Prognostic evaluation in patients with advanced cancer in the last months of life: ESMO Clinical Practice Guideline

•This ESMO Clinical Practice Guideline provides key recommendations for using prognostic estimates in advanced cancer. •The guideline covers recommendations for patients with cancer and an expected survival of months or less. •An algorithm for use of clinical predictions, prognostic factors and multivariable risk prediction models is presented. •The author group encompasses a multidisciplinary group of experts from different institutions in Europe, USA and Asia. •Recommendations are based on available scientific data and the authors’ collective expert opinion.

The Prognosis in Palliative care Study II (PiPS2): A prospective observational validation study of a prognostic tool with an embedded qualitative evaluation

Background

Prognosis in Palliative care Study (PiPS) models predict survival probabilities in advanced cancer. PiPS-A (clinical observations only) and PiPS-B (additionally requiring blood results) consist of 14- and 56-day models (PiPS-A14; PiPS-A56; PiPS-B14; PiPS-B56) to create survival risk categories: days, weeks, months. The primary aim was to compare PIPS-B risk categories against agreed multi-professional estimates of survival (AMPES) and to validate PiPS-A and PiPS-B. Secondary aims were to assess acceptability of PiPS to patients, caregivers and health professionals (HPs).

Methods and findings

A national, multi-centre, prospective, observational, cohort study with nested qualitative sub-study using interviews with patients, caregivers and HPs. Validation study participants were adults with incurable cancer; with or without capacity; recently referred to community, hospital and hospice palliative care services across England and Wales. Sub-study participants were patients, caregivers and HPs. 1833 participants were recruited. PiPS-B risk categories were as accurate as AMPES [PiPS-B accuracy (910/1484; 61%); AMPES (914/1484; 61%); p = 0.851]. PiPS-B14 discrimination (C-statistic 0.837) and PiPS-B56 (0.810) were excellent. PiPS-B14 predictions were too high in the 57–74% risk group (Calibration-in-the-large [CiL] -0.202; Calibration slope [CS] 0.840). PiPS-B56 was well-calibrated (CiL 0.152; CS 0.914). PiPS-A risk categories were less accurate than AMPES (p<0.001). PiPS-A14 (C-statistic 0.825; CiL -0.037; CS 0.981) and PiPS-A56 (C-statistic 0.776; CiL 0.109; CS 0.946) had excellent or reasonably good discrimination and calibration. Interviewed patients (n = 29) and caregivers (n = 20) wanted prognostic information and considered that PiPS may aid communication. HPs (n = 32) found PiPS user-friendly and considered risk categories potentially helpful for decision-making. The need for a blood test for PiPS-B was considered a limitation.

Conclusions

PiPS-B risk categories are as accurate as AMPES made by experienced doctors and nurses. PiPS-A categories are less accurate. Patients, carers and HPs regard PiPS as potentially helpful in clinical practice.

Study registration

ISRCTN13688211.

Prognostic tools or clinical predictions: Which are better in palliative care?

PURPOSE

The Palliative Prognostic (PaP) score; Palliative Prognostic Index (PPI); Feliu Prognostic Nomogram (FPN) and Palliative Performance Scale (PPS) have all been proposed as prognostic tools for palliative cancer care. However, clinical judgement remains the principal way by which palliative care professionals determine prognoses and it is important that the performance of prognostic tools is compared against clinical predictions of survival (CPS).

METHODS

This was a multi-centre, cohort validation study of prognostic tools. Study participants were adults with advanced cancer receiving palliative care, with or without capacity to consent. Key prognostic data were collected at baseline, shortly after referral to palliative care services. CPS were obtained independently from a doctor and a nurse.

RESULTS

Prognostic data were collected on 1833 participants. All prognostic tools showed acceptable discrimination and calibration, but none showed superiority to CPS. Both PaP and CPS were equally able to accurately categorise patients according to their risk of dying within 30 days. There was no difference in performance between CPS and FPN at stratifying patients according to their risk of dying at 15, 30 or 60 days. PPI was significantly (p<0.001) worse than CPS at predicting which patients would survive for 3 or 6 weeks. PPS and CPS were both able to discriminate palliative care patients into multiple iso-prognostic groups.

CONCLUSIONS

Although four commonly used prognostic algorithms for palliative care generally showed good discrimination and calibration, none of them demonstrated superiority to CPS. Prognostic tools which are less accurate than CPS are of no clinical use. However, prognostic tools which perform similarly to CPS may have other advantages to recommend them for use in clinical practice (e.g. being more objective, more reproducible, acting as a second opinion or as an educational tool). Future studies should therefore assess the impact of prognostic tools on clinical practice and decision-making.

