Vascular Access Team Central Line Dressing Changes to Reduce Infection Risk: A Focused Two-Person Approach in High-Risk Patients.

Due to low compliance by bedside nursing with a central line-associated bloodstream infection (CLABSI) prevention bundle and increased CLABSI rates, a mandatory re-education initiative at a 1200-bed university-affiliated hospital was undertaken. Despite this, 2 units, housing high-risk immunocompromised patients, continued to experience increased CLABSI rates. A quality improvement before-after project design in these units replaced bedside nursing staff with 2 nurses from the vascular access team (VAT) to perform central vascular access device (CVAD) dressing changes routinely every 7 days or earlier if needed. The VAT consistently followed the bundled components, including use of chlorhexidine gluconate (CHG)-impregnated dressings on all patients unless an allergy was identified. In this case, a non-CHG transparent semipermeable membrane dressing was used. There were 884 patients with 14 211 CVAD days in the preimplementation period and 1136 patients with 14 225 CVAD days during the postimplementation period. The VAT saw 602 (53.0%) of the 1136 patients, performing at least 1 dressing change in 98% of the patients (n = 589). The combined CLABSI rate for the 2 units decreased from 2.53 per 1000 CVAD days preintervention to 1.62 per 1000 CVAD days postintervention. The estimated incidence rate ratio (IRR) for the intervention was 0.639, a 36.1% reduction in monthly CLABSI rates during the postimplementation period.

Skeletal muscle mitochondrial capacity in patients with statin-associated muscle symptoms (SAMS).

OBJECTIVE: The objective of this article is to evaluate near-infrared spectroscopy (NIRS), a non-invasive technique to assess tissue oxygenation and mitochondrial function, as a diagnostic tool for statin-associated muscle symptoms (SAMS). METHODS: We verified SAMS in 39 statin-treated patients (23 women) using a double-blind, placebo-controlled, cross-over protocol. Subjects with suspected SAMS were randomised to simvastatin 20 mg/day or placebo for 8 weeks, followed by a 4-week no treatment period and then assigned to the alternative treatment, either simvastatin or placebo. Tissue oxygenation was measured before and after each statin or placebo treatment using NIRS during handgrip exercise at increasing intensities of maximal voluntary contraction (MVC). RESULTS: 44% (n=17) of patients were confirmed as having SAMS (11 women) because they reported discomfort only during simvastatin treatment. There were no significant differences in percent change in tissue oxygenation in placebo versus statin at all % MVCs in all subjects. The percent change in tissue oxygenation also did not differ significantly between confirmed and unconfirmed SAMS subjects on statin (-2.4% vs -2.4%, respectively) or placebo treatment (-1.1% vs -9%, respectively). The percent change in tissue oxygenation was reduced after placebo therapy in unconfirmed SAMS subjects (-10.2%) (p≤0.01) suggesting potential measurement variability. CONCLUSIONS: NIRS in the forearm cannot differentiate between confirmed and unconfirmed SAMS, but further research is needed to assess the usability of NIRS as a diagnostic tool for SAMS. TRIAL REGISTRATION NUMBER: NCT03653663.

Reliability and Time Course of Postexercise Hypotension during Exercise Training among Adults with Hypertension.

Postexercise hypotension (PEH), or the immediate decrease in blood pressure (BP) lasting for 24 h following an exercise bout, is well-established; however, the influence of exercise training on PEH dynamics is unknown. This study investigated the reliability and time course of change of PEH during exercise training among adults with hypertension. PEH responders (n = 10) underwent 12 weeks of aerobic exercise training, 40 min/session at moderate-to-vigorous intensity for 3 d/weeks. Self-measured BP was used to calculate PEH before and for 10 min after each session. The intraclass correlation coefficient (ICC) and Akaike Information Criterion (AIC) determined PEH reliability and goodness-of-fit for each week, respectively. Participants were obese (30.6 ± 4.3 kg∙m-2), middle-aged (57.2 ± 10.5 years), and mostly men (60%) with stage I hypertension (136.5 ± 12.1/83.4 ± 6.7 mmHg). Exercise training adherence was 90.6 ± 11.8% with 32.6 ± 4.2 sessions completed. PEH occurred in 89.7 ± 8.3% of these sessions with BP reductions of 9.3 ± 13.1/3.2 ± 6.8 mmHg. PEH reliability was moderate (ICC ~0.6). AIC analysis revealed a stabilization of maximal systolic and diastolic BP reductions at 3 weeks and 10 weeks, respectively. PEH persisted throughout exercise training at clinically meaningful levels, suggesting that the antihypertensive effects of exercise training may be largely due to PEH. Further studies in larger samples and under ambulatory conditions are needed to confirm these novel findings.

