Quantifying the Travel Undertaken by Cancer Patients Receiving Radiotherapy in Victoria, Australia

PURPOSE/OBJECTIVE(S)

This study aimed to investigate the travel distance for cancer patients treated with radiotherapy in Victoria, Australia, during a 9-year period relative to their home address. Additionally, the study aimed to quantify 'excess' travel distance where patients travelled to treatment centers that were not their closest.

MATERIALS/METHODS

The PRedicting the health economic IMPact of new and current CAncer Treatments (PRIMCAT) dataset was used for the study. PRIMCAT is a multi-institution research initiative taking a data-driven modelling approach to understand and forecast cancer treatment utilization in Australia. The PRIMCAT dataset is a comprehensive linked dataset including a retrospective cohort of patients 18 years and over, diagnosed with cancer included in the Victorian Cancer Registry between January 2010 to December 2019. For each patient in the cohort, data linkage includes a range of datasets managed by state and federal health departments including the Victorian Radiotherapy Minimum Dataset. A distance matrix was constructed using the Google Distance Matrix API that included driving distance between postcodes of selected patients and the postcodes of radiotherapy facilities. The centroid of each post-code was used for driving distance measurements. We first analyzed the realized travel distances of patients followed by the excess travel by patients. The excess travel was further quantified separately for public and private radiotherapy facilities.

RESULTS

There were 86,408 unique patient-radiotherapy courses available and of sufficient data quality to analyze. Patients travelled an average of 42.5km (s.d. = 72.2km) one-way, with a median travel distance of 16.5km. The largest distance travelled was 723km with 95% of patients travelling between 0km and 257km. Of the patients who received radiotherapy in a public facility, 44.3% travelled to a facility that was not their closest public facility. The average excess travel of these patients was 26.8km, with the median excess travel being 13.6km. Additionally, of patients who received care in a public facility, 47.4% travelled past a closer private facility. The average excess travel distance of these patients was 23.1km and the median excess travel was 11.5km. In the case of patients who received radiotherapy at a private facility, 92.8% travelled to a clinic that was not their closest. The average excess of these patients was 36.6km with a median excess travel distance of 15.6km.

CONCLUSION

Access to radiotherapy facilities remains unequal in Victoria with some patients having to travel significantly greater distances than average. This significant travel may require patients to take time off work or live away from home presenting additional financial challenges. The reasons for the large travel distances and any excess travel have not yet been identified but will be the subject of further study.

Fear of Cancer Recurrence (FCR) in Human Papillomavirus-Associated Oropharyngeal Cancer (HPVOPC) Patients 12 months (12m) after (Chemo)Radiation (RT/CRT)

PURPOSE/OBJECTIVE(S)

This study constitutes a planned secondary endpoint analysis from a longitudinal unmet needs study. The aim was to: (1) describe FCR outcomes 12m after RT/CRT; (2) examine associations between FCR severity scores 12m after RT/CRT and patient and disease characteristics and other patient-reported outcomes (PROs); and (3) to evaluate preferred FCR referral pathways.

MATERIALS/METHODS

Eligible HPVOPC patients scheduled for curative RT/CRT were approached for enrolment. FCR was assessed with the 42-item Fear of Cancer Recurrence Inventory (FCRI) 12m after RT/CRT, as were patients' preferences for FCR referral pathways, using customized questions. Optimism (LOT-R) and resilience (Connor-Davidson Resilience Scale) were assessed at enrolment. Health-related quality of life (HRQL, EORTC QLQ-C30), disease-specific symptom severity and interference (MDASI-HN) and emotional distress (PROMIS Anxiety 7a, Depression 8a) were assessed 12m after RT/CRT.

RESULTS

A total of 100/129 eligible patients were enrolled between October 2020 and November 2021. 85/93 (91%) alive patients without recurrence completed the FCRI; patients were mostly men (n = 73, 86%), with a median age of 60 years (range 44-77). A majority had stage I disease (n = 46, 54%) and received CRT (n = 82, 96%). The mean FCRI total score was 45.4 (SD = 26.3, range 0-102, possible range 0-168). The mean FCRI severity score was 12.1 (SD = 7.4, median = 11.0, range 0-29); 13%, 31% and 56% of respondents scored in the severe (≥22), moderate (>12-22) and low (≤12) range, respectively. Univariable regression analysis indicated that lower resilience, lower HRQL (global health status, all functional domains), higher emotional distress (anxiety, depression), and higher symptom severity and interference were associated with higher FCR severity scores 12m after RT/CRT. Apart from lower levels of education, associations between FCRI severity scores and other patient and disease factors were not statistically significant. If FCR had been a problem (n = 66), 86%, 44%, 14% and 5% of patients indicated they would like to discuss it with their oncologist, primary care physician, a psychologist or nurse, respectively (multiple responses allowed). If specific FCR interventions were available, 70/85 indicated their preferred sources for delivery (ordered by median rank) were oncologist, primary care physician, psychologist or nurse (tied), self-management or group sessions (tied).

CONCLUSION

Almost half of HPVOPC patients reported moderate-to-severe FCR 12m after RT/CRT. Increased FCR severity was associated with education and self-reported resilience at baseline and with other measures of HRQL, toxicity and emotional distress at 12m. While patients view oncologists as central in FCR management, education about the benefits of other FCR-reducing approaches may be necessary.

Comparison of ventilatory and oxygen consumption measurements of yearling Thoroughbred colts and fillies exercising unridden on an all-weather track

Sex effects on ventilatory and oxygen consumption (V̇O2) measurements during exercise have been identified in humans. This study's aim was to evaluate the hypothesis that there are sex effects on ventilatory and V̇O2 measurements in exercising, untrained yearling Thoroughbreds (Tb). Forty-one Tbs (16 colts, 25 fillies; 19.8 ± 1.4 months old) were recruited. Physiological, ventilatory and exercise data were gathered from horses exercising unridden at high intensity on an all-weather track from a global positioning-heart rate unit and a portable ergospirometry system. Data were analysed with an unpaired Student's t-test and the Benjamini-Hochberg correction for multiple testing (P ≤ 0.05 significant). Mean bodyweight (BW, P = 0.002) and wither height (P = 0.04) were greater for colts than fillies. There were no differences in physiological and exercise data and absolute peak V̇O2 between groups. However, fillies had a higher mass specific peak V̇O2 (P = 0.03) than colts (121.5 ± 21.6 mL/kg.min vs. 111.9 ± 27.4 mL/kg.min). The peak breathing frequency was greater for fillies (P < 0.001) while the peak inspiratory (P < 0.001) and expiratory air flow (P < 0.001), peak expiratory tidal volume (VTE; P < 0.001) and peak minute ventilation (V̇E; P = 0.01) were greater for colts; there were no differences for peak VTE and V̇E when adjusted for BW. Differences in BW explain the differences in mass specific peak V̇O2 between groups. Given their morphological differences, it is likely that lung volumes and airway diameters are smaller for fillies, resulting in greater resistance and lower air flows and volumes. Further research is required to investigate the ventilatory differences and how they may change with maturation and impact performance.

