A Dedicated Outpatient Pharmacy Improves Access to Discharge Medications in a Pediatric Emergency Department: A Quality Improvement Study.

STUDY OBJECTIVE: Following discharge from a pediatric emergency department (ED) or urgent care, many families do not pick up their prescribed medications. The aim of this quality improvement study was to increase the percentage of patients discharged home with medications in-hand from 6% to 30% within 6 months. METHODS: Due to the planned construction of a new ED, urgent care, and dedicated pharmacy, a multidisciplinary team was formed to increase access to discharge medications. We performed a pilot study in the urgent care to improve the discharge prescription process and expanded its scope to the ED. We evaluated the effect of our interventions on the percentage of patients discharged with medications in-hand through statistical process control charts. Process measures included the percentage of prescriptions electronically prescribed and directed to an on-site pharmacy. RESULTS: Between June 21, 2021 and March 27, 2022, 7,678 patients were discharged with at least 1 medication in-hand. The percentage of patients discharged with medications in-hand increased from 6.2% to 60.6%. The percentage of prescriptions e-prescribed and directed to an on-site pharmacy increased to 94.6% and 65.6% respectively. CONCLUSIONS: In this study, the availability of a 24-hour on-site pharmacy appears to be the most impactful intervention increasing access to discharge medications for families. Other interventions, such as a pilot study in the urgent care and implementing default electronic prescribing, may have potentiated the effect of the new pharmacy.

Designing a wholly online, multidisciplinary Master of Cancer Sciences degree.

BACKGROUND: Improving oncology-specific knowledge and skills of healthcare professionals is critical for improving the outcomes of people with cancer. Many current postgraduate education offerings may be inaccessible to busy professionals, contain minimal consumer input or do not focus on the multidisciplinary nature of cancer care. In response to these needs, a Master of Cancer Sciences degree was developed. Our aim is to describe the development of the Master of Cancer Sciences. METHODS: We describe the development of the Master of Cancer Sciences, including its theoretical and its pedagogical underpinnings. RESULTS: Our approach to curriculum design was guided by Kern's Six-Step Approach to Medical Curriculum and underpinned by the Seven Principles of Online Learning. These approaches were further underpinned by the Cognitive Theory of Multimedia Learning which informed our approach to audio and visual information design. The pedagogy is interactive, experiential, interprofessional and importantly, includes consumers as educators. In practice, learning activities include peer feedback, multidisciplinary team meeting simulations, group work and clinical role plays. The online environment was visually shaped through infographics, high-quality educational videos and gamification. CONCLUSION: We have designed a Master of Cancer Sciences that is one of the first wholly online, cancer-specific Masters' programs. Its industry-led curriculum using evidence-based pedagogical choices utilises a range of novel digital formats and integrates the consumer perspective to provide a holistic overview of the field. Quantitative and qualitative evaluation of learning outcomes is ongoing.

Protein intake is not associated with functional biomarkers of physical frailty: A cross-sectional analysis of community-dwelling older adults with type 2 diabetes mellitus.

BACKGROUND AND AIM: Frailty has emerged as a third category of complication in patients with type 2 diabetes mellitus (T2DM). It has been suggested that adequate protein intake is an important dietary strategy for counteracting frailty. Therefore, we explored the association between protein intake and functional biomarkers of frailty in older adults with T2DM. METHODS AND RESULTS: Frailty was operationalized as the presence of three of the following: exhaustion, low muscle strength, low physical activity, slow gait speed, and weight loss. Functional biomarkers included handgrip strength (HGS), chair stands, the short physical performance battery and gait speed. Eighty-seven older adults (71.2 ± 8.2 years; 66.7% males) were included. A total of n = 6 (~7%) and n = 32 (~37%) participants were identified as frail and pre-frail respectively. No significant difference was observed for protein intake across staging of frailty (pre-frail/frail: 1.3 ± 0.4 g/kg BW; non-frail: 1.4 ± 0.4 g/kg BW; P = 0.320). A significant association was observed for total protein intake and HGS (ß = 0.44; 95% CI: 0.23-1.8; P = 0.01). However, this was no longer significant after adjusting for age, gender, physical activity, energy intake and total appendicular lean muscle (ß = 0.03; 95% CI: -0.45-0.60; P = 0.78). Nil other associations were observed between total protein intake and functional biomarkers of frailty. CONCLUSION: Adequate protein intake was not associated with functional biomarkers in older adults with T2DM. Future research should focus on the efficacy of protein on attenuating functional decline in vulnerable older adults with low protein intake.