Physiological adaptation to irradiance in duckweeds is species and accession specific and depends on light habitat niche.

Duckweeds span 36 species of free-floating aquatic organisms with body sizes ranging from 2 mm to 10 mm, where each plant body plan is reduced to a largely leaf-like structure. As an emerging crop, their fast growth rates offer potential for cultivation in closed systems. We describe a novel UK collection derived from low light (dLL) or high light (dHL) habitats, profiled for growth, photosynthesis, and photoprotection (non-photochemical quenching, NPQ) responses. Twenty-three accessions of three Lemna species and one Spirodela polyrhiza were grown under relatively low light (LL: 100 µmol m-2 s-1) and high light (HL: 350 µmol m-2 s-1) intensities. We observed broad within- and between-species level variation in photosynthesis acclimation. Duckweeds grown under HL exhibited a lower growth rate, biomass, chlorophyll, and quantum yield of photosynthesis. In HL compared with LL, carotenoid de-epoxidation state and NPQ were higher, whilst PSII efficiency (φPSII) and Chl a:b ratios were unchanged. The dLL plants showed relatively stronger acclimation to HL compared with dHL plants, especially Lemna japonica accessions. These achieved faster growth in HL with concurrent higher carotenoid levels and NPQ, and less degradation of chlorophyll. We conclude that these data support local adaptation to the light environment in duckweed affecting acclimation in controlled conditions.

Trainee nursing associates in England: A multisite qualitative study of higher education institution perspectives.

AIM: To explore the experiences of university employees on the development and implementation of the nursing associate programme. BACKGROUND: As part of wider policy initiatives to address workforce shortages, provide progression for healthcare assistants and offer alternative routes into nursing, England recently introduced the nursing associate level of practice. Little research has yet considered university perspectives on this new programme. METHODS: An exploratory qualitative study reported following COREQ criteria. Twenty-seven university staff working with trainee nursing associates in five universities across England were recruited. Data, collected via semi-structured interviews from June to September 2021, were analysed through a combined framework and thematic analysis. RESULTS: Three themes developed: 'Centrality of partnerships' considered partnerships between employers and universities and changing power dynamics. 'Adapting for support' included responding to new requirements and changing pedagogical approaches. 'Negotiating identity' highlighted the university's role in advocacy and helping trainees develop a student identity. CONCLUSIONS: Nursing associate training in England has changed the dynamics between universities and healthcare employers, shifting learners' identity more to 'employee' rather than 'student'. Universities have adapted to support trainees in meeting academic and professional standards whilst also meeting employer expectations. While challenges remain, the ability of nurse educators to make adjustments, alongside their commitment to quality educational delivery, is helping establish this new training programme and thereby meet government policy initiatives. IMPLICATIONS FOR NURSING POLICY: The international movement of apprenticeship models in universities has the potential to change the status of the learner in nursing educational contexts. National policies that encourage this model should ensure that the implications and challenges this change of status brings to learners, employers and education institutions are fully considered prior to their implementation.

A randomised controlled trial of a nutrition and a decision support intervention to enable partnerships with families of critically ill patients.

