The barriers to interprofessional care for cancer cachexia among Japanese healthcare providers: A nationwide survey.

BACKGROUND: Cancer cachexia is a severe complication of advanced malignancy, with few therapeutic options. To promote interprofessional care for cancer cachexia, healthcare providers' needs should be addressed in detail. This pre-planned subgroup analysis of the Global Educational Needs Evaluation: a systemic interprofessional study in cancer cachexia (GENESIS-CC) survey aimed to identify barriers to interprofessional care of cancer cachexia in Japan. METHODS: A nationwide survey was electronically conducted for healthcare providers in oncological or general healthcare facilities from January to March 2021 in Japan. The Japanese Regional Advisory Board developed a barrier scoring system with 33 from the 58 original survey items to quantify six domains of barriers: (1) lack of confidence, (2) lack of knowledge, (3) barriers in personal practice, (4) barriers in perception, (5) barriers in team practice and (6) barriers in education. The largest possible barrier score was set at 100 points. We compared the scores by profession. RESULTS: A total of 1227 valid responses were obtained from 302 (24.6%) physicians, 252 (20.5%) pharmacists, 236 (19.2%) nurses, 218 (17.8%) dietitians, 193 (15.7%) rehabilitation therapists and 26 (2.0%) other professionals. Overall, 460 (37.5%) were not very or at all confident about cancer cachexia care, 791 (84.1%) agreed or strongly agreed that care was influenced by reimbursement availability and 774 (81.9%) did not have cancer cachexia as a mandatory curriculum. The largest mean barrier score (± standard deviation) was 63.7 ± 31.3 for education, followed by 55.6 ± 21.8 for team practice, 43.7 ± 32.5 for knowledge, 42.8 ± 17.7 for perception and 36.5 ± 16.7 for personal practice. There were statistically significant interprofessional differences in all domains (P < 0.05), especially for pharmacists and nurses with the highest or second highest scores in most domains. CONCLUSIONS: There is a need to improve the educational system and team practices of cancer cachexia for most Japanese healthcare providers, especially pharmacists and nurses. Our study suggests the need to reform the mandatory educational curriculum and reimbursement system on cancer cachexia to promote interprofessional care for cancer cachexia in Japan.

Identification and management of cancer cachexia in patients: Assessment of healthcare providers' knowledge and practice gaps.

BACKGROUND: Cancer cachexia negatively impacts patient outcomes, quality of life and survival. Identification and management of cancer cachexia remains challenging to healthcare professionals (HCPs). The aim of this assessment was to identify current gaps in HCPs' knowledge and practice for identifying and managing adults with cancer-related cachexia. Results may guide development of new educational programmes to close identified gaps and improve outcomes of cancer patients. METHODS: An international assessment was conducted using a mixed-methods approach including focus group interviews with subject matter experts and an electronic survey of practising HCP. The assessment was led by the Society on Sarcopenia, Cachexia and Wasting Disorders (SCWD) and was supported by in-country collaborating organizations. RESULTS: A quantitative survey of 58 multiple-choice questions was completed by physicians, nurses dietitians and other oncology HCP (N = 2375). Of all respondents, 23.7% lacked confidence in their ability to provide care for patients with cancer cachexia. Patients with gastrointestinal, head and neck, pulmonary cancers and leukaemia/lymphoma were reported as those at highest risk for cachexia. Only 29.1% of respondents recognized a key criterion of cancer cachexia as >5% weight loss from baseline, but many (14.4%) did not utilize a standardized definition of cancer cachexia. Despite this, most clinicians (>84%) were able to identify causes of weight loss-reduced oral intake, progressive disease, side effects of therapy and disease-related inflammation. Of all respondents, 52.7% indicated newly diagnosed patients with cancer should be screened for weight loss. In practice, 61.9% reported that patient weight was systematically tracked over time, but only 1125 (47.4%) reported they weigh their cancer patients at each visit. Treatment of cachexia focused on increasing the patient's nutritional intake by oral nutritional supplements (64.2%), energy and protein fortified foods (60.3%) and counselling by a dietitian (57.1%). Whereas many respondents (37.3%) considered cachexia inevitable, most (79.2%) believed that an interprofessional team approach could improve care and that use of standardized tools is critical. CONCLUSIONS: Findings from this international assessment highlight the challenges associated with the care of patients with cancer cachexia, opportunities for interventions to improve patient outcomes and areas of variance in care that would benefit from further analysis.

Moving from data collection to application: a systematic literature review of surgical capacity assessments and their applications.