Adherence with an Acute Agitation Algorithm and Subsequent Restraint Use.

Timely use of pharmacological interventions to treat acute agitation has the potential to decrease physical restraint use. The aim of this study is to determine if adherence to standardized pharmacological recommendations for the treatment of acutely agitated pediatric patients decreases physical restraint use. Additionally, this study aims to identify predictors of physical restraint use and describe treatment related adverse events. This is a retrospective chart review of patient visits between September 1, 2016 and August 31, 2017. Patient visits were included if the patient presented to the pediatric emergency department, met ICD-10 codes, and received pharmacologic management or physical restraint to treat acute agitation. The differences in rate of physical restraint was assessed between patients treated according to the standardized pharmacological recommendations and patients who were not. 447 patients were included with a mean age of 13 years. No significant difference in physical restraint use was found when standardized pharmacological recommendations were followed compared to when they were not (P = 0.16). Only presentation on day shift when compared to evening shift resulted in increased odds of being restrained (OR 2.03; 95% CI 1.18, 3.50). Nine adverse events possibly related to medications were identified with none considered to be of significant clinical concern. Standardized pharmacological treatment recommendations was not associated with a decrease in physical restraint use for agitated patients presenting to the pediatric emergency department. The pharmacologic strategies utilized were generally safe and well tolerated in this patient population.

Self-reported and objective taste and smell evaluation in treatment-naive solid tumour patients.

BACKGROUND: Taste and smell abnormalities (TSA) commonly occur in cancer and are associated with anorexia, early satiety, malnutrition, weight loss and reduced quality of life. A recent study found a high TSA prevalence in newly diagnosed cancer patients before treatment. This suggests that TSA may originate from the tumour itself. No previous study has examined TSA, both subjectively and objectively, in newly diagnosed, treatment-naïve cancer patients. This study aimed to address this gap. METHODS: This prospective observational study recruited consecutive, newly diagnosed, treatment-naïve patients with solid tumours at Radiation Oncology Out-patients. Self-reported taste and smell changes since becoming ill were evaluated using modified Taste and Smell Survey, and objective taste and smell tests were conducted using 'Sniffin' Sticks Olfactory Test® and Burghart Taste Strips®. Nutritional status was assessed with abridged Patient-Generated Subjective Global Assessment. RESULTS: Thirty completed the study. Seventy-four per cent had at least one TSA. Taste changes and/or abnormalities were more prevalent than smell, and subjective taste changes more common than objective abnormalities. Although less common, smell abnormalities impacted quality of life more. TSA characteristics were heterogeneous. Forty-seven per cent were at malnutrition risk. No association was found between TSA and nutritional status. CONCLUSIONS: Over two thirds had at least one TSA and almost half were at malnutrition risk. Self-reported TSA included changes in taste and smell perception, and most commonly persistent bad taste. This study demonstrated the complexity of TSA assessment and the prevalence, severity and impact of these and related symptoms in treatment-naïve cancer patients.

Diet and nutrition information on nine national cancer organisation websites: A critical review.

INTRODUCTION: National Cancer Organisations (NCO) provide web-based diet and nutrition information for patients with all types and stages of cancer. We examined diet and nutrition information provided by nine NCO in English-speaking countries. METHODS: Diet and nutrition information was examined under four headings: disease phases, treatment modalities, nutrition impact symptoms and cancer primary sites. We also examined the degree of concordance between NCO websites and appraised the readability of materials. RESULTS: Nine NCO websites from six English-speaking countries were included: Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States. All provided general healthy eating advice. Information at diagnosis and pre-treatment was inadequate, but well-addressed for survivorship. Specific treatment modalities such as biological and hormone therapy were largely ignored. Symptom management was well-addressed, with some exceptions. Cancer site-specific advice was readily available. All recommended consultation with a dietitian/healthcare professional for personalised guidance. Only one met the universal health literacy standard. CONCLUSIONS: NCO websites provided important general diet and nutrition information for cancer patients. The information was reliable and safe, but more in-depth, evidence-based and health-literate information is required. There is an urgent need for an international consensus for consistent cancer diet and nutrition advice.