AIMS AND OBJECTIVES: The aim of the study was to investigate the effect of supporting family members to partner with health professionals on nutrition intakes and decision-making and to evaluate intervention and study feasibility. BACKGROUND: Family partnerships can improve outcomes for critically ill patients and family members. Interventions that support families to engage with health professionals require evaluation. DESIGN: A multi-centre, randomised, parallel group superiority Phase II randomised controlled trial. METHODS: In nine intensive care units (ICUs) across three countries, critically ill patients ≥60 years, or those 55-59 years with advanced chronic diseases and expected ICU length of stay >72 h and their family member were enrolled between 9 May 2017 and 31 March 2020. Participants were randomised (1:1:1) to either a decision support or nutrition optimisation family-centred intervention, or usual care. Primary outcomes included protein and energy intake during ICU and hospital stay (nutrition intervention) and family satisfaction (decision support). Study feasibility was assessed as a composite of consent rate, intervention adherence, contamination and physician awareness of intervention assignment. RESULTS: We randomised 135 patients/family members (consent rate 51.7%). The average rate of randomisation was 0.5 (0.13-1.53) per month. Unavailability (staff/family) was the major contributor to families not being approached for consent. Declined consent was attributed to families feeling overwhelmed (58/126, 46%). Pandemic visitor restrictions contributed to early study cessation. Intervention adherence for the decision support intervention was 76.9%-100.0% and for the nutrition intervention was 44.8%-100.0%. Nutritional adequacy, decisional conflict, satisfaction with decision-making and overall family satisfaction with ICU were similar for all groups. CONCLUSIONS: Active partnerships between family members and health professionals are important but can be challenging to achieve in critical care contexts. We were unable to demonstrate the efficacy of either intervention. Feasibility outcomes suggest further refinement of interventions and study protocol may be warranted. RELEVANCE TO CLINICAL PRACTICE: Interventions to promote family partnerships in critical illness are needed but require a greater understanding of the extent to which families want and are able to engage and the activities in which they have most impact. REPORTING METHOD: This study has been reported following the Consolidated Standards of Reporting Trials (CONSORT) and the Template for Intervention Description and Replication (TIDieR) guidelines. PATIENT OR PUBLIC CONTRIBUTION: Patients and caregivers were engaged in and contributed to the development and subsequent iterations of the two family-centred interventions use in this study. CLINICAL TRIAL REGISTRATION NUMBER: Trial registration. CLINICALTRIALS: gov, ID: NCT02920086. Registered on 30 September 2016. First patient enrolled on 9 May 2017 https://clinicaltrials.gov/ct2/results?cond=&term=NCT02920086&cntry=&state=&city=&dist=.

Original Research: Patient Perception of Fall Risk in the Acute Care Setting.

PURPOSE: Hospitals are implementing a variety of fall prevention programs to reduce the fall rates of hospitalized patients. But if patients don't perceive themselves to be at risk for falling and don't adhere to fall prevention strategies, such programs are likely to be less effective. The purpose of this study was to describe the perceptions of fall risk among hospitalized patients across four acute care specialty services. METHODS: One hundred patients who had been admitted to the study hospital and who had a Morse Fall Scale score over 45 were asked to complete the Patient Perception Questionnaire, a tool designed to explore a patient's confidence regarding their fall risk, fear of falling, and intention to engage in fall prevention activities. Morse Fall Scale scores were collected via retrospective chart review. Data were analyzed using descriptive statistics, Pearson correlation coefficients, and independent sample t tests. RESULTS: Participants' mean age was 65 years; 52% were male, 48% female. Although all 100 participants were deemed at risk for falls per their Morse Fall Scale scores, only 55% considered themselves to be at such risk. As patients' confidence in their ability to perform mobility tasks increased, their intention to ask for help and fear of falling significantly decreased. Patients who had been admitted as the result of a fall demonstrated significantly lower confidence scores and higher fear scores. CONCLUSIONS: Patients who score high on fall risk assessments often don't perceive themselves to be at high risk for falling, and thus might not engage in fall prevention activities. Developing a fall risk assessment method that incorporates both a patient's physiological condition and their perception of their fall risk could help reduce fall rates in the acute care setting.

Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations

To develop evidence-based recommendations for clinicians caring for adults with acute liver failure (ALF) or acute on chronic liver failure (ACLF) in the ICU. The guideline panel comprised 27 members with expertise in aspects of care of the critically ill patient with liver failure or methodology. We adhered to the Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development. In part 2 of this guideline, the panel was divided into four subgroups: neurology, peri-transplant, infectious diseases, and gastrointestinal groups. We developed and selected Population, Intervention, Comparison, and Outcomes (PICO) questions according to importance to patients and practicing clinicians. For each PICO question, we conducted a systematic review and meta-analysis where applicable. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements. We report 28 recommendations (from 31 PICO questions) on the management ALF and ACLF in the ICU. Overall, five were strong recommendations, 21 were conditional recommendations, two were best-practice statements, and we were unable to issue a recommendation for five questions due to insufficient evidence. Multidisciplinary, international experts formulated evidence-based recommendations for the management ALF and ACLF patients in the ICU, acknowledging that most recommendations were based on low quality and indirect evidence.

Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations.

OBJECTIVES: To develop evidence-based recommendations for clinicians caring for adults with acute liver failure (ALF) or acute on chronic liver failure (ACLF) in the ICU. DESIGN: The guideline panel comprised 27 members with expertise in aspects of care of the critically ill patient with liver failure or methodology. We adhered to the Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development. INTERVENTIONS: In part 2 of this guideline, the panel was divided into four subgroups: neurology, peri-transplant, infectious diseases, and gastrointestinal groups. We developed and selected Population, Intervention, Comparison, and Outcomes (PICO) questions according to importance to patients and practicing clinicians. For each PICO question, we conducted a systematic review and meta-analysis where applicable. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements. MEASUREMENTS AND MAIN RESULTS: We report 28 recommendations (from 31 PICO questions) on the management ALF and ACLF in the ICU. Overall, five were strong recommendations, 21 were conditional recommendations, two were best-practice statements, and we were unable to issue a recommendation for five questions due to insufficient evidence. CONCLUSIONS: Multidisciplinary, international experts formulated evidence-based recommendations for the management ALF and ACLF patients in the ICU, acknowledging that most recommendations were based on low quality and indirect evidence.

The Relationship between Postexercise Hypotension and Heart Rate Variability before and after Exercise Training.

Because data are scarce, we examined the relationship between postexercise hypotension (PEH) and heart rate variability (HRV) before and after aerobic exercise training among adults with hypertension. Participants completed a 12 w aerobic training program. Before and after training, they performed a peak graded exercise stress test (GEST) and nonexercise control (CONTROL) and were left attached to an ambulatory BP monitor. Prior to CONTROL, HRV was measured supine for 5 min using a 12-lead electrocardiogram (ECG). The participants (n = 18) were middle-aged (52.1 ± 11.7 y) and 50% men with hypertension (131.7 ± 9.8/85.9 ± 8.5 mmHg) and obesity (30.0 ± 3.7 kg·m-2). Before training, ambulatory systolic BP (ASBP) and diastolic ABP (ADBP) decreased by 3.2 ± 2.1 mmHg and 2.5 ± 1.5 mmHg, respectively, from baseline after the GEST versus CONTROL (p < 0.05). After training, ASBP tended to decrease by 3.5 ± 2.2 mmHg (p = 0.055) and ADBP decreased by 1.7 ± 2.5 mmHg (p = 0.001) from baseline after the GEST versus CONTROL. Before training, HRV high frequency (HFms2) (ß = -0.441), age (ß = 0.568), and resting SBP (ß = 0.504) accounted for 66.8% of the ASBP response (p = 0.001), whereas the low frequency (LF)/HF ratio (ß = 0.516) and resting DBP (ß = 0.277) accounted for 35.7% of the ADBP response (p = 0.037). After training, the standard deviation of NN intervals (SDNN) (ß = -0.556), age (ß = 0.506), and resting SBP (ß = 0.259) accounted for 60.7% of the ASBP response (p = 0.004), whereas SDNN (ß = -0.236) and resting DBP (ß = 0.785) accounted for 58.5% of the ADBP response (p = 0.001). Our preliminary findings show that adults with hypertension and parasympathetic suppression (i.e., lower SDNN and HFms2 and higher LF/HF) may elicit PEH to the greatest degree independent of training status versus adults with parasympathetic predominance, suggesting that resting HRV may be an important determinant of PEH.

The effects of an acute weight stigma exposure on cardiovascular reactivity among women with obesity and hypertension: A randomized trial.