A Prospective Study Evaluating Sexual Health Outcomes in Patients Undergoing (Chemo)Radiation (CRT/RT) for Human Papillomavirus-Associated Oropharyngeal Cancer (HPVOPC)

PURPOSE/OBJECTIVE(S)

The primary endpoint of this study was to describe the course of sexual health outcomes prior to, during and following CRT/RT and to determine the importance of sexual function in a broader context of other oncological and functional outcomes.

MATERIALS/METHODS

Eligible patients with locoregionally confined HPVOPC suitable for curative CRT/RT were approached for enrolment. Patients were assessed before treatment (baseline), week 7 of treatment (FU1), and 3- and 12-months post-treatment (FU2 and FU3, respectively). Study outcomes included sexual health (EORTC SHQ-22), quality of life (EORTC QLQ-C30), symptom burden (MDASI-HN), emotional distress (PROMIS Anxiety 7a, Depression 8b) and facial appearance and appearance distress (FACE-Q). Patient preferences were elicited using a modified version ('keeping sexual function' added) of the Chicago Priorities Scale (CPS) at baseline and FU3; items were sorted into top, middle or lower priorities; then ranked from 1-13.

RESULTS

From October 2020 to November 2021, 100/129 eligible patients were enrolled from 3 centers: median age 61 (range 44-79), male (n = 87, 87%), partnered (n = 75, 77%), heterosexual (n = 95, 95%). Most patients received CRT (n = 97, 97%), 52% had stage I disease (n = 52). Compliance with SHQ-22 at FU3 was 89/98 alive patients. Mean sexual satisfaction scores were 52 (SD = 27, range 0-100) at baseline, 27 (SD = 20) at FU1, 40 (SD = 24) at FU2 and 48 (SD = 28) at FU3. Mixed model results indicated a clinically significant reduction in sexual satisfaction at FU1 (-25, 95% CI = -31, -20; p < 0.001) and FU2 (-12, 95% CI = -17, -7; p<0.001) from baseline, but not FU3 (-4, 95% CI = -9, 1; p = 0.15). Univariable regression analysis indicated that patient factors (cohabiting, having a sexual partner, being sexually active, non-smoker), higher global health status, other SHQ-22 items (higher importance of sex life, libido, security with satisfying their partner, erection confidence, lower fatigue affecting sex life), lower depression, as well as 'keeping sexual function' being a top priority were associated with higher sexual satisfaction at FU3. Associations with MDASI-HN symptom and interference scales, and oral toxicity measures (pain, dry mouth, taste, mouth/throat sores) were not statistically significant. For 30/87 patients, treatment affected their sexual activity quite a bit or very much. Amongst the 13 CPS priorities, 'keeping sexual function' had a median rank of 10 and 9 at baseline and FU3, respectively; 24% and 26% identified it as a top priority at these assessments.

CONCLUSION

Sexual satisfaction is affected during and after CRT/RT for HPVOPC; however, on average, score differences before and 12 months after treatment are not clinically significant. Approximately one-quarter of patients consider sexual function a 'top' priority during survivorship.

Predictors of distress associated with altered appearance and function in people treated surgically for oral cancers: a cross-sectional study

This cross-sectional study was performed to examine sources of variation in distress associated with altered appearance and fundamental functions in oral cancer patients at 2 months, 12-15 months, 24-36 months, and ≥ 5 years post-definitive treatment. Eligible patients completed six scales from the FACE-Q Head and Neck Cancer Module. Pre-specified regression models were used to examine sources of variation in study outcomes for 145 patients. Patient self-reports indicated that distress associated with altered appearance and fundamental functions was highly variable, and distress was present beyond 5 years post-definitive treatment in some patients. Associations between distress scores and time post-definitive treatment, reconstructive surgery, and adjuvant therapy were not statistically significant. There was, however, moderate to strong evidence against the null hypothesis of no association between eating distress scores and sex, primary cancer site, and T-stage; smiling distress scores and age and primary cancer site; appearance distress scores and geographical remoteness and primary cancer site; and speaking distress scores and primary cancer site. Primary cancer site was the only significant independent predictor of multiple distress scores. These findings suggest that predicting the psychological impact of oral cancer treatment remains a challenge for the multidisciplinary team. Screening and interventions for psychological distress are essential beyond the preoperative and acute care settings.

Apoplastic effector candidates of a foliar forest pathogen trigger cell death in host and non-host plants

Forests are under threat from pests, pathogens, and changing climate. A major forest pathogen worldwide is the hemibiotroph Dothistroma septosporum, which causes dothistroma needle blight (DNB) of pines. While D. septosporum uses effector proteins to facilitate host infection, it is currently unclear whether any of these effectors are recognised by immune receptors to activate the host immune system. Such information is needed to identify and select disease resistance against D. septosporum in pines. We predicted and investigated apoplastic D. septosporum candidate effectors (DsCEs) using bioinformatics and plant-based experiments. We discovered DsCEs that trigger cell death in the angiosperm Nicotiana spp., indicative of a hypersensitive defence response and suggesting their recognition by immune receptors in non-host plants. In a first for foliar forest pathogens, we developed a novel protein infiltration method to show that tissue-cultured pine shoots can respond with a cell death response to a DsCE, as well as to a reference cell death-inducing protein. The conservation of responses across plant taxa suggests that knowledge of pathogen-angiosperm interactions may also be relevant to pathogen-gymnosperm interactions. These results contribute to our understanding of forest pathogens and may ultimately provide clues to disease immunity in both commercial and natural forests.

Does Care for Australians With Pancreatic Cancer Compare Favourably to a Consensus-Based Standard of Optimal Care?