Dispensing Medications at the Hospital Upon Discharge From an Emergency Department.

Although most health care services can be provided in the medical home, children will be referred or require visits to the emergency department (ED) for a variety of conditions ranging from nonurgent to emergent. Continuation of medical care after discharge from an ED is dependent on parents or caregivers' understanding of follow-up instructions and adherence to medication administration recommendations. Barriers to obtaining medications after ED visits include lack of access because of pharmacy hours, affordability, and lack of understanding the importance of medication as part of treatment. ED visits often occur at times when community-based pharmacies are closed. Caregivers are typically concerned with getting their ill or injured child directly home once discharged from the ED. Approximately one-third of patients fail to obtain priority medications from a pharmacy after discharge from an ED. The option of judiciously dispensing medications at ED discharge from the outpatient pharmacy within the health care facility is a major convenience that helps to overcome this obstacle, improving the likelihood of medication adherence. Emergency care encounters should routinely be followed by visits to the primary care provider medical home to ensure complete and comprehensive care.

Taste and smell abnormalities in advanced cancer: Negative impact on subjective food intake.

BACKGROUND: Taste and smell abnormalities (TSAs) are present in all cancer stages and may contribute to malnutrition. Despite this, they are rarely screened for. This study examined the prevalence and characteristics of TSAs and their influence on subjective food intake in advanced cancer. METHODS: Consecutive patients with advanced cancer were recruited. A modified Taste and Smell Survey assessed subjective TSAs. Objective TSAs were assessed with validated taste strips and "Sniffin Sticks." A six-item food intake questionnaire identified any effect TSAs had on food preferences/aversions. Nutrition status was evaluated with the abridged Patient-Generated Subjective Global Assessment. RESULTS: All 30 participants had either subjective or objective TSAs. The prevalence of TSAs varied based on the assessment tool used. Participants were more aware of taste changes (TCs) than smell changes (SCs). TCs caused reduced food intake in 13 participants. Six reported SCs affected food intake. Food choices caused by TSAs were inconsistent. Some foods preferred because of TSAs were avoided by other participants. None received nutrition counseling on TSA management. Almost all were at malnutrition risk (97%). Almost half (47%) felt TSAs reduced quality of life (QoL). Participants reported "not looking forward to meals" and "can't sit down and eat anything" because of TSAs. CONCLUSION: TSAs were highly prevalent and impactful on food intake. Both TCs and SCs were complex and varied on an individual basis. Despite the effect on health and QoL, no patients received any nutrition counseling on TSA management. Individualized screening and advice are needed for TSAs in advanced cancer.

Cardiac dysfunction in solid tumours: scoping review.

Cardio-oncology is a dynamic field. Research has suggested that cancer itself can damage the heart, independent of cancer treatment-related cardiac dysfunction (CTRCD). The aim of this study was to establish the nature of cardiovascular abnormalities reported in cancer, excluding CTRCD. Scoping review search included cardiovascular abnormalities in adults with solid tumour malignancies, and excluded CTRCD and thrombotic events. Three databases (CINAHL, Embase, Medline) were searched, supplemented by a handsearch. All screening and data extraction was done by two researchers with consensus reached for any conflicts. Given the heterogeneous nature of the studies identified, data synthesis was narrative. The search identified 42 366 studies. Following deduplication and title/abstract screening, 195 studies were assessed for full-text eligibility. Forty-four studies are included in the final analysis. There are 19 prospective observational studies, 13 retrospective studies, 9 case reports and 3 cross-sectional studies. Types of abnormality identified include cardiomyopathy (16, including Takotsubo (9)), autonomic nervous system (ANS) dysfunction (10), biomarker disturbances (9), reduced myocardial strain (6) and others (3). Due to variable study design, the prevalence was not determined. Cardiovascular abnormalities were associated with morbidity (chest pain, dyspnoea, fatigue) and shortened prognosis. In conclusion: (1) There is evidence for cardiovascular dysfunction in patients with solid tumour malignancies, distinct from CTRCD. People with solid tumours have higher rates of cardiac disease, even when newly diagnosed and treatment naïve. (2) Abnormalities manifest mainly as cardiomyopathies, ANS dysfunction and raised biomarker levels and are associated with significant symptoms. (3) Treatment plans need to take account of these risks, and widen criteria for screening.