OBJECTIVE: Weight stigma induces cardiovascular health consequences for people with obesity. How stigma affects cardiovascular reactivity in individuals with both obesity and hypertension is not known. METHODS: In a randomized experiment, we assessed the influence of two video exposures, depicting either weight stigmatizing (STIGMA) or non-stigmatizing (NEUTRAL) scenes, on cardiovascular reactivity [resting blood pressure (BP), heart rate (HR), ambulatory BP (ABP), and ambulatory HR (AHR)], among women with obesity and high BP (HBP; n=24) or normal BP (NBP; n=25). Systolic ABP reactivity was the primary outcome. Laboratory BP and HR were measured before/during/following the videos, and ABP and AHR were measured over 19 hours (10 awake hours, 9 sleep hours) upon leaving the laboratory. A repeated measures ANCOVA tested differences in BP and HR changes from baseline in the laboratory and over ambulatory conditions between the two groups after each video, controlling for body mass index, baseline BP and HR. RESULTS: Laboratory SBP/DBP increased 5.5+7.3/2.4+8.8mmHg more in women with HBP than NBP following the STIGMA versus NEUTRAL video (Ps<0.05). For the primary outcome, ABP increased more in HBP than NBP over sleep (SBP/DBP=4.2+20.6/4.7+14.2mmHg; Ps<0.05) following the STIGMA versus NEUTRAL video, as did HR during sleep (7.5+15.7bpm more in HBP than NBP; P<0.05). CONCLUSIONS: Weight stigma increases cardiovascular reactivity among women with obesity and HBP in the laboratory and under ambulatory conditions. CLINICAL TRIAL REGISTRATION: Registered at ClinicalTrials.gov (Identifier: NCT04161638).

Association of Outpatient Behavioral Health Treatment With Medical and Pharmacy Costs in the First 27 Months Following a New Behavioral Health Diagnosis in the US.

Importance: Outpatient behavioral health treatment (OPBHT) is an effective treatment for behavioral health conditions (BHCs) that may also be associated with improved medical health outcomes, but evidence regarding the cost-effectiveness of OPBHT across a large population has not been established. Objective: To investigate whether individuals newly diagnosed with a BHC who used OPBHT incurred lower medical and pharmacy costs over 15 and 27 months of follow-up compared with those not using OPBHT. Design, Setting, and Participants: This retrospective cohort study of commercially insured individuals in the US was conducted using administrative insurance claims data for individuals newly diagnosed with 1 or more BHCs between January 1, 2017, and December 31, 2018. Data were examined using a 12-month period before BHC diagnosis and 15- and 27-month follow-up periods. Participants included individuals aged 1 to 64 years who received any OPBHT with or without behavioral medication or who did not receive OPBHT or behavioral medication in the 15 months following diagnosis. Data were analyzed from May to October 2021. Exposures: Receipt of OPBHT both as a dichotomous variable and categorized by number of OPBHT visits. Main Outcomes and Measures: The main outcome was the association between OPBHT treatment and 15- and 27-month medical and pharmacy costs, assessed using a generalized linear regression model with γ distribution, controlling for potential confounders. Results: The study population included 203 401 individuals, of whom most were male (52%), White, non-Hispanic (75%), and 18 to 64 years of age (67%); 22% had at least 1 chronic medical condition in addition to a BHC. Having 1 or more OPBHT visits was associated with lower adjusted mean per-member, per-month medical and pharmacy costs across follow-up over 15 months (no OPBHT: $686 [95% CI, $619-$760]; ≥1 OPBHT: $571 [95% CI, $515-$632]; P < .001) and 27 months (no OPBHT: $464 [95% CI, $393-$549]; ≥1 OPBHT: $391 [95% CI, $331-$462]; P < .001). Furthermore, almost all doses of OPBHT across the 15 months following diagnosis were associated with lower costs compared with no OPBHT. Conclusions and Relevance: In this cohort study, medical cost savings were associated with OPBHT among patients newly diagnosed with a BHC in a large, commercially insured population. The findings suggest that promoting and optimizing OPBHT may be associated with reduced overall medical spending among patients with BHCs.

Cardiometabolic Biomarkers and Habitual Caffeine Consumption Associate with the Adverse Ambulatory Blood Pressure Response to Strenuous Physical Exertion among Firefighters.