BACKGROUND: Over the past decade, assessments of surgical capacity in low- and middle-income countries (LMICs) have contributed to our understanding of barriers to the delivery of surgical services in a number of countries. It is yet unclear, however, how the findings of these assessments have been applied and built upon within the published literature. METHODS: A systematic literature review of surgical capacity assessments in LMICs was performed to evaluate current levels of understanding of global surgical capacity and to identify areas for future study. A reverse snowballing method was then used to follow-up citations of the identified studies to assess how this research has been applied and built upon in the literature. RESULTS: Twenty-one papers reporting the findings of surgical capacity assessments conducted in 17 different LMICs in South Asia, East Asia and Pacific, Latin America and the Caribbean, and sub-Saharan Africa were identified. These studies documented substantial deficits in human resources, infrastructure, equipment, and supplies. Only seven additional papers were identified which applied or built upon the studies. Among these, capacity assessment findings were most commonly used to develop novel tools and intervention strategies, but they were also used as baseline measurements against which updated capacity assessments were compared. CONCLUSIONS: While the global surgery community has made tremendous progress in establishing baseline values of surgical capacity in LMICs around the world, further work is necessary to build upon and apply the foundational knowledge established through these efforts. Capacity assessment data should be coordinated and used in ongoing research efforts to monitor and evaluate progress in global surgery and to develop targeted intervention strategies. Intervention strategy development may also be further incorporated into the evaluation process itself.

Development of a surgical capacity index: opportunities for assessment and improvement.

BACKGROUND: Significant gaps exist in the provision of surgical care in low- and middle-income countries (LMICs). The purpose of this study was to develop a metric to monitor surgical capacity in LMICs. METHODS: The World Health Organization developed a survey called the Tool for Situational Analysis to Assess Emergency and Essential Surgical Care. Using this tool, we developed a surgical capacity scoring index and assessed its usefulness with data from Sierra Leone, Liberia, and the Solomon Islands. RESULTS: There were data from 10 hospitals in Sierra Leone, 16 hospitals in Liberia, and 9 hospitals in the Solomon Islands. The levels of surgical capacity were created using our scoring index based on a possible 100 points: level 1 for hospitals with <50 points, level 2 with 50-70 points, level 3 with 70-80 points, and level 4 with >80 points. In Sierra Leone, 44% of the hospitals had a surgical capacity rating of level 1, 50% level 2, and 10% level 3. In Liberia, 37.5% of the hospitals had a surgical capacity rating of level 1, 56.3% level 2, and only one hospital level 3. For Sierra Leone and Liberia, two factors--infrastructure and personnel--had the greatest deficits. In the Solomon Islands, 44.4% of the hospitals had their surgical capacity rated at level 1, 22.2% at level 2, 11.1% at level 3, and 22.2% at level 4. CONCLUSIONS: Pending pilot testing for reliability and validity, it appears that a systematic hospital surgical capacity index can identify areas for improvement and provide an objective measure for monitoring changes over time.

Implementing Liberia's poverty reduction strategy: An assessment of emergency and essential surgical care.

OBJECTIVE: To document infrastructure, personnel, procedures performed, and supplies and equipment available at all county hospitals in Liberia using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care. DESIGN: Survey of county hospitals using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care. SETTING: Sixteen county hospitals in Liberia. MAIN OUTCOME MEASURES: Infrastructure, personnel, procedures performed, and supplies and equipment available. RESULTS: Uniformly, gross deficiencies in infrastructure, personnel, and supplies and equipment were identified. CONCLUSIONS: The World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care was useful in identifying baseline emergency and surgical conditions for evidenced-based planning. To achieve the Poverty Reduction Strategy and delivery of the Basic Package of Health and Social Welfare Services, additional resources and manpower are needed to improve surgical and anesthetic care.

Association of intramyocardial high energy phosphate concentrations with quantitative measures of the ventricular fibrillation electrocardiogram waveform.

BACKGROUND: Quantitative measures of the ventricular fibrillation (VF) electrocardiogram (ECG) have been correlated with the success of rescue shocks, making them ideal measures for guiding resuscitative interventions. Correlation of intramyocardial energy stores with the change in quantitative VF ECG measures would provide mechanistic insight into their utility. We sought to investigate the relationship between intramyocardial energy stores and four quantitative ECG measures. METHODS: Eighteen mixed-breed, domestic swine were sedated, anaesthetized and paralyzed. Swine were block randomized into three groups receiving 5, 10, or 15 min of untreated VF. Thoracotomy was performed and the heart was delivered. VF was induced by a 100 mA transthoracic shock while ECG was recorded. Biopsies of myocardial tissue were taken from the left and right ventricles after the prescribed duration of VF. Adenosine triphosphate (ATP) and adenosine diphosphate (ADP) concentrations in the tissue samples were measured. ECG data immediately prior to each biopsy were analyzed by each of four quantitative ECG methods: Scaling Exponent (ScE), Median Slope (MS), Amplitude Spectrum Area (AMSA), and logarithm of the Absolute Correlation (LAC). ATP and ADP concentrations of VF duration groups were compared. ATP and ADP concentrations were regressed against each quantitative ECG measure. RESULTS: ATP concentrations differed between VF duration groups, but ADP concentrations differed only between 5 and 10 min groups. A significant association existed between ATP and three quantitative measures--ScE, MS, and AMSA--but no significant relationship was found for ADP. CONCLUSION: Intramyocardial ATP levels correlate with quantitative measures of the ECG during ventricular fibrillation.