Screen-based digital learning methods in radiation oncology and medical education.

The field of radiation oncology is rapidly advancing through technological and biomedical innovation backed by robust research evidence. In addition, cancer professionals are notoriously time-poor, meaning there is a need for high quality, accessible and tailored oncological education programs. Digital learning (DL) is well-placed to cater to these needs, as it provides teaching options that can be delivered flexibly and on-demand from anywhere in the world. The evidence for usage of these techniques in medical education has expanded rapidly in recent years. However, there remains many reservations in the oncological community to adopting and developing DL, largely due to a poor familiarity with the pedagogical evidence base. This article will review the application of the screen-based DL tools that are at educators' disposal. It will summarize best-practice in developing tailored, made-for-screen videos, gamification, and infographics. It also reviews data behind the following practical tips of 1) strategically combining text with graphics to decrease cognitive load, 2) engaging users through use of interactive elements in digital content, and 3) maximizing impact through thoughtful organization of animations/images. Overall, the digital space evolving is well placed to cater to the evolving educational needs of oncology learners. This review and its practical tips aim to inspire further development in this arena, production of high-yield educational products, use of engaging delivery methods and programs that are tailored to individual learning needs.

Virtual reality and augmented reality in radiation oncology education - A review and expert commentary.

The field of radiation oncology is rapidly advancing through technological and biomedical innovation backed by robust research evidence. However, cancer professionals are notoriously time-poor, meaning there is a need for high quality, accessible and tailored oncologic education programs. While traditional teaching methods including lectures and other in-person delivery formats remain important, digital learning (DL) has provided additional teaching options that can be delivered flexibly and on-demand from anywhere in the world. While evidence of this digital migration has been evident for some time now, it has not always been met with the same enthusiasm by the teaching community, in part due to questions about its pedagogical effectiveness. Many of these reservations have been driven by a rudimentary utilisation of the medium and inexperience with digital best-practice. With increasing familiarity and understanding of the medium, increasingly sophisticated and pedagogically-driven learning solutions can be produced. This article will review the application of immersive digital learning tools in radiation oncology education. This includes first and second-generation Virtual Reality (VR) environments and Augmented Reality (AR). It will explore the data behind, and best-practice application of, each of these tools as well as giving practical tips for educators who are looking to implement (or refine) their use of these learning methods. It includes a discussion of how to match the digital learning methods to the content being taught and ends with a horizon scan of where the digital medium may take us in the future. This article is the second in a two-part series, with the companion piece being on Screen-Based Digital Learning Methods in Radiation Oncology. Overall, the digital space is well-placed to cater to the evolving educational needs of oncology learners. Further uptake over the next decade is likely to be driven by the desire for flexible on demand delivery, high-yield products, engaging delivery methods and programs that are tailored to individual learning needs. Educational programs that embrace these principles will have unique opportunities to thrive in this space.

Diet and Nutrition Advice After a Solid Tumor Diagnosis.

PURPOSE: Credible evidence-based diet and nutrition advice is essential for patients with cancer. This study aimed to explore what advice patients with cancer obtained before a formal dietetic visit. METHODS: A multicenter, observational study was conducted in seven hospital-based oncology services. Consecutive patients were recruited at first dietetic assessment. In addition to routine dietetic assessment, participants completed a four-item questionnaire describing diet and nutrition advice obtained since diagnosis. RESULTS: Seventy-seven patients participated. More than 80% had multiple nutrition-impact symptoms. In total, 53 (69%) obtained advice from professional and nonprofessional sources before dietetic visit. Family and friends were the most common sources of advice. More than one third got advice from (nondietetic) healthcare professionals. Most advice related to "foods to include" (61%) and "foods to avoid" (54%) in the diet. Many of the "foods to avoid" were important sources of micro- and macronutrients. Advice about dietary supplements (31%) and specific diets (28%) was common, rarely evidence-based, and frequently contradictory. Participants found it difficult to discern what advice was trustworthy and reliable. Despite this, most followed the advice. CONCLUSION: The majority of patients received diet and nutrition advice before first dietetic visit. Most of this came from nonprofessional sources. Any advice from nondietetic healthcare professionals was inconsistent or vague. This was mainly related to the avoidance and/or inclusion of particular foods and was often contradictory. Nevertheless, patients usually followed such advice fully. To help manage their frequent nutrition-impact symptoms and resolve the contradictory advice they had received, many expressed the need for earlier professional dietetic consultation.