Caffeine has beneficial effects on firefighter job performance reducing fatigue and improving psychomotor vigilance. However, excessive caffeine intake may raise blood pressure (BP) following a bout of acute exercise among adults with elevated BP. The influence of caffeine intake on the ambulatory BP (ABP) response to vigorous physical exertion among firefighters has not been studied. In this sub-study we conducted secondary statistical analyses from a larger clinical trial (NCT04514354) that included examining the influence of habitual caffeine intake, and cardiometabolic biomarkers shown to influence BP, on the ABP response following a bout of sudden vigorous exertion over 19 h among firefighters. Previously, we found high amounts of calcium and sodium intake raised BP following a bout of acute exercise among adults with elevated BP. Thus, other secondary aims were to examine the influence of habitual calcium and sodium intake, and cardiometabolic biomarkers have shown to influence BP, on the ABP response following sudden vigorous exertion over 19 h among firefighters. Firefighters (n = 15) completed a Food-Frequency Questionnaire assessing habitual dietary intake over the past year. They randomly completed a maximal graded exercise stress test (GEST) and non-exercise CONTROL on separate non-workdays leaving the laboratory wearing an ABP monitor for 19 h. Prior to and immediately after the GEST, fasting venous blood was collected to measure lipid-lipoproteins, c-reactive protein, and blood glucose. Height and weight were taken to calculate body mass index. Repeated measures ANCOVA tested if the ABP response differed after GEST vs. CONTROL. Linear mixed models examined the relationships among caffeine, calcium, sodium, cardiometabolic biomarkers, and the ABP response following GEST vs. CONTROL. Firefighters were middle-aged (40.2 ± 9.5 year), overweight (29.0 ± 3.9 kg/m2) men with elevated BP (124.1 ± 10.3/79.6 ± 11.5 mmHg) who consumed 542.0 ± 348.9 mg of caffeine/day, about ~50% more than the dietary reference intake. Unexpectedly, systolic ABP was higher by 18.0 ± 6.7 mmHg and diastolic ABP by 9.1 ± 5.4 mmHg (ps < 0.01) over 19 h following GEST vs. CONTROL. We found 24% of the variance in the adverse ABP response to maximal physical exertion was explained by caffeine intake, and when combined with c-reactive protein, non-high-density lipoprotein-cholesterol, body mass index, blood glucose, and resting heart rate, up to 74% of the variability in the ABP response was explained. Additionally, we found calcium (ps < 0.001) and sodium (p < 0.0001) intake each explained up to 24% of the ABP response. Further investigation is needed in a larger, more diverse sample of firefighters to better establish how caffeine contributes to the adverse BP response to strenuous physical exertion.

Employment and family caregiving in palliative care: An international qualitative study.

BACKGROUND: Family caregivers provide the majority of palliative care. The impact of family caregiving on employment and finances has received little research attention in the field of palliative care. AIM: The aim of this study was to explore perspectives and experiences of combining paid employment with palliative care family caregiving, and to assess the availability and suitability of employment support across three countries - the United Kingdom (UK), Aotearoa New Zealand and Canada. DESIGN: A qualitative descriptive study design was used. Semi-structured interviews were held with 30 key informants with professional or personal experience in palliative care from the UK (n = 15), Aotearoa New Zealand (n = 6) and Canada (n = 9). Interviews were recorded, transcribed and analysed using the principles of thematic analysis. RESULTS: Four main themes were identified: (1) significant changes to working practices are required to enable end of life family carers to remain in work; (2) the negative consequences of combining caregiving and employment are significant, for both patient and carer; (3) employer support for working end of life caregivers is crucial but variable and; (4) national, federal and government benefits for working end of life family carers are necessary. CONCLUSION: Supporting carers to retain employment whilst providing care has potential benefits for the patient at end of life, the caregiver, and the wider economy and labour market. Employers, policymakers and governments have a role to play in developing and implementing policies to support working carers to remain in employment.

A systematic review and meta-analysis assessing the impact of body mass index on long-term survival outcomes after surgery for colorectal cancer.

