.006); fear of movement restriction (p=0.041) and ever had an anxiety attack (p=0.034). Sensitivity ranged from 0.57 to 0.75 and specificity ranged from 0.68 to 0.90. Only session disruption at baseline predicted disruption at Treatment 1 (p<0.01). CONCLUSIONS: This study offers some preliminary insights into the prevalence of patient anxiety severe enough to cause session disruption and patient self-report measures which might be used to flag patients for prophylactic treatment. Further development and replication in a larger sample is warranted before introduction of these measures into routine practice.

Caregiver satisfaction with out-patient oncology services: utility of the FAMCARE instrument and development of the FAMCARE-6.

PURPOSE: To evaluate caregivers' experience of oncology services for ambulatory patients and to develop a short instrument (FAMCARE-6) suitable for computerised administration in the clinical setting. METHODS: A sample of 234 caregivers recruited from 388 ambulatory oncology patients completed a computerised version of the 20-item family satisfaction with advanced cancer care (FAMCARE) instrument, which was originally developed for use in palliative care settings. RESULTS: Caregivers reported generally high satisfaction with all aspects of ambulatory oncology services: overall score; mean, 3.96 (SD, 0.67); information giving, 3.88 (0.78); physical patient care, 4.00 (0.71); availability of care, 3.89 (0.77); and psychosocial care, 4.05 (0.72), from a possible score of 5. Factor analyses identified a single factor structure; the items were reduced to six (FAMCARE-6), which yielded a scale with adequate psychometric properties (completion rates over 90% for every item, correlation of 0.7 or above with the factor identified in the individual item factor analysis, and internal reliability of α = 0.85). The overall mean score was 3.91 (SD, 0.73) for the FAMCARE-6. CONCLUSIONS: FAMCARE-6 can be used to assess caregiver satisfaction with ambulatory oncology services and may be suitable to be included as part of a computerised screening system for the psychological care of oncology patients.