Background: Pancreatic cancer has one of the lowest survival rates of all cancer types, with an incidence to mortality ratio approaching one. People with pancreatic cancer experience a rapid decline in health characterized by pain, nausea, fatigue and weight loss. For most people, the disease is detected at an advanced stage and the focus of treatment is palliative. In Victoria, Australia, knowledge regarding patterns of care for people with pancreatic cancer is out-of-date, but central to quality improvement initiatives targeting unwarranted variations in care and improvement in supports that are consistent with patient preferences. Aim: Our aim was to compare care received by patients with pancreatic cancer with a consensus-based standard representing optimal care to identify deviations from best practice and highlight processes that may improve the quality and safety of care provided. Methods: Eligible patients included those with pancreatic cancer, first treated in 2015, at one of three tertiary hospitals in Victoria, Australia. Once identified, dates and details of events indicated by the optimal care pathway were extracted from the medical record of each patient. Data were summarized using descriptive statistics and process maps: a visualization method that illuminates gaps, duplication, deviations from best practice and processes that may be amenable to improvement. Results: Thirty-two of 165 care pathways have been mapped to date. The nature and timing of care received appears highly variable. Only nine of 32 patients (28%) received all of their cancer care at a single institution; the remainder (n=23, 72%) received care in multiple tertiary and community facilities. Apart from four (13%) emergency presentations, referrals for specialist care came from general/primary practitioners (n=26, 81%). The timeframe for general/primary practitioner investigations ranged from one to 57 days. Once referred to a tertiary setting, most patients (n=23, 72%) were discussed at a multidisciplinary team meeting and received standard therapies. Only four had resectable disease. Nineteen patients (60%) had documented referrals to hospital- or community-based palliative care services. Where observed, deviations from the consensus-based standard tended to be related to the difficult nature of diagnosing pancreatic cancer, and determining appropriate care for patients with an advanced cancer with nonspecific symptoms. Conclusion: Process mapping provided a useful and efficient means of comparing care received with a consensus-based standard; however, the assessment of adherence to optimal timeframes and specific care events was complicated by missing data. Implications for quality improvement activities will be considered in the context of study limitations. We will also emphasize the importance of engaging patients and carers in setting improvement priorities.

Variation in the Quality of Experiences of Cancer Care at Five Large Metropolitan Health Services in Australia: Implications for Performance Measurement and Improvement

Background: Using insights gained from the National Health Service in England, an alliance of organizations committed to cancer control in Australia conducted a large-scale survey aimed at better understanding the quality of cancer care. Aims: To understand sources of variation in the quality of patients' experiences of cancer care; and to identify patients with the largest potential to benefit from strategic quality improvement initiatives. Methods: The Victorian Comprehensive Cancer Centre commissioned a cross-sectional survey of adult cancer patients treated as day cases or inpatients at five partner health services in 2015. Data comprised responses to the National Health Service (NHS) Cancer Patient Experiences Survey, ICD-10-AM codes and postcodes. Some survey items were modified to suit the Australian population based on advice from local experts and consumers. Aspects of care covered by the survey included: timeliness and experience of diagnosis; treatment decision-making; provision of support information; experience of operations, hospital doctors, ward nurses, hospital care and home care and support; experience of care as a day or outpatient; follow-up care with general practitioners; and overall cancer care. Consistent with NHS methodology, cancer care questions were recoded to binary variables reflecting more or less positive experiences and cancer type was defined based on ICD-10-AM codes. Postcodes were converted to an index of relative socioeconomic advantage and disadvantage using an Australian standard. Proportions were used to summarize the characteristics of patients who had more and less positive experiences of cancer care; then, logistic regression was used to model the probability of having less positive experiences. Age, gender, language spoken at home, socioeconomic group and cancer type were included in the models. Univariate models were used to calculate unadjusted odds ratios. Multivariate models were used to calculate the odds ratios of less positive experiences adjusting for patient characteristics and cancer type. Results: A total of 2526 patients completed the survey (response rate: 41%). As a general rule, and consistent with findings from the NHS, a substantial majority of patients (80% or more) reported positively on many aspects of care. Even so, more often than not aggregated data obscured striking disparities between patients diagnosed with different types of cancers. Overall, patients diagnosed with pancreatic cancer fared the worst; more than half reported less favorably on multiple aspects of care. Variation in perceptions of care was not as pronounced for different age groups, genders and language groups and we identified little variation between socioeconomic groups. Conclusion: At the very least, cancer system performance should be appraised by cancer type. Aggregation may conceal gross inequities and thwart attempts to identify those patients most likely to benefit from targeted service improvements.

Immunotherapy in Advanced Melanoma: Patient and Informal Caregiver Perspectives

Background: Immunotherapy has dramatically changed the treatment landscape and survival outcomes for patients with advanced melanoma. However, the success rates for immunotherapy are varied, and unpredictable. Immunotherapy can result in a range of treatment related toxicities, many of which can impact significantly on quality of life (QoL); or become life-threatening. Immunotherapies are administered in an ambulatory setting and as such, much of the responsibility for side-effect recognition, reporting, and monitoring falls to patients and their informal caregivers. Given the importance of early side-effect identification and management, it is important to understand the patient and caregiver experience of immunotherapy to facilitate patient safety. Aim: To: Explore the experiences of patients with advanced melanoma who received immunotherapy, and their informal caregivers Investigate the impact of immunotherapy treatment (in particular toxicities) on QoL of patients and their caregivers Identify behaviors and strategies patients and caregivers' used to manage immunotherapy treatment and toxicities. Methods: This cross-sectional, exploratory study used qualitative interviews with patients with stage IV melanoma who had completed, or were receiving nivolumab, pembrolizumab or ipilimumab as monotherapy, and their caregivers. Analysis used interpretive description methodology. Results: Twenty three patients and nine caregivers took part. Patients and caregivers discussed feelings of uncertainty regarding immunotherapy efficacy and toxicities; and raised concerns about correctly identifying relevant and reportable symptoms. Some participants did not see the link between symptoms experienced and treatment despite being satisfied with the level of information provided by their healthcare team. This highlights a potential lack of understanding about side-effects and/or deficiencies in the way treatment education is delivered. This was particularly concerning when resulting in delayed nursing or medical intervention. Findings identified the integral role caregivers have in the care of patients receiving immunotherapy. Conclusion: Despite immunotherapy improving survival rates for many patients with melanoma their QoL, and that of their caregivers can be negatively impacted by uncertainty about efficacy and the identification and reporting of potential side effects. Patient and caregiver experience may be improved with better education about what to expect, provided in various formats and at multiple time points, in conjunction with defined pathways for rapid access to the nursing and medical advice.