The Occurrence of Back Pain in School Children and Exposure to Risk Factors in Schools can they be Measured?

Back pain is a significant financial burden on industry and the economy, but more importantly it is the cause of suffering and disability to countless individuals. Therefore if the symptoms and risk factors of back pain could be identified at an early stage, the opportunities for remedial action would be improved. The study aims to identify the extent of back pain experienced by 11 to 14 year old school children, and establish the intensity, duration and frequency of exposure to mechanical risk factors present in schools. The following criteria were formulated to meet the study objectives, The method should record the intensity, duration, and frequency of the exposure, be continuous, unobtrusive, valid, reliable and feasible. None of the existing methods satisfied all the criteria, therefore new methods must be developed, or those methods which came closest to fulfilling the criteria, might be adapted to suit the participants and the research setting.

Potential Health Effects of Non-Keyboard Input Devices (NKID): Results of Manager and User Surveys

This paper reports the findings of two questionnaire surveys, the first distributed to IT and health and safety managers and the second to users of non-keyboard input devices (NKID). This is part of a two year study investigating the potential health effects of non-keyboard input devices.

Systems mapping workshops and their role in understanding medication errors in healthcare

Systems mapping workshops have been applied to the problem of medication errors in healthcare. The workshops were designed using experiential group work principles. They involved a range of stakeholders from within the health service as well as those who supply the health sector, including designers who may be able to enhance the safety of products and systems used in healthcare. Research has shown that the method encourages stakeholder participation, provides robust results within a limited time and enhances understanding across specialist interest groups. Additional, creative design workshops that considered the same topic showed significant promise in developing concepts from which potential solutions could be developed further.

Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

INTRODUCTION

Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes.

METHODS

A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement.

RESULTS

The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff's high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems.

CONCLUSIONS

That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

Patient safety, systems design and ergonomics

The complexity of the health care environments necessitates an holistic and systematic ergonomics approach to understand the potential for accidents and errors to occur. The health service is also a socio-technical system, and design needs must be met within this context. This paper aims to present the design challenges and emphasises the specialised needs of the health care sector, when dealing with patient safety. It also provides examples of approaches and methods that ergonomists can bring to help inform our knowledge of these systems and the potential towards improving their safety. Mapping workshops provide an example of such methods. Results from these are used to illustrate how the knowledge base required for better design requirements can be generated. The workshops were developed specifically to help improve the design of medication packaging and thereby reduce the probability of medication error. The issues raised are now the subject of further research, design requirements guidance and new design concepts. The paper illustrates the need to engage with the design community and, through the use of robust scientific methods, to generate appropriate design requirements.

Assessing investment in manual handling risk controls: a scoring system for use in observational studies

Most UK hospitals now have manual handling policies, but few studies have assessed their impact. To facilitate such research, a system for ranking the investment in manual handling risk controls was devised and applied to 109 acute hospitals in the UK. High scoring hospitals performed well on all aspects of manual handling risk management. Low scoring hospitals had a manual handling policy and recorded accidents and sickness absence, but had limited resource for expert manpower and equipment.

Manual handling risk controls in hospitals (MARCH): a cross-sectional survey of UK hospitals

Injury and ill health among healthcare staff associated with handling patients is an important area of risk for UK National Health Service (NHS) employers. Since the introduction of a specific legal duty to control this risk in 1992, many Trusts have developed manual handling risk management strategies. Anecdotally, however, practice varies between Trusts and there is no published description of common practice among NHS employers. The latter would be useful as a benchmark for risk managers. Therefore, we undertook a cross-sectional survey of 158 UK trusts (81% of those invited) using a structured interviewer-administered questionnaire to collect information about manual handling risk controls. Most Trusts had basic systems for risk management, including defined management accountability, written policies, provision of handling equipment, training, expert advice about manual handling and access to occupational health services and physiotherapy for injured employees. However, there was wide variation in important aspects, including the extent of expert manpower and criteria for referral to occupational health. Arrangements for monitoring risk controls were generally poor, and the variation in practice was a cause for concern. These data will help NHS employers by providing a benchmark against which to measure and develop risk management systems for manual handling. Future research should aim to develop standards through consensus opinion and ultimately evidence of effectiveness of risk controls.

