Factors influencing clinician prescribing of disease-modifying anti-rheumatic drugs for inflammatory arthritis: A systematic review and thematic synthesis of qualitative studies.

Understanding factors that influence prescribing of disease-modifying anti-rheumatic drugs (DMARDs) will inform strategies to optimise care of people with inflammatory arthritis. We performed a systematic review and thematic synthesis of qualitative studies to explore these factors. Inclusion criteria were: use of qualitative or mixed methods; rheumatologist, nurse or pharmacist perspectives; prescription of any DMARD (conventional [cs], targeted synthetic [ts], biologic [b], biosimilars) and/or glucocorticoids; in any healthcare setting in any country. MEDLINE, Embase and EBSCOhost CINAHL Plus were searched from inception to 15 June 2021. Pairs of review authors independently identified studies for inclusion, assessed methodological quality using the Critical Appraisal Skills Programme checklist, and extracted and thematically synthesised data. Confidence in synthesis themes was evaluated using the GRADE Confidence in Evidence from Reviews of Qualitative research (CERQual) approach. We included 15 studies involving 716 clinicians (683 rheumatologists, 27 nurses, 6 pharmacists) across 10 countries, all focusing on management of patients with rheumatoid arthritis (RA). Six themes were identified: Rheumatologist prescribing is influenced by patients' characteristics, preferences, symptoms and negative responses to medication; Rheumatologist knowledge, experience, habits and subjective judgements are strong drivers of prescribing behaviour; High demands on consultation time impede shared decision-making; Costs and complexity of medication funding arrangements limit prescribing options; Clinicians recognise the importance of providing patient education about medication options; and Clinicians value colleagues' opinions and support to inform prescribing decisions. The majority of themes were graded as moderate confidence (n  =  4), reflecting they are likely to reasonably represent the factors influencing prescribing of DMARDs to people with RA. Quality improvement strategies that address these factors are likely to support best practice pharmacologic management of RA and may be potentially applicable to other types of inflammatory arthritis. High demand on consultation time and complexity of medication funding arrangements are system factors that may or may not be amenable to change. Easily accessible living national guidelines which include lay summaries and treatment algorithms to support prescribing decisions may address some of the themes.

Health economic evaluations of sepsis interventions in critically ill adult patients: a systematic review.

BACKGROUND: Sepsis is a global health priority. Interventions to reduce the burden of sepsis need to be both effective and cost-effective. We performed a systematic review of the literature on health economic evaluations of sepsis treatments in critically ill adult patients and summarised the evidence for cost-effectiveness. METHODS: We systematically searched MEDLINE, Embase, and the Cochrane Library using thesaurus (e.g. MeSH) and free-text terms related to sepsis and economic evaluations. We included all articles that reported, in any language, an economic evaluation of an intervention for the management of sepsis in critically ill adult patients. Data extracted included study details, intervention details, economic evaluation methodology, and outcomes. Included studies were appraised for reporting quality using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. RESULTS: We identified 50 records representing 46 economic evaluations for a variety of interventions including antibiotics (n = 5), fluid therapy (n = 2), early goal-directed therapy and other resuscitation protocols (n = 8), immunoglobulins (n = 2), and interventions no longer in clinical use such as monoclonal antibodies (n = 7) and drotrecogin alfa (n = 13). Twelve (26%) evaluations were of excellent reporting quality. Incremental cost-effectiveness ratios (ICERs) ranged from dominant (lower costs and higher effectiveness) for early goal-directed therapy, albumin, and a multifaceted sepsis education program to dominated (higher costs and lower effectiveness) for polymerase chain reaction assays (LightCycler SeptiFast testing MGRADE®, SepsiTest™, and IRIDICA BAC BSI assay). ICERs varied widely across evaluations, particularly in subgroup analyses. CONCLUSIONS: There is wide variation in the cost-effectiveness of sepsis interventions. There remain important gaps in the literature, with no economic evaluations identified for several interventions routinely used in sepsis. Given the high economic and social burden of sepsis, high-quality economic evaluations are needed to increase our understanding of the cost-effectiveness of these interventions in routine clinical practice and to inform decision makers. TRIAL REGISTRATION: PROSPERO CRD42018095980.

Psychosocial factors associated with posttraumatic stress and growth in Australian women with ovarian cancer.

The study examined psychosocial factors (quality of life, depression, anxiety, optimism, coping, and social support) in relation to symptoms of posttraumatic stress disorder (PTSD) and posttraumatic growth (PTG) in 108 women diagnosed with ovarian cancer. Canonical correlational analysis showed that both PTSD and PTG were related to poorer quality of life, lack of social supports, and avoidant coping styles. However, higher PTG was also associated with the use of meaning and social support to cope with their experience. The findings highlight both negative and positive posttraumatic outcomes but longitudinal studies are now needed to more fully evaluate these relationships.