The modified Memorial Symptom Assessment Scale Short Form: a modified response format and rational scoring rules

PURPOSE

The Memorial Symptom Assessment Scale Short Form (MSAS-SF) is a widely used symptom assessment instrument. Patients who self-complete the MSAS-SF have difficulty following the two-part response format, resulting in incorrectly completed responses. We describe modifications to the response format to improve useability, and rational scoring rules for incorrectly completed items.

METHODS

The modified MSAS-SF was completed by 311 women in our Peer and Nurse support Trial to Assist women in Gynaecological Oncology; the PeNTAGOn study. Descriptive statistics were used to summarise completion of the modified MSAS-SF, and provide symptom statistics before and after applying the rational scoring rules. Spearman's correlations with the Functional Assessment for Cancer Therapy-General (FACT-G) and Hospital Anxiety and Depression Scale (HADS) were assessed.

RESULTS

Correct completion of the modified MSAS-SF items ranged from 91.5 to 98.7%. The rational scoring rules increased the percentage of useable responses on average 4% across all symptoms. MSAS-SF item statistics were similar with and without the scoring rules. The pattern of correlations with FACT-G and HADS was compatible with prior research.

CONCLUSION

The modified MSAS-SF was useable for self-completion and responses demonstrated validity. The rational scoring rules can minimise loss of data from incorrectly completed responses. Further investigation is recommended.

Validation of masks for determination of V̇O2 max in horses exercising at high intensity

BACKGROUND

The need for a horse to be ridden while wearing a measurement device that allows unrestricted ventilation and gas exchange has hampered accurate measurement of its maximal oxygen consumption (V̇O₂ max) under field conditions.

OBJECTIVES

Design and validate a facemask with the potential to measure V̇O₂ max accurately in the field.

STUDY DESIGN

Experiment with 6 × 6 Latin square design.

METHODS

Two variations of a mask and associated electronic control module (ECM) were designed to enable breath-by-breath measurement of airflows through two 7.8 cm diameter pneumotachometers located 7.5 cm in front of each narus. The ECM was comprised of an analogue-to-digital converter and a lithium-ion battery that provided power and signal filtering to the pneumotachometers and an oxygen sensing cell, and powered a pump connected to gas sampling ports between the nares and pneumotachometers. Airflow and oxygen content of inspired and expired gases were recorded through the ECM and electronically transferred to a notebook. V̇O₂ was determined from these recordings using a customised software program. Mask B encased the lower jaw. Mask R left the jaw free so the horse could wear a bit if ridden. V̇O₂ max and arterial blood gases were measured in 6 horses during multiple treadmill tests. Each mask was worn twice and results compared to those from an established open flow-through system (O) by ANOVA-RM (P<0.05). System utility was evaluated using the intraclass correlation coefficient of 4 independent raters.

RESULTS

Blood gases and V̇O₂ max (151.9±7.0 [mean±s.d.; O], 151.5±9.6 [B], 149.5±7.5 [R] ml/[kg.min]) were not different between masks. V̇O₂ max measures were reproducible for each mask. Intraclass correlation coefficient between raters = 0.99.

MAIN LIMITATIONS

Some rebreathing of expired air from mask dead space.

CONCLUSION

Masks capable of measuring V̇O₂ max during treadmill exercise were developed, tested and found to be accurate. Mask R has potential application to measurement of V̇O₂ max under field conditions.

Adolescents and young adult cancer survivors: exercise habits, quality of life and physical activity preferences

INTRODUCTION

Given the decades of survivorship for adolescent and young adult (AYA) cancer survivors, it is important to promote behaviours that enhance physical and mental well-being and quality of life (QoL). The purpose of this study was to explore the exercise programming preferences and information needs of AYA survivors and to examine the impact of a cancer diagnosis on physical activity behavior and QoL.

METHODS

Participants aged 15-25 years at time of diagnosis and referred to a specialist AYA cancer service between January 2008 and February 2012 were recruited. Eligible participants were mailed a self-administered questionnaire assessing demographic and disease-related information, physical activity levels over time and exercise information preferences. QoL was measured using the Assessment of Quality of Life-6D (AQoL-6D).

RESULTS

Seventy-four (response rate 52 %) participants completed the questionnaire. The mean age was 23 years with 54 % female, with prevalent diagnoses included hematological malignancy (45 %) and sarcoma (24 %). Results indicated a significant reduction in the average minutes of physical activity post diagnosis (p =< 0.001) and during treatment (p = < 0.001). AYA who met public health physical activity guidelines (n = 36) at questionnaire completion had significantly higher QoL than those not meeting the guidelines (n = 38) (median (Mdn) = 0.87, interquartile range (IQR) = 0.73 to 0.98 and Mdn = 0.81, IQR = 0.57 to 0.93, respectively; p = 0.034). Most participants wanted exercise information at some point after diagnosis (85 %) but many did not receive any information (45 %).

CONCLUSIONS

Findings suggest that AYA with cancer experience a significant impact on physical activity levels and QoL. Moreover, survivors experience considerable difficulty returning to premorbid levels of activity. Our study suggests that interventions promoting physical activity and healthy lifestyle behaviours would be well accepted within this population and may be essential to improve their long-term health and QoL during survivorship.

An audit of the efficacy of a structured handover tool in obstetric anaesthesia

INTRODUCTION

The SAFE handover tool was developed to reduce critical omissions during handovers in obstetric anaesthesia. It comprises a simple proforma onto which the outgoing team documents patients who fall into one of four anaesthetically relevant categories: Sick patients; At-risk patients (of emergency caesarean section, major haemorrhage or anaesthetic problems); Follow-ups; and Epidurals. We hypothesised that its use would reduce the number of critical omissions at handover.

METHODS

The efficacy of the SAFE handover tool was assessed through several audit cycles in a single maternity unit. The four SAFE categories were considered the gold standard, since they encompassed the consensus opinion of senior obstetric anaesthetists with respect to parturients they most wanted to know about at handover. Against these criteria it was possible to compare the number of cases that should have been handed-over against the number that were actually handed-over.