Risk factors for incident neck and shoulder pain in hospital nurses

AIM

To assess the incidence and risk factors for neck and shoulder pain in nurses.

METHODS

A longitudinal study of neck and shoulder pain was carried out in female nurses at two hospitals in England. Personal and occupational risk factors were assessed at baseline. The self reported incidence of symptoms in the neck and shoulder region was ascertained at three-monthly intervals over two years. A Cox regression model was used to estimate hazard ratios (HRs) for incident neck/shoulder pain during follow up in nurses who had been pain free for at least one month at baseline.

RESULTS

The baseline response rate was 56%. Of 903 women who were pain free at baseline, 587 (65%) completed at least one follow up while still in the same job. During an average of 13 months, 34% of these (202 women) reported at least one episode of neck/shoulder pain. The strongest predictor of pain in the neck/shoulder was previous history of the symptom (HRs up to 3.3). For physical exposures at work, the highest risks (HRs up to 1.7) were associated with specific patient handling tasks that involved reaching, pushing, and pulling. Nurses who reported low mood or stress at baseline were more likely to develop neck/shoulder pain later (HR 1.5). Workplace psychosocial factors (including job demands, satisfaction, and control) were not associated with incident neck/shoulder symptoms.

CONCLUSIONS

Neck/shoulder pain is common among hospital nurses, and patient handling tasks that involve reaching and pulling are the most important target for risk reduction strategies.

Current techniques for assessing physical exposure to work-related musculoskeletal risks, with emphasis on posture-based methods

Physical exposure to risks for potential work-related musculoskeletal injuries has been assessed using a variety of methods, including pen and paper based observation methods, videotaping and computer-aided analysis, direct or instrumental techniques, and various approaches to self-report assessment. These methods are critically reviewed in this paper. The applications of these techniques in ergonomic and epidemiologic studies are considered, and their advantages and shortcomings are highlighted. Finally, a strategy that considers both the ergonomics experts' view and the practitioners' needs for developing a practical exposure assessment tool is then discussed.

Mattress evaluation--assessment of contact pressure, comfort and discomfort

The ergonomic evaluation of mattresses is largely ignored in the current literature. This is somewhat surprising given their importance and the length of time spent using them. This study considers some ergonomic aspects of their design, including body contact pressure and subjective ratings of comfort. Subjects (12 females) found all of the mattresses tested to be significantly more comfortable than an incompressible wooden reference surface. However, no significant differences were found between mattress types, which included orthopaedic and normal designs. Analysis of body contact pressures (measured at the shoulder, elbow, hip, knee and ankle) found few significant differences between experimental conditions. It is argued that limitations in the methodology may not take account of the change in surface area and anatomical sites of contact under different conditions of mattress compressibility. No significant associations were found between comfort ratings and peak body contact pressures. It seems likely that subjective ratings of mattress comfort are dependent on a wider set of factors than contact pressure alone, a finding reported elsewhere in studies of seating.

A questionnaire survey of the ergonomic problems associated with pipettes and their usage with specific reference to work-related upper limb disorders

This study has considered the ergonomic problems associated with the use of pipettes through a questionnaire study of users. The study groups comprised an exposed (i.e. pipette users) and a non-exposed (i.e. non-users) cohort. Eighty questionnaire responses were returned by pipette users and 85 by non-users from six organisations; a response rate of approximately 55% for each of the study cohorts. The reported occurrence of elbow and hand complaints [using the general version of the Nordic musculoskeltal questionnaire (Kuorinka et al, 1987)] was significantly higher in the pipette user population as compared to the control population. There is an increase in the percentage of those reporting hand complaints as the duration of the working period involving continuous use of pipettes increases. Almost 90% of subjects in the longest exposure group (continuous use for more than 60 min) reported hand complaints. Users identified a number of features which made plunger operated pipettes more difficult to use: almost all of the female population who reported difficulties identified plunger operation as a design deficiency. Users also identified features of the general working environment which made the pipetting tasks more difficult. The study concludes that a number of work-related factors may affect the efficiency and comfort of staff performing laboratory tasks using pipettes.