Adiposity is inversely associated with strength in older adults with type 2 diabetes mellitus.

BACKGROUND AND PURPOSE: Several biological mechanisms describing the pathway to mobility disability and functional decline in older adults with type 2 diabetes mellitus (T2DM) have been postulated, including skeletal muscle atrophy and the concurrent accumulation of fat mass. Therefore, we explored the association between adiposity, muscle strength and physical performance in community-dwelling older adults with T2DM. METHODS: Adiposity was measured by waist circumference (WC) or body fat percentage (BF %) derived from dual-energy X-ray absorptiometry (DXA). The Short Physical Performance Battery (SPPB) and gait speed were used to evaluate lower extremity physical function. Muscle strength was assessed using hand-grip strength (HGS) or chair stands. Multiple regression analysis was used to examine the association between measures of adiposity, SPPB score, gait speed, HGS and chair stands adjusted for age, gender and total appendicular skeletal muscle (ASM). RESULTS: A total of n = 87 participants (71.2 ± 8.2 years; BMI 29.5 ± 5.8 kg/m2; BF % 37.8 ± 7.3%) were included in this cross-sectional analysis. Pearson's correlation coefficients revealed that BF% was negatively associated with hand-grip strength (r = - 0.430; P < 0.001) and total ASM (r = - 0.223; P = 0.03), but positively associated with increased time to compete chair stands (r = 0.366; P < 0.001). After adjusting for age, gender and total ASM, WC and BF% were inversely associated with HGS (WC: ß = -0.385; P = 0.001; BF% ß = - 0.487; P < 0.001). Similarly, in the adjusted model, both WC and BF% were positively associated with increased time to complete chair stands (WC: ß = 0.479; P < 0.001; BF% ß = 0.415; P = 0.002). CONCLUSION: Adiposity, independent of the criteria used, was inversely associated with muscle strength, suggesting that adiposity negatively influences muscle quality in older adults with T2DM. Screening for poor muscle strength and quality has the potential to facilitate early exercise and dietary interventions aimed at preserving muscle function in older adults with T2DM.

Diagnostic differences and agreement between the original and revised European Working Group (EWGSOP) consensus definition for sarcopenia in community-dwelling older adults with type 2 diabetes mellitus.

AIM: We aimed to compare diagnostic differences for identification of sarcopenia using the original operational definition developed by the European Working Group on Sarcopenia in Older People (EWGSOP1) and the most recently revised EWGSOP2 definition in community dwelling older adults with type 2 diabetes mellitus (T2DM). METHODS: Appendicular Lean Mass (ALM) corrected for height (ALM/m2) was assessed by dual energy X-ray absorptiometry. Muscle strength was assessed using hand-grip strength (HGS) or chair stands, and the Short Physical Performance Battery (SPPB) and gait speed were used to evaluate lower extremity physical function. Cohen's kappa (κ) statistic was applied to determine the degree of agreement between the two definitions. Chi-square analysis with Bonferroni post hoc corrections were applied to determine differences in the prevalence of sarcopenic case-findings. RESULTS: A total of n = 87 older adults (71.2 ±â€¯8.2 years; 66.7% males; BMI: 29.5 ±â€¯5.8 kg/m2) were included. Agreement between the two definitions was low and non-significant (κ value = 0.118; P =  0.144). Significantly more cases of sarcopenia were identified when applying the EWGSOP1 definition (EWGSOP1: n = 6 (7%); EWGSOP2: n = 2 (2%); P = 0.004). No sex specific differences were observed. Only 2 of the 6 (33.3%) cases of sarcopenia identified by EWGSOP1 were also identified as sarcopenic when applying the EWGSOP2 diagnostic criteria. CONCLUSIONS: We showed significant discordance and limited overlap in the number of sarcopenic case-findings when applying both EWGSOP definitions. It is unknown as to whether the new diagnostic criteria are better at identifying adverse clinical outcomes in patients with T2DM. Future investigation is therefore warranted.