RESULTS

After implementation of the handover tool, patients were four times more likely to be handed-over than without the use of the tool: an increase from 49% to 79% of relevant cases (P<0.0001, OR 4.1, 95% CI 2.19-7.6). The handover tool was particularly effective at increasing the handover rates of Sick and At-risk parturients, which increased from 21% to 67% (P<0.0001, OR 7.7, 95% CI 2.7-21.7) and 25% to 78% (P<0.01, OR 9.9, 95% CI 1.6-61.6), respectively.

CONCLUSION

The SAFE handover tool significantly increased handover rates of anaesthetically relevant parturients. It is easy to remember and consistent with UK National Health Service Litigation Authority's guidance on risk management in maternity units.

Non-occupational post-exposure prophylaxis for HIV at St Michael's Hospital, Toronto: a retrospective review of patient eligibility and clinical outcomes

Stringent eligibility criteria, drug costs and antiretroviral toxicities are challenges in delivering HIV non-occupational post-exposure prophylaxis (nPEP). We reviewed patients’ nPEP eligibility and clinical outcomes at St Michael's Hospital, Toronto, Canada to identify opportunities for improvement. Of 241 patients, 59%, 36% and 6% presented for high- (receptive anal/vaginal, blood), medium- (insertive anal/vaginal) and low-risk (oral) sexual exposures, respectively, and nearly all (93%) presented within 72 hours. Of 205 patients given nPEP, 20 were known to have discontinued nPEP prematurely: three due to costs but none due to toxicities. Two HIV seroconversions occurred in patients with suspected ongoing potential exposures. Five asymptomatic syphilis diagnoses were made among 71 tested. Only 39% and 19% of nPEP patients returned to our institution for follow-up at 3–4 and six months, respectively. Our findings underscore the feasibility and importance of nPEP programmes to HIV and sexually transmitted infection control, while identifying opportunities for improvement.

Impact of a novel nurse-led prechemotherapy education intervention (ChemoEd) on patient distress, symptom burden, and treatment-related information and support needs: results from a randomised, controlled trial

BACKGROUND

High levels of distress and need for self-care information by patients commencing chemotherapy suggest that current prechemotherapy education is suboptimal. We conducted a randomised, controlled trial of a prechemotherapy education intervention (ChemoEd) to assess impact on patient distress, treatment-related concerns, and the prevalence and severity of and bother caused by six chemotherapy side-effects.

PATIENTS AND METHODS

One hundred and ninety-two breast, gastrointestinal, and haematologic cancer patients were recruited before the trial closing prematurely (original target 352). ChemoEd patients received a DVD, question-prompt list, self-care information, an education consultation≥24 h before first treatment (intervention 1), telephone follow-up 48 h after first treatment (intervention 2), and a face-to-face review immediately before second treatment (intervention 3). Patient outcomes were measured at baseline (T1: pre-education) and immediately preceding treatment cycles 1 (T2) and 3 (T3).

RESULTS

ChemoEd did not significantly reduce patient distress. However, a significant decrease in sensory/psychological (P=0.027) and procedural (P=0.03) concerns, as well as prevalence and severity of and bother due to vomiting (all P=0.001), were observed at T3. In addition, subgroup analysis of patients with elevated distress at T1 indicated a significant decrease (P=0.035) at T2 but not at T3 (P=0.055) in ChemoEd patients.

CONCLUSIONS

ChemoEd holds promise to improve patient treatment-related concerns and some physical/psychological outcomes; however, further research is required on more diverse patient populations to ensure generalisability.

Virologic and immunologic effectiveness of tipranavir/ritonavir (TPV/r)- versus darunavir/ritonavir (DRV/r)-based regimens in clinical practice

BACKGROUND

Although both tipranavir and darunavir are important options for the management of patients with multidrug resistant HIV, there are at present no studies comparing the effectiveness and safety of these 2 antiretroviral drugs in this population of patients.

OBJECTIVE

To compare the effectiveness and safety of ritonavir (TPV/r)- and darunavir/ritonavir (DRV/ r)-based therapies in treatment-experienced patients (n = 38 and 47, respectively).

METHODS

Multicenter, retrospective cohort study.

RESULTS

The median baseline viral load and CD4 count were 4.7 copies/mL (interquartile range [IQR] 4.3, 5.2) and 168 cells/mm( 3) (IQR 80, 252) for TPV/r patients and 4.7 copies/mL (IQR 3.7, 5.1) and 171 cells/mm(3) (IQR 92, 290) for DRV/r patients. The median number of years on antiretroviral therapy (ART) prior to starting DRV/r or TPV/r were 12.7 (10.2-15.5) and 10.5 (8.4-12.6), respectively (P < .01). Current raltegravir (RAL) use (odds ratio [OR] 5.53, 95% CI 1.08-28.34) was significantly associated with virologic suppression at week 24 in multivariable logistic regression models, whereas the use of TPV/r was not significantly associated with virologic suppression compared to DRV/r (OR 0.93, 95% CI 0.27-3.18, P = .91).

CONCLUSION

No significant difference was observed between DRV/r and TPV/r in terms of virologic suppression.

Prevalence of community-associated methicillin-resistant Staphylococcus aureus colonization in men who have sex with men

Summary

Outbreaks of skin and soft tissue infections mediated by community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) are being reported with increasing frequency among men who have sex with men (MSM). However, the potential role of asymptomatic colonization with this organism in perpetuating these infections is unclear. The purpose of this cross-sectional study was to determine the prevalence of colonization with CA-MRSA among a cohort of 500 MSM recruited from two inner city clinics in Toronto, Canada. Following the provision of informed consent, subjects completed a questionnaire capturing demographic and clinical variables, which may be associated with MRSA colonization. A nasal swab for MRSA was collected from each subject, and instructions were provided regarding the self-collection of a rectal swab. Cultured MRSA underwent pulsed-field gel electrophoresis and virulence testing for Panton-Valentine leukocidin gene expression. The prevalence of CA-MRSA colonization was 1.6% (95% CI: 0.5–2.6%).