The effect of adenosine A1 receptor antagonism on return of spontaneous circulation and short-term survival in prolonged ventricular fibrillation.

BACKGROUND: Endogenous adenosine (ADO) is cardioprotective during ischemia and its myocardial concentration increases during untreated ventricular fibrillation (VF). We have previously shown that ADO A1 receptor (ADOA1R) antagonism hastens the time-dependent decay in VF waveform morphology during the circulatory phase of cardiac arrest. OBJECTIVE: To determine the effect of ADOA1R antagonism on ROSC and short-term survival in prolonged VF. METHODS: Thirty-six swine were assigned by block randomization to one of three groups: a group that received only vehicle (CONTROL), an ADOA1R antagonist pretreatment group (PRE), and a group that was given ADOA1R antagonist during resuscitation (DURING). The animals were instrumented under anesthesia, and ADOA1R antagonist or vehicle, per group assignment, was infused 5 minutes prior to VF induction. At minute 8 of untreated VF, chest compression with ventilation was initiated and a standard drug cocktail, with ADOA1R antagonist or vehicle, was given. The first rescue shock (150 J biphasic) was delivered after 11 minutes of VF. Proportions with 95% confidence intervals (CIs) were calculated for the two outcome measures. RESULTS: The baseline characteristics and chemistry values for the three groups were mathematically the same. The DURING group had a greater proportion of female animals (seven of 12) in comparison with the CONTROL group (two of 12) (p=0.03). ADOA1R antagonism hastened the decay of VF as previously demonstrated, but the rate of ROSC was the same for all groups: CONTROL=seven of 12, PRE=six of 12, and DURING=seven of 12. There were also no differences in short-term survival: CONTROL=four of 12, PRE=five of 12, and DURING=seven of 12. CONCLUSIONS: In this study, ADOA1R antagonism had no effect on outcome whether given before induction of VF or upon resuscitation after 8 minutes of untreated VF. The role of endogenous ADO in prolonged VF remains unclear.

Adenosine A1 receptor antagonism hastens the decay in ventricular fibrillation waveform morphology during porcine cardiac arrest.

BACKGROUND: Endogenous adenosine (ADO) is known to be cardioprotective during acute myocardial ischemia. Coronary sinus ADO concentration has recently been shown to increase nearly 13-fold over baseline levels after 5 min of untreated ventricular fibrillation (VF). The role of ADO in VF has never been previously examined. The objective of this study was to determine the effect of ADO receptor antagonism, as measured by the scaling exponent (ScE), on the degeneration of VF over time during the circulatory phase of cardiac arrest. METHODS AND RESULTS: A well-established swine model of prolonged VF arrest was used for this experiment. Eighteen domestic mixed-breed swine were assigned by block randomization to receive either DTI-0017 (5mg/kg), a potent ADO A(1) receptor antagonist or placebo in a double-blind fashion. The animals were instrumented under general anesthesia and acclimatized. The assigned solution was infused over 5 min. One minute after the infusion was completed, VF was induced with a 3s, 60 Hz, 100 mA transthoracic shock and left untreated. Lead II ECG was monitored continuously and recorded at 1000 samples/s. It was determined a priori that evaluation of the plots would be limited to a previously observed plateau phase historically occurring between 5 and 8 min corresponding to the circulatory phase of cardiac arrest. The scaling exponent values over this period were calculated for each of the 18 recordings using custom MATLAB routines. Using the Wald statistic to produce the Chi square distributions the null hypothesis, that there was no difference between the two groups, was tested. The Wald statistic calculation based on eight epochs from 300 to 475 s in placebo and DTI groups was significant to reject the null hypothesis of no difference in the groupxtime interaction at the 0.015 level (Chi square distribution for Wald=17.49, d.f.=7). CONCLUSIONS: In this swine model, adenosine A(1) receptor antagonism accelerated the natural decay in the ECG VF waveform during the circulatory phase of cardiac arrest. Our findings would suggest that endogenous adenosine has cardioprotective effects during sudden cardiac arrest by slowing the time-dependent degeneration of VF.