Upper limb disorders and work: the importance of physical and psychosocial factors

Upper limb, shoulder, and neck disorders cause both acute and chronic pain, as well as significant functional impairment. They impose a heavy financial burden on societies, industries, and individuals. Our understanding of the pathology of many of the disorders is poor. The epidemiological pursuit of causal relationships is hampered by the nature of the disorders and by the diverse and interactive exposures both at, and away from, the workplace. Current studies suggest that forceful, repetitive manual work, along with prolonged static loading and exposure to vibration are established areas of risk. Much less is known about the possible contribution of psychological factors. Perception of work characteristics, for example, low decision latitude and lack of social support, appear to show increased associations with a number of upper limb disorders, although mechanisms to explain these observations are still broadly theoretical. Research into individual factors is limited, but age and gender both appear to be important.

Musculoskeletal Disorders: Work-related Risk Factors and Prevention

Work-related musculoskeletal disorders cause chronic pain and functional impairment, impose heavy costs on society, and reduce productivity. In this position paper from the Scientific Committee for Musculoskeletal Disorders of the ICOH, the most important risk factors at work are described. Work-related musculoskeletal disorders have high incidences and prevalences among workers who are exposed to manual handling, repetitive and static work, vibrations, and poor psychological and social conditions. The application of ergonomic principles in the workplace is the best method for prevention. International organizations should develop standards, common classifications, and terminologies. Surveillance systems should be further developed nationally and in workplaces, and more effort should be directed to information dissemination, education, and training.

Effect of inhaled 3% CO2 on Cheyne-Stokes respiration in congestive heart failure

Cheyne-Stokes respiration (CSR) in severe stable congestive heart failure (CHF) may be associated with significant nocturnal arterial oxygen desaturation and sleep disruption. Previous investigations of inhaled CO2 in CSR have been uncontrolled and of short duration, sleep has not been monitored electroencephalographically, and most patients studied have had neurological disease with or without cardiac disease. The purpose of our study was to document the effects of inhaled CO2 on CSR in patients with severe stable CHF (left ventricular ejection fraction < 35% and NYHA class 3 or 4 dyspnea) in controlled all-night polysomnographic studies. Six patients were studied for 3 nights and days: adaptation, control and inhalation of CO2. These patients received a constant F1CO2 = 0.03 in air (with a 4-5 mm Hg increase in PaCO2) on night 3. This caused virtual abolition of CSR as reflected by CSR duration/total sleep time (62-2.2%; p = 0.0012) and CSR duration/nonrapid eye movement (NREM) sleep time (73-2.4%; p = 0.00064), and NREM apnea index was reduced from 33.5 to zero (p = 0.026). The apparatus used to accurately control F1CO2, however, was intrusive and some features of sleep structure such as sleep latency were adversely affected. We conclude that inhalation of CO2 with a constant F1CO2 = 0.03 virtually eradicates CSR in all-night polysomnographically monitored studies in patients with severe stable CHF. The clinical significance of these findings remains to be determined.

Nocturnal cluster headache associated with sleep apnea. A case report

We describe a 49-year-old man with chronic cluster headache unresponsive to all medications. Following investigation in the sleep lab he was found to have obstructive sleep apnea (OSA) with associated oxygen desaturations during rapid eye movement (REM) sleep. He awakened during one of these episodes with a typical headache. Treatment with nasal CPAP abolished his OSA and desaturations, and largely abolished his headaches. He then developed central apneas during REM sleep. Further treatment with BiPAP, with a set backup rate, abolished both the apneas and the headaches. We conclude that there may be a link between nocturnal cluster headaches and sleep apnea.

A conceptual model for work-related neck and upper-limb musculoskeletal disorders

This paper presents a conceptual model for the pathogenesis of work-related musculoskeletal disorders. The model contains sets of cascading exposure, dose, capacity, and response variables, such that response at one level can act as dose at the next. Response to one or more doses can diminish or increase the capacity for responding to successive doses. The model is used as a framework for discussing the development of work-related muscle, tendon, and nerve disorders. It is intended as a beginning, to be modified to explain new findings as they become available. In research, it can help to identify areas needing additional data for the development and expression of work-related musculoskeletal disorders. Researchers can use it to design laboratory and field studies. In practice, it demonstrates the relationship between common exposure factors and different responses. This information can be used to evaluate and design jobs for the prevention of work-related musculoskeletal disorders.