Developing more positive attitudes towards mental health nursing in undergraduate students: part 2--The impact of theory and clinical experience

Previous research examining the impact of education on nursing students' attitudes towards mental health nursing as a career has highlighted clinical experience as the primary influencing factor and generally has not considered the impact of theory. The current study compared a cohort of second-year and a cohort of third-year nursing students from the same university. Second-year students had received more theory and clinical experience than their counterparts. Questionnaires were distributed to the total population of students before commencement of, and after completion of clinical placement. This paper examines students' perceived preparedness for and satisfaction with clinical experience, attitudes towards people with mental illness, and attitudes towards mental health nursing as a career option following the completion of differing amounts of theory and clinical experience. The results demonstrate some statistically significant differences with increased amounts of theory and clinical experience in the second-year cohort being positively influential. The findings suggest that an increased component of theoretical and clinical experience in psychiatric/mental health nursing is likely to produce more positive attitudes towards people with mental illness and psychiatric/mental health nursing. However, little difference in perceived preparedness for and satisfaction with clinical experience was noted between the two cohorts.

Developing more positive attitudes towards mental health nursing in undergraduate students: part 1--does more theory help?

Negative attitudes towards mental illness and the mental health nursing profession have deterred many undergraduate nursing students from considering this area as an attractive career option. Positive clinical experience has been identified as the most important factor in producing more favourable attitudes. While the quantity of theory is identified as important, its impact on attitudes has not been examined through research. This study compared two groups of students undertaking different numbers of theoretical and clinical hours in mental health nursing to determine if this increase has an impact on nursing students' attitudes. Anonymous questionnaires were distributed to the total population of students following completion of the theoretical component of the programme but prior to clinical experience. The questionnaire was designed to assess: (1) nursing student's preparedness for and attitudes towards the mental health field; (2) consumers of mental health services; and (3) the students' career preferences. This first paper in a two-part series examines the impact of theoretical hours and suggests that while other attitudes are fairly similar between the two groups, the group exposed to more theory exhibited significantly more positive attitudes towards psychiatric nursing as a career.

A large prospective study assessing injection site reactions, quality of life and preference in patients using the Biojector vs standard needles for enfuvirtide administration

OBJECTIVES

To determine the severity of injection site reactions (ISRs), patient quality of life (QoL) and preference when enfuvirtide is administered by the Biojector (Bioject, Medical Technologies, Inc., Tualatin, OR, USA) relative to standard needles.

METHODS

A total of 201 HIV-positive patients on stable enfuvirtide-based therapy (n=184) or initiating such therapy (n=17) were evaluated prospectively after switching from standard needles to the Biojector system. Patients used needles for a minimum of 2 weeks prior to switching to the Biojector. Questionnaires to assess the incidence and severity of ISRs (31-item score) and QoL [Medical Outcomes Study HIV Health Survey (MOS-HIV)] were administered at baseline and following a minimum of 14 days of Biojector use.

RESULTS

The median changes in ISR score and number of ISRs following a median of 1.0 month [interquartile range (IQR) 0.9, 1.3] of Biojector use were -3 (IQR -7, 1) and -1 (IQR -3, 1), respectively. The severity of pain (P<0.0001), induration (P<0.0001), pruritus (P<0.0001), nodules (P<0.0001) and erythema (P<0.0001) all decreased with the Biojector. Administration of enfuvirtide with the Biojector was associated with an improved patient QoL (P<0.0001), and was preferred by 72% of patients.

CONCLUSIONS

Compared with needles, the Biojector was associated with a decreased severity of ISRs and improved QoL in patients taking enfuvirtide.

Assay of HIV gp41 amino acid sequence to identify baseline variation and mutation development in patients with virologic failure on enfuvirtide

In this study, we retrospectively assessed a gp41 genotypic assay in 404 enfuvirtide-naïve individuals (340 clade B, 64 non-B clade) to determine the prevalence of baseline polymorphisms and in 41 patients virologically failing enfuvirtide to determine correlates of resistance to this agent. Conserved and polymorphic regions of gp41 were identified in clade B isolates, with 127 of 328 codons (38.7%) being highly conserved (<1.0% variation) and 74 of 328 codons (22.6%) being partially conserved (1.0-5.0% variation). Polymorphisms were observed throughout gp41 in non-B clade virus sequences compared to the clade B reference strain, ranging from 53 natural substitutions in clade D to 76 in clade A. Insertions were common at positions 3, 105, 215 and 276. In the patients failing enfuvirtide, mutations were detected in the 10 amino acid region at positions 36-45 in all plasma virus sequences. Six additional mutations were selected outside of the common region which may be clinically significant at positions 33, 73, 75, 126, and 138. Two or three mutations at positions 36-45 were observed in the majority of plasma virus sequences from patients with virologic failure following the use of enfuvirtide. Further study is required to determine the clinical relevance of the clade related polymorphisms and the new mutations identified in the patients with virologic failure.

Incidence of and risk factors for tenofovir-induced nephrotoxicity: a retrospective cohort study

OBJECTIVES

Despite the recent publication of case reports describing various manifestations of tenofovir-related nephrotoxicity, data regarding the incidence of and risk factors for this adverse effect are currently lacking.

METHODS

A retrospective cohort study of patients from four centres in Toronto, Canada, enrolled in the tenofovir expanded access programme with a minimum of 3 months follow up, was carried out.

RESULTS

A total of 172 patients receiving tenofovir disoproxil fumarate (TDF) for a median of 16 months (range 3-25 months) were included in the study. Seven (4%) patients developed grade 1 (>44 micromol/L from baseline) increases in serum creatinine (SCr) during follow up; no patient developed grade 2 or higher nephrotoxicity. Fifteen (8.7%) patients had an increase in SCr of greater than 1.5 times baseline values during follow up. Four (2.3%) patients discontinued TDF because of an increase in SCr and/or abnormal urinalysis. Of 62 patients with a urinalysis, grade 1 or higher proteinuria (< 3 g/L) was observed in 27 (43%) patients. Only baseline SCr [odds ratio (OR)=0.51 per 10 micromol/L increase; P=0.0005] and baseline creatinine clearance (1.26 per 10 mL/min increase; P=0.01) were significantly associated with ever having a 1.5-fold increase in serum creatinine. Twenty-eight (16%) and 11 (6%) patients developed grade 1 (serum phosphorus < or = 0.71 mmol/L) and grade 2 (serum phosphorus < or = 0.61 mmol/L) hypophosphataemia during follow-up, respectively.

CONCLUSIONS

Although slight increases in SCr did occur after starting TDF, clinically significant nephrotoxicity was rare. The clinical significance of TDF-related hypophosphataemia and proteinuria requires further study.