Psychosocial distress in women diagnosed with gynecological cancer.

Many women with gynecological cancer report psychosocial distress, and clarification of the risks, vulnerabilities, and protective factors is required. The aim of this study was to investigate the lived experience of gynecological cancer patients and to understand the factors that underlie psychosocial distress. Semi-structured interviews with seven women diagnosed with gynecological cancer revealed the role of social support, or its absence, selective withholding of information, and existential loneliness in women's experience of distress. Social support provided a buffer against distress, while feelings of alienation and being alone exacerbated distress. Interventions to address these concerns may lead to improved quality of life for this patient group.

Does rumination mediate the relationship between mindfulness and depressive relapse?

OBJECTIVES: Major depressive disorder is a significant mental illness that is highly likely to recur, particularly after three or more previous episodes. Increased mindfulness and decreased rumination have both been associated with decreased depressive relapse. The aim of this study was to investigate whether rumination mediates the relationship between mindfulness and depressive relapse. DESIGN: This prospective design involved a secondary data analysis for identifying causal mechanisms using mediation analysis. METHODS: This study was embedded in a pragmatic randomized controlled trial of mindfulness-based cognitive therapy (MBCT) in which 203 participants (165 females, 38 males; mean age: 48 years), with a history of at least three previous episodes of depression, completed measures of mindfulness, rumination, and depressive relapse over a 2-year follow-up period. Specific components of mindfulness and rumination, being nonjudging and brooding, respectively, were also explored. RESULTS: While higher mindfulness scores predicted reductions in rumination and depressive relapse, the relationship between mindfulness and relapse was not found to be mediated by rumination, although there appeared to be a trend. CONCLUSIONS: Our results strengthen the argument that mindfulness may be important in preventing relapse but that rumination is not a significant mediator of its effects. The study was adequately powered to detect medium mediation effects, but it is possible that smaller effects were present but not detected. PRACTITIONER POINTS: Mindfulness may be one of several components of MBCT contributing to prevention of depressive relapse. Although the original rationale for MBCT rested largely on a model of relapse causally linked to rumination, our findings suggest that the mechanism by which mindfulness impacts relapse is more complex than a simple effect on rumination.

Introducing a model incorporating early integration of specialist palliative care: A qualitative research study of staff's perspectives.

BACKGROUND: Palliative care has evolved to encompass early integration, with evaluation of patient and organisational outcomes. However, little is known of staff's experiences and adaptations when change occurs within palliative care services. AIM: To explore staff experiences of a transition from a service predominantly focused on end-of-life care to a specialist service encompassing early integration. DESIGN: Qualitative research incorporating interviews, focus groups and anonymous semi-structured questionnaires. Data were analysed using a comparative approach. Service activity data were also aggregated. SETTING/PARTICIPANTS: A total of 32 medical, nursing, allied health and administrative staff serving a 22-bed palliative care unit and community palliative service, within a large health service. RESULTS: Patients cared for within the new model were significantly more likely to be discharged home (7.9% increase, p = 0.003) and less likely to die in the inpatient unit (10.4% decrease, p < 0.001). While early symptom management was considered valuable, nurses particularly found additional skill expectations challenging, and perceived patients' acute care needs as detracting from emotional and end-of-life care demands. Staff views varied on whether they regarded the new model's faster-paced work-life as consistent with fundamental palliative care principles. Less certainty about care goals, needing to prioritise care tasks, reduced shared support rituals and other losses could intensify stress, leading staff to develop personalised coping strategies. CONCLUSION: Services introducing and researching innovative models of palliative care need to ensure adequate preparation, maintenance of holistic care principles in faster work-paced contexts and assist staff dealing with demands associated with caring for patients at different stages of illness trajectories.

Correlates of post-traumatic stress symptoms and growth in cancer patients: a systematic review and meta-analysis.

OBJECTIVE: The aim of this study is to examine the relationships among demographic, medical, and psychosocial factors and post-traumatic stress symptoms (PTSS) and post-traumatic growth (PTG) in oncology populations. METHOD: A systematic search identified k = 116 relevant studies published between 1990 and 2012. Meta-analyses synthesized results from studies that reported data on correlates of PTSS (k = 26) or PTG (k = 48). A meta-analysis was performed for k = 5 studies reporting the correlation between PTSS and PTG. RESULTS: Post-traumatic stress symptoms were associated with depression (r = 0.56), anxiety (r = 0.65), distress (r = 0.62), social support (r = -0.33), and physical quality of life (r = -0.44). PTG was associated with age (r = -0.08), gender (r = -0.15), distress (r = -0.16), depression (r = -0.06), social support (r = 0.30), optimism (r = 0.27), positive reappraisal (r = 0.46), spirituality (r = 0.33), and religious coping (r = 0.36). There was a small positive relationship between PTSS and PTG (r = 0.13). CONCLUSIONS: Post-traumatic stress symptoms and PTG appear to be independent constructs, rather than opposite ends of a single dimension. This is reflected in a small relationship between these variables and different psychosocial correlates. PTSS were strongly associated with variables reflecting a general state of negative affect. Optimism, spirituality, and positive coping styles were associated with PTG. It remains unclear how they are associated with PTSS, given the lack of relevant studies. Longitudinal research is required to examine how psychosocial factors influence the relationship between PTSS and PTG.

Symptoms of posttraumatic stress in Australian women with ovarian cancer.

OBJECTIVE: The aim of the study was to assess the prevalence and nature of symptoms of posttraumatic stress disorder (PTSD) in women with ovarian cancer. A further aim was to examine the demographic, medical and psychosocial factors associated with PTSD symptoms. METHOD: One hundred and eight women with ovarian cancer were assessed for PTSD, quality of life, depression, anxiety, posttraumatic growth, optimism, coping and social support. RESULTS: Clinically significant symptoms were experienced by 9.25% of participants for PTSD, 5.6% for depression and 13.9% for anxiety. Poorer quality of life was associated with total PTSD symptoms, and avoidance and intrusive symptoms. Depression was associated with avoidance and intrusive symptoms. Anxiety was associated with total, avoidance, intrusive and hyperarousal symptoms. Finally, coping by substance use/self-blame was associated with total, avoidance and hyperarousal PTSD symptoms. CONCLUSIONS: Levels of PTSD in women with ovarian cancer were equivalent to that of the general population. Poorer quality of life, depression, anxiety and maladaptive coping, characterised by avoidance, substance use and self-blame, were associated with increased symptoms of PTSD.

Anxiety in the management of localised prostate cancer by active surveillance.

OBJECTIVES: To describe a range of anxieties in men on active surveillance (AS) for prostate cancer and determine which of these anxieties predicted health-related quality of life (HRQL). PATIENTS AND METHODS: In all, 260 men with prostate cancer on AS were invited to complete psychological measures including the Hospital and Anxiety Depression Scale; the State-Trait Anxiety Inventory-Trait Scale; the Memorial Anxiety Scale for Prostate Cancer; and the Functional Assessment of Cancer Therapy Scale-Prostate. Overall, 86 men with a mean (sd, range) age of 65.7 (5.4, 51-75) years returned data, yielding a response rate of 33%. Outcome measures were standardised psychological measures. Pearson's correlations were used to examine bivariate relationships, while regression analyses were used to describe predictors of dependent variables. RESULTS: When compared with the findings of prior research, the men in our cohort had normal levels of general anxiety and illness-specific anxiety and high prostate cancer-related HRQL. Age, trait anxiety and fear of recurrence (FoR) were significant predictors of prostate cancer-related HRQL; trait anxiety and FoR were significant predictors of total HRQL. Results should be interpreted in context of sample characteristics and the correlational design of the study. CONCLUSIONS: Participants reported low levels of anxiety and high HRQL. Trait anxiety and FoR were significant predictors of both prostate cancer-related and total HRQL. The administration of a short trait-anxiety screening tool may help identify men with clinically significant levels of anxiety and those at risk of reduced HRQL.

Quality of life among acoustic neuroma patients managed by microsurgery, radiation, or observation.

OBJECTIVE: The main aim of this study was to examine differences in quality of life (QoL) among acoustic neuroma patients across the management options of microsurgery, radiation, and observation. Additional aims were to describe QoL and investigate management, medical, and demographic factors that predicted QoL in this patient group. STUDY DESIGN: Cross-sectional design, using a postal questionnaire. SETTING: Tertiary referral centers. PATIENTS: Participants included 180 adults diagnosed with, or treated for, a unilateral acoustic neuroma within 5 years of questionnaire distribution. The mean age of participants was 56.5 years, and 107 (59.4%) were female. INTERVENTION(S): Patients' acoustic neuromas were managed with microsurgery, radiation, or observation. MAIN OUTCOME MEASURE(S): Current QoL was measured using the Short Form 12 Version 2 (SF-12), and postmanagement changes in QoL were assessed with the Glasgow Benefit Inventory (GBI). RESULTS: No significant differences in SF-12 scores were found across microsurgery, radiation, and observation patients. However, microsurgery patients reported more deterioration on the GBI general well-being subscale than radiation patients and more improvement in the GBI social support scale than observation patients. Number of symptoms was a consistent predictor of SF-12 and GBI scores. CONCLUSION: This is only the second study to use multivariate statistical techniques and a large sample to examine QoL across the acoustic neuroma management options of microsurgery, radiation, and observation. There were few differences in QoL outcomes across management groups. Number of symptoms was an important factor in current QoL and postmanagement changes in QoL.