BACKGROUND: The impact of body mass index (BMI) on long-term survival outcomes after colorectal cancer surgery is debated. DESIGN: A systematic literature review and meta-analysis was performed to compare long-term survival outcomes of patients of different BMI categories after colorectal cancer surgery. RESULTS: Of the 2588 articles screened, 56 articles met the inclusion criteria, reporting on 72,582 participants. Patients with BMI <18.5 had significantly worse overall survival [hazard ratio (HR) 1.91; P < 0.0001], cancer-specific survival (HR = 1.91; P < 0.0001), disease-free survival (HR = 1.50; P < 0.0001) and recurrence-free survival (HR = 1.13; P = 0.007) compared to patients with a BMI of 18.5-25. There was no significant difference between those with BMI 25-30 and 18.5-25 in overall survival, cancer-specific survival, disease-free survival and recurrence-free survival, except for the subgroup of patients with colon cancer where patients with BMI 25-30 had significantly improved overall survival (HR = 0.90; P = 0.05) and disease-free survival (HR = 0.90; P = 0.04). Patients with BMI >30 had significantly worse disease-free survival (HR = 1.05; P = 0.03) compared to patients with a BMI of 18.5-25, but no significant difference in overall survival, cancer-specific survival and recurrence-free survival. Patients with BMI >35 compared to 18.5-25 had significantly worse overall survival (HR = 1.24; P = 0.02), cancer-specific survival (HR = 1.36; P = 0.01), disease-free survival (HR = 1.15; P = 0.03) and recurrence-free survival for colon (HR = 1.11; P = 0.04) and rectal (HR = 4.10; P = 0.04) cancer. CONCLUSIONS: Being underweight (BMI < 18.5) or class II/III obese (BMI > 35) at the time of colorectal cancer surgery may result in worse long-term survival outcomes, whereas being overweight (BMI 25-30) may improve survival in a subgroup of patients with colon cancer. Optimising BMI may preoperatively improve long-term survival after surgery for colorectal cancer.

Clinical nurse specialist role in providing generalist and specialist palliative care: A qualitative study of mesothelioma clinical nurse specialists.

AIM: To explore perspectives of Mesothelioma UK clinical nurse specialists (CNSs) on their role in providing palliative care for patients with mesothelioma and their families. DESIGN: A qualitative descriptive approach using focus group and interview methods. METHODS: Focus groups and semi-structured interviews were conducted with 16 Mesothelioma UK clinical nurse specialists using the online software Google Meet. Data collection was carried out in Jan-Feb 2021 and data were analysed using thematic analysis. The consolidated criteria for reporting qualitative research (COREQ) was used as the reporting guideline for this paper. RESULTS: Four main themes were identified from the data: Mesothelioma UK clinical nurse specialist role in relation to palliative care; joint working with specialist palliative care and community services; patients and family carer's willingness to engage with palliative care services; and the impact of COVID-19 on palliative care for mesothelioma patients. CONCLUSION: This study provides valuable insights into palliative care needs in mesothelioma. Patients with mesothelioma and their families have significant palliative care needs throughout the course of their illness from diagnosis to the end of life. Mesothelioma UK CNS's play a crucial role in supporting patients' and families palliative care needs, and are highly skilled in providing this care. IMPACT: By acknowledging the role of Mesothelioma UK CNS's in palliative care provision, and supporting collaborative working between specialist and generalist palliative care providers, there is the capacity to significantly improve palliative care in mesothelioma and improve outcomes for patients and their families.

Optimizing the nutrition support care model: Analysis of survey data.

BACKGROUND: Malnutrition is underrecognized and underdiagnosed, despite high prevalence rates and associated poor clinical outcomes. The involvement of clinical nutrition experts, especially physicians, in the care of high-risk patients with malnutrition remains low despite evidence demonstrating lower complication rates with nutrition support team (NST) management. To facilitate solutions, a survey was designed to elucidate the nature of NSTs and physician involvement and identify needs for novel nutrition support care models. METHODS: This survey assessed demographics of NSTs, factors contributing to the success of NSTs, elements of nutrition education, and other barriers to professional growth. RESULTS: Of 255 respondents, 235 complete surveys were analyzed. The geographic distribution of respondents correlated with population concentrations of the United States (r = 90.8%, p < .0001). Most responding physicians (46/57; 80.7%) reported being a member of NSTs, compared with 56.5% (88/156) of dietitians. Of those not practicing in NSTs (N = 81/235, 34.4%), 12.3% (10/81) reported an NST was previously present at their institution but had been disbanded. Regarding NSTs, financial concerns were common (115/235; 48.9%), followed by leadership (72/235; 30.6%), and healthcare professional (HCP) interest (55/235; 23.4%). A majority (173/235; 73.6%) of all respondents wanted additional training in nutrition but reported insufficient protected time, ability to travel, or support from administrators or other HCPs. CONCLUSION: Core actions resulting from this survey focused on formalizing physician roles, increasing interdisciplinary nutrition support expertise, utilizing cost-effective screening for malnutrition, and implementing intervention protocols. Additional actions included increasing funding for clinical practice, education, and research, all within an expanded portfolio of pragmatic nutrition support care models.