Subjective and Objective Assessment of Taste and Smell Sensation in Advanced Cancer.

CONTEXT: Taste and smell abnormalities (TSA) occur throughout the cancer trajectory regardless of cancer primary site and contribute to cancer-associated malnutrition. TSA etiology is poorly understood. Tumor-related inflammation is a possible cause. OBJECTIVE: This study examined the prevalence, characteristics, and severity of TSA in advanced cancer and explored the relationship between TSA and nutritional status. No previous study combined subjective and objective measures for both taste and smell assessment in this population. METHOD: Consecutive advanced cancer hospice patients were recruited. A modified version of the "Taste and Smell Survey" assessed subjective TSA. Validated taste strips and "Sniffin' Sticks" were the objective measures. The abridged patient-generated subjective global assessment evaluated nutritional status. RESULTS: A 93% prevalence of TSA in 30 patients with advanced cancer was identified. When subjective and objective evaluations were combined, 28 had taste abnormalities, 24 smell abnormalities, and 24 both. Taste changes included "persistent bad taste" (n = 18) and changes in how basic tastes were perceived. Half reported smell was not "as strong" as prediagnosis, while more than half (n = 16) had an objective smell abnormality. Most (97%) were at risk of malnutrition. Fatigue, dry mouth, early satiety, and anorexia were common nutrition-impact symptoms. No statistically significant relationship was found between TSA and malnutrition scores. CONCLUSIONS: TSA were highly prevalent. Subjective taste and smell changes did not always accord with objective TSA, suggesting both assessments are valuable. TSA characteristics varied, and particular foods tasted and smelled different and were not enjoyed as before. TSA are common, high-impact problems in advanced cancer.

Attitudes of healthcare workers to influenza vaccination.

BACKGROUND: Whilst annual influenza vaccination is recommended for healthcare workers (HCWs), many remain unvaccinated. Our study aim was to identify the main motivators and barriers that influenced the decisions of HCWs regarding influenza vaccination. METHODS: A cross-sectional study design was employed using a survey for data collection. From June - September 2015, 327 HCWs employed at Canberra Hospital were surveyed. Data were collected on employment position, influenza vaccination history, reasons behind individual decisions on vaccination, and attitudes to ongoing vaccination. Both fixed and optional free-text responses were sought and analysed. RESULTS: Major motivators for vaccination included protection of others, personal protection and professional habit. Major barriers to vaccination included concerns about vaccine safety and efficacy, and difficulties accessing vaccination. The main factors that would encourage unvaccinated staff to be vaccinated included protecting patients and family, and reassurance regarding the safety and efficacy of vaccination. CONCLUSION: Both educational messages and operational strategies need to be implemented to optimise vaccine uptake. Educational material needs to focus on professional responsibility, the broad protective benefits of vaccination and misconceptions about the safety and efficacy of the vaccine. Operational strategies should cover workplace access to vaccination, communication on vaccination policies, and leadership from senior staff.

Linking Item Response Model Parameters.

With a few exceptions, the problem of linking item response model parameters from different item calibrations has been conceptualized as an instance of the problem of test equating scores on different test forms. This paper argues, however, that the use of item response models does not require any test score equating. Instead, it involves the necessity of parameter linking due to a fundamental problem inherent in the formal nature of these models-their general lack of identifiability. More specifically, item response model parameters need to be linked to adjust for the different effects of the identifiability restrictions used in separate item calibrations. Our main theorems characterize the formal nature of these linking functions for monotone, continuous response models, derive their specific shapes for different parameterizations of the 3PL model, and show how to identify them from the parameter values of the common items or persons in different linking designs.