Direct access ambulatory BP monitoring???the Edinburgh experience

The use of electronic measurement of blood pressure and, in particular, ambulatory blood pressure monitoring offers the opportunity to determine which patients with apparent hypertension have truly sustained elevation of their blood pressure levels. Given the high prevalence of hypertension and the even larger number of individuals who appear to be hypertensive but may not be so, it is difficult to deliver ambulatory blood pressure monitoring to all individuals who might benefit from it. In Edinburgh, Scotland, we have piloted a system of direct access ambulatory blood pressure monitoring whereby physicians in primary care can request of the hospital service, an ambulatory monitor on their patient without the patients attending a formal hospital clinic. In the 7 years since the service was first instituted, almost 6,000 monitors have been performed with referrals running at approximately 100 per month in recent times. The present study was set up to assess the impact of the ambulatory monitor result on clinical decision making in primary care. The referral form invited primary care physicians to indicate their planned management if an ambulatory monitor had not been available and we thereafter audited patient records to determine what ultimately happened following the advice given on the basis of the ambulatory monitoring record.A random sample of results was obtained on untreated patients and approximately 500 were analysed. It was clear that if the advice to the primary care physician based upon the ABPM was not to treat, that this was largely followed with some 94% of patients not receiving treatment within 3 months of the monitor. If, however, the advice given was to start treatment, this was less reliably followed and in only 76% of patients treatment was started within 3 months. At the time of the audit this figure had increased to 82%. Primary care physicians had indicated that they would have treated 60% of the individuals referred and in reality only treated 40%. The potential saving in drug costs from the reduction by 20% of those treated would have significant impact on health care budgets.

Ambulatory blood pressure monitoring: is it necessary for the routine assessment of hypertension in people with diabetes?

AIMS

The British Hypertension Society (BHS) has recommended that, for people with diabetes, the target 'clinic' blood pressure should be < 140/80 mmHg. Ambulatory monitoring of blood pressure (ABPM) is used widely in the assessment of hypertension and the BHS has recommended that the target 'awake' ambulatory blood pressure for people with diabetes should be < 130/75 mmHg. The purpose of the present study was to determine the utility of ABPM in the assessment of hypertension in patients with diabetes, over and above a careful 'clinic' measurement of blood pressure.

METHODS

The records of 540 patients with diabetes who underwent ABPM (using SpaceLabs monitors) were retrospectively analysed. With respect to current BHS recommendations, the positive and negative predictive values of 'clinic' blood pressure (measured by trained nurses using mercury sphygmomanometers) on 'awake' ambulatory blood pressure (ABP) were calculated.

RESULTS

The positive predictive value of the 'clinic' BP, its ability to detect patients whose ABP was above BHS targets, was 99%. The negative predictive value of 'clinic' blood pressure was 27%.

CONCLUSIONS

With regard to current BHS guidelines, ABPM is generally unnecessary in the assessment of hypertension in patients with diabetes, provided careful 'clinic' measurements of blood pressure are made.

Synechococcus mutants resistant to an enamine mechanism inhibitor of glutamate-1-semialdehyde aminotransferase

An enamine mechanism-based inactivator of mammalian delta-aminobutyric acid aminotransferase, 4-amino 5-fluoropentanoic acid is a potent inhibitor of cell growth and pigment formation in the cyanobacterium Synechococcus PCC 6301. It was demonstrated that 4-amino 5-fluoropentanoic acid inhibits the aminolaevulinate synthesis at glutamate 1-semialdehyde aminotransferase and that in the mutant obtained by exposing cells to 40 microM 4-amino 5-fluoropentanoic acid, this enzyme was insensitive to the inhibitor. The specific activity of glutamate 1-semialdehyde aminotransferase in cell extracts was lower in the mutant, although the cell growth rate was unaffected. The decrease in sensitivity to 4-amino 5-fluoropentanoic acid in the mutant is due to a structural gene mutation, a single base change in the hemL gene resulting in a S162T substitution in the gene product.

Adjudicating ventilator-associated pneumonia in a randomized trial of critically ill patients

PURPOSE

The purpose of this study was to evaluate an adjudication strategy for diagnosing ventilator-associated pneumonia (VAP) in a randomized trial.

MATERIALS AND METHODS

In a double-blind trial of sucralfate versus ranitidine, one of four pairs of adjudicators examined each case of clinically suspected VAP. Nurse and physician notes and all relevant laboratory data were allocated to each adjudication pair in groups of five patients. Each reader in the pair decided whether the patient had VAP; differences were resolved by consensus discussion.

RESULTS

The overall unadjusted study odds ratio for VAP was 0.82 (P = .21) representing a trend toward less pneumonia with sucralfate compared with ranitidine. The odds ratio adjusted for adjudication pair was 0.85 (P = .27). The proportion of charts adjudicated as VAP positive among pairs ranged from 50% to 92%; crude agreement between readers in each pair varied from 50% to 82%. When adjudicators disagreed, the final consensus was split evenly between the two adjudicators' initial opinions in two pairs; in the other two pairs, the final decision reflected one dominant initial opinion. Personnel time to adjudicate all patients with a suspicion of VAP was 74 days.

CONCLUSIONS

Though adjudication of outcomes such as VAP is time-consuming, consistent decision-making requires strict criteria, training, and calibration. Patients should be assigned to adjudication teams through random allocation.

A suicide vector for allelic recombination involving the gene for glutamate 1-semialdehyde aminotransferase in the cyanobacterium Synechococcus PCC 7942

Gabaculine (2,3-dihydro 3-amino benzoic acid) is a potent inhibitor of tetrapyrrole biosynthesis in organisms that use the C5 pathway for the synthesis of delta-aminolaevulinic acid. Glutamate semialdehyde aminotransferase (GSA-AT), the enzyme catalysing the formation of this key precursor of tetrapyrroles, is normally inhibited by concentrations of gabaculine in the order of 5 microM. However, in Synechococcus 6301 strain GR6, a cyanobacterium that is resistant to 100 microM gabaculine, this enzyme has undergone two changes in structure: a deletion of three amino acids from positions 5 to 7 and the substitution of isoleucine for methionine at position 248. To establish the effect in vivo of these specific changes in the gene for GSA-AT (hemL), a suicide vector (pHS7) containing an antibiotic cassette was constructed to achieve the replacement, by homologous recombination, of the wild-type hemL gene in the chromosome by a modified form of the gene. Recombinant strains of Synechococcus 7942 obtained using pHS7-hemLGR6 were indistinguishable from Synechococcus 6301 GR6 in terms of the resistance of growth and of chlorophyll accumulation to high concentrations of gabaculine, while a wild-type recombinant produced using pHS7-hemLWT had retained its sensitivity. Southern hybridisation using gene probes for hemL, ampr and cmr confirmed that chromosomal integration of the plasmids had occurred in both WT and GR6 recombinants. Growth and chlorophyll accumulation in equivalent strains with the hemL gene containing either the deletion or the transition characteristic of Synechococcus 6301 GR6 were inhibited by 10 microM gabaculine. Consequently, resistance in vivo to high concentrations of this compound is dependent on both the changes in gene/enzyme structure. This investigation has established the effectiveness of the suicide vector pHS7 for studying the effect in vivo of specific changes in the hemL gene. It has also demonstrated that replacement of the wild-type gene by that from Synechococcus 6301 GR6 is sufficient to confer resistance in vivo to high concentrations of gabaculine.

Ambulatory blood pressure on and off continuous positive airway pressure therapy for the sleep apnea/hypopnea syndrome: effects in "non-dippers"

Ambulatory blood pressure (BP) monitoring was performed in 13 patients with the sleep apnea/ hypopnea syndrome (SAHS) during a randomized, placebo controlled crossover trial of the effects of continuous positive airway pressure (CPAP) therapy. BP was monitored at half-hourly intervals for a 24-hour period both on CPAP and on an oral placebo, each given for a minimum of 3 weeks. Objective effective CPAP use averaged 4.3 hours per night. Weight and anti-hypertensive medications remained stable over the study period. Systolic, diastolic and mean arterial BP for 24-hour, daytime and nighttime periods were not significantly different on placebo compared to CPAP. Those patients with no significant overnight fall in BP on placebo ("non-dippers") showed a significant improvement in daytime mean arterial BP on CPAP (98 +/- 4 mm Hg) compared to placebo (102 +/- 4 mm Hg; p = 0.01). These findings, in a well-controlled trial, suggest that BP is not reduced by CPAP in a heterogeneous group of SAHS patients, but it may be selectively improved in those patients most at risk for cardiovascular morbidity and mortality.

The accuracy of automated blood pressure measuring devices in patients with controlled atrial fibrillation

OBJECTIVE

To determine whether automated blood pressure measuring devices can measure blood pressure accurately in patients with atrial fibrillation.

DESIGN

Comparison of the accuracy of two electronic sphygmomanometers [Takeda UA-751 (Takeda) and Copal UA-251 (Copal)] and two ambulatory blood pressure monitors [Accutracker 1 (Accutracker) and SpaceLabs 90207 (SpaceLabs)] with that of a trained observer using a Hawksley random-zero sphygmomanometer (Hawksley), using the sequential same-arm technique.

SETTING

University teaching hospital: medical wards and outpatient department.

SUBJECTS

Twenty-eight patients, mean +/- SD age 72 +/- 9 years, blood pressure range 90-158/40-96 mmHg, in atrial fibrillation with a controlled ventricular rate.

MAIN OUTCOME MEASURES

The proportion of machine readings > 5 mmHg different from the Hawksley reading was compared with that obtained by three sequential Hawksley measurements. The variability of each measuring method was assessed by determining the SDD for the paired readings from each device.

RESULTS

Five per cent of Takeda, 5% of Copal, 14% of Accutracker and 21% of SpaceLabs readings could not be obtained. Sequential testing with the Hawksley resulted in an accuracy at the 5-mmHg level of (systolic/diastolic) 79/79%, compared with 64/54% (P < 0.05 for diastolic) for the Takeda, 68/75% (NS) for the Copal, 50/36% (P < 0.01 for both) for the Accutracker and 50/29% (P < 0.01 for systolic, P < 0.001 for diastolic) for the SpaceLabs. Intrapatient variability, as assessed by SDD, was 8.3/8.6 mmHg for the Hawksley, similar to that for the Copal (7.7/7.3 mmHg) but higher for the Takeda (11.2/19.7 mmHg), the Accutracker (22.4/26.3 mmHg) and the SpaceLabs (7.5/14.8 mmHg).

CONCLUSIONS

Accurate measurement of blood pressure with an electronic device is possible in patients who have atrial fibrillation; the Copal UA-251 provides a satisfactory level of accuracy. However, the marked difference between devices and the limited accuracy of the other machines tested here demonstrates the need to ensure that such devices are of proven accuracy in this patient group.

Disulfiram treatment of alcoholism

To assess the efficacy of supervised disulfiram as an adjunct to out-patient treatment of alcoholics, a randomised, partially blind, six-month follow-up study was conducted in which 126 patients received 200 mg disulfiram or 100 mg vitamin C under the supervision of a nominated informant. In the opinion of the (blinded) independent assessor, patients on disulfiram increased average total abstinent days by 100 and patients on vitamin C by 69, thus enhancing by one-third this measure of treatment outcome. Mean weekly alcohol consumption was reduced by 162 units with disulfiram, compared with 105 units with vitamin C, and the disulfiram patients reduced their total six-month alcohol consumption by 2572 units compared with an average reduction of 1448 units in the vitamin C group. Serum gamma-GT showed a mean fall of 21 IU/I in patients on disulfiram but rose by a mean of 13 IU/I with vitamin C. Unwanted effects in the disulfiram group led to a dose reduction in seven patients and to treatment withdrawal in four (and in one vitamin C patient). Two-thirds of the disulfiram group asked to continue the treatment at the end of the study. There were no medically serious adverse reactions.

Rice tungro disease is caused by an RNA and a DNA virus

We present evidence that rice tungro spherical virus (RTSV) has a genome of polyadenylated single-stranded RNA of about 10 kb whereas rice tungro bacilliform virus (RTBV) contains double-stranded circular DNA. RTBV DNA has been mapped and shown to have two discontinuities, one in each strand, at specific sites; it thus resembles that of the caulimoviruses. Gel electrophoresis of RTSV preparations revealed two protein bands (Mr 35K and 26K). RTBV yielded two major protein bands of 37K and 33K together with several minor species of higher and lower Mr which react with antiviral serum.