The effect of short-term nasal CPAP on Cheyne-Stokes respiration in congestive heart failure

We studied male patients (BMI = 27.6 +/- 3.4, mean +/- SD), mean age 54.1 +/- 8.9 years, with stable NYHA class 3-4 congestive heart failure (CHF) (LVEF = 24.3 +/- 11.5 percent) and normal daytime arterial blood gas values. These patients underwent three consecutive nights of full polysomnography; adaptation, control, and treatment with nasal CPAP. Each night's study was followed during the day by cognitive testing and multiple sleep latency tests (MSLT). The purpose of the study was to document the effect of nasal CPAP on these variables. The main findings of the study showed no significant differences between control and treatment nights with respect to the amount of Cheyne-Stokes respiration (CSR) observed, the nocturnal oxygenation, or sleep quality. Both subjective and objective measures of sleep quality showed no change from night to night. In addition, the degree of cognitive functioning and daytime sleepiness (as measured by MSLT) showed no significant differences between control and treatment nights. We conclude that short-term treatment with nasal CPAP in patients with CHF does not improve either CSR, nocturnal oxygenation, or sleep quality. Furthermore, most of our patients did not tolerate nasal CPAP therapy.

Nasal CPAP reduces gastroesophageal reflux in obstructive sleep apnea syndrome

Anecdotal reports suggest that obstructive sleep apnea syndrome (OSAS) patients may suffer from frequent nocturnal gastroesophageal reflux (GER) and that nasal continuous positive airway pressure may be an effective form of antireflux therapy in this population. To confirm these clinical impressions, we performed two consecutive days of 24-h esophageal pH monitoring, nocturnal esophageal pressure recording, and polysomnography on six OSAS patients complaining of regular nocturnal GER. On night one, the patients were untreated. Five of six subjects had abnormal amounts of nocturnal GER. Arousal, movement and swallowing were more frequent (p less than 0.043) and nadir intrathoracic pressure lower (p less than 0.005) in the 30 s prior to precipitous drops in esophageal pH (greater than or equal to 2 pH units) than during random control periods. A direct association between obstructive apneas and GER was not identified. On night two, nasal CPAP was administered and successfully treated apnea in five of six subjects. In these patients, there was also dramatic reduction in GER frequency and duration on CPAP. The mean percentage of time pH less than 4 dropped from 6.3 +/- 2.1 to 0.1 +/- 0.1 percent (p less than 0.025). We believe that OSAS may predispose to nocturnal GER by lowering intrathoracic pressure and increasing arousal and movement frequency. Nasal CPAP can correct these predisposing factors and reduce GER.

The contribution of ergonomics to the rehabilitation of back pain patients

The role of ergonomics in existing rehabilitation programmes is considered through a review of studies undertaken both in the United Kingdom and elsewhere. In general, little consideration has been paid to what the rehabilitees are undertaking in their work or to how intervention at the workplace might be implemented. This occurs despite the evidence that ergonomic advice has been shown to be beneficial. Current approaches to rehabilitation stress the need for the patient to resume normal activities as soon as possible. It seems also prudent to identify ergonomic mismatches in the workplace as soon as possible during rehabilitation in order to reduce the number of repeat attacks. A number of examples have been presented which illustrate how ergonomics can help, and the dangers of inappropriate or delayed interventions. The occupational physician is considered to be a key individual in initiating ergonomic interventions. This is in keeping with the International Labour Office model of occupational health services.

Musculoskeletal disorders of the upper extremities: the use of epidemiologic approaches in industrial settings

This article illustrates the use of a simple questionnaire in identifying those sections of a work force at risk for musculoskeletal disorders and chronic discomfort of the upper extremities. Two research studies are described. The first, conducted in a chicken-processing factory, illustrates the use of self-administered questionnaires in the assessment of the musculoskeletal health of the work force and in the identification of groups of workers who may be at increased risk and for whom ergonomic reappraisal of the tasks performed may be beneficial. A second study of retail trade staff suggests that chronic musculoskeletal discomfort is widespread. The article further considers the importance of such data for those persons concerned with the allocation of health care. The need to consider the broader spectrum of musculoskeletal health from discomfort to clinical disorder is stressed.

Epidemiological aspects of back pain within the nursing profession

This paper describes a number of epidemiological findings relating to the size of the back pain problem within nursing, its distribution across nursing specialties and the comparison of these data with other occupational groups. The extent of the problem within the nursing profession has been estimated through a number of research studies. Unfortunately these studies cannot be easily compared because of differing methodologies and criteria for identifying those with back pain and inconsistent use of prevalence and incidence data. Results from a study of 3912 NHS nurses are considered in detail as is the extent to which back pain is a contributory factor in the decision of nurses to leave the profession. The use of epidemiological methods to identify factors associated with the occurrence of the disorder has also been discussed, although the difficulty of quantifying exposure for factors such as postural requirements necessitates caution in their interpretation.