Telehealth in cancer care during the COVID-19 pandemic

INTRODUCTION

The Victorian COVID-19 Cancer Network (VCCN) Telehealth Expert Working Group aimed to evaluate the telehealth (TH) experience for cancer patients, carers and clinicians with the rapid uptake of TH in early 2020 during the COVID-19 pandemic.

METHODS

We conducted a prospective multi-centre cross-sectional survey involving eight Victorian regional and metropolitan cancer services and three consumer advocacy groups. Patients or their carers and clinicians who had TH consultations between 1 July 2020 and 31 December 2020 were invited to participate in patient and clinician surveys, respectively. These surveys were opened from September to December 2020.

RESULTS

The acceptability of TH via both video (82.9%) and phone (70.4%) were high though acceptability appeared to decrease in older phone TH users. Video was associated with higher satisfaction compared to phone (87.1% vs 79.7%) even though phone was more commonly used. Various themes from the qualitative surveys highlighted barriers and enablers to rapid TH implementation.

DISCUSSION

The high TH acceptability supports this as a safe and effective strategy for continued care and should persist beyond the pandemic environment, where patient preferences are considered and clinically appropriate. Ongoing support to health services for infrastructure and resources, as well as expansion of reimbursement eligibility criteria for patients and health professionals, including allied health and nursing, are crucial for sustainability.

Hypercapnia is not excluded by normoxia in neuromuscular disease patients: implications for oximetry

Background

Pulse oximetry is widely used in the assessment of chronic respiratory failure in neuromuscular disease (NMD) patients. Chronic respiratory failure is the major cause of morbidity and mortality, necessitating early diagnosis and intervention. Guidelines suggest that an arterial blood gas (ABG) measurement is indicated if oxygen saturation (S pO2 ) is ≤94% in the absence of lung disease. However, hypercapnia with normoxia (S pO2 ≥95%) has been observed on ABGs of patients with NMD, in particular those with motor neurone disease.

Methods

A single-centre retrospective audit of room-air ABGs in stable hypercapnic chronic respiratory failure patients from 1990 to 2020 was performed. Patients with parenchymal lung disease were excluded. Patients were grouped into three main categories: non-NMD, other NMD and motor neurone disease.

Findings

297 ABGs with hypercapnia from 180 patients with extrinsic restrictive lung disease were analysed. No patients with non-NMD, 54% of patients with other NMD and 36% of motor neurone disease patients demonstrated hypercapnia with normoxia (Chi-squared 61.33; p<0.001). The potential mechanism is proposed to be a difference in calculated respiratory quotient. If the alveolar-arterial gradient is assumed to be normal, the calculated respiratory quotient was significantly higher in motor neurone disease patients and other NMD patients compared with non-NMD patients (estimated marginal mean 0.99, 95% CI 0.94-1.03; 0.86 0.76-0.96; 0.73, 0.63-0.83, respectively; p<0.001) by mixed-model analysis.

Interpretation

Hypercapnia is not excluded with normal oximetry in NMD patients and may be due to an elevated respiratory quotient. This has implications in the diagnosis and monitoring of respiratory insufficiency in NMD patients with oximetry alone.

Standards for the care of people with cystic fibrosis (CF); recognising and addressing CF health issues

This is the third in a series of four papers updating the European Cystic Fibrosis Society (ECFS) standards for the care of people with CF. This paper focuses on recognising and addressing CF health issues. The guidance was produced with wide stakeholder engagement, including people from the CF community, using an evidence-based framework. Authors contributed sections, and summary statements which were reviewed by a Delphi consultation. Monitoring and treating airway infection, inflammation and pulmonary exacerbations remains important, despite the widespread availability of CFTR modulators and their accompanying health improvements. Extrapulmonary CF-specific health issues persist, such as diabetes, liver disease, bone disease, stones and other renal issues, and intestinal obstruction. These health issues require multidisciplinary care with input from the relevant specialists. Cancer is more common in people with CF compared to the general population, and requires regular screening. The CF life journey requires mental and emotional adaptation to psychosocial and physical challenges, with support from the CF team and the CF psychologist. This is particularly important when life gets challenging, with disease progression requiring increased treatments, breathing support and potentially transplantation. Planning for end of life remains a necessary aspect of care and should be discussed openly, honestly, with sensitivity and compassion for the person with CF and their family. CF teams should proactively recognise and address CF-specific health issues, and support mental and emotional wellbeing while accompanying people with CF and their families on their life journey.

What Impact Does Participation in a Communication Skills Training Program Have on Health Professionals' Communication Behaviors: Findings from a Qualitative Study

Communication skills training can enhance health professionals' knowledge and repertoire of effective communication practices. This paper describes the conceptual model underlying a 3-day retreat communication skills training program, methods used for training, and participant perception of outcomes from the training using qualitative interviews. Repeated qualitative telephone interviews (approximately 6 months apart) with participants of a 3-day Clinical Consultation Skills Retreat. Fourteen participants (70% response, 57% doctors) took part at Time 1, with 12 participating at Time 2. Semi-structured interviews were recorded and transcribed, and directional content analysis was conducted to assess themes in areas of key learnings, implementation of skills, and barriers. The training was received very positively with participants valuing the small group learning, role play, and facilitator skills. Key learnings were grouped into two themes: (i) tips and strategies to use in clinical practice and (ii) communication frameworks/methods, with the second theme reflecting an awareness of different communication styles. Most participants had tried to implement their new skills, with implementation reported as a more deliberate activity at T1 than at T2. Those implementing the new skills noted more open conversations with patients. Practical barriers of lack of time and expectations of others were mentioned more often at T2. A 3-day retreat-based communication training program was positively received and had a positive impact on the use of new communication skills. While further work is needed to determine whether effects of training are evidenced in objective clinical behaviors, the positive longer-term benefits found suggest this work would be worthwhile.

Non-invasive ventilation for people with neuromuscular disorders in Australia and New Zealand: a qualitative study of clinician perspectives

OBJECTIVES

To explore the experiences of Australian and New Zealand clinicians with respect to care pathways, their awareness and use of non-invasive ventilation guidelines, and their perspectives on delivering quality non-invasive ventilation services to people with neuromuscular disorders.

DESIGN, SETTING, PARTICIPANTS

Qualitative study; semi-structured focus groups and individual interviews with Australian and New Zealand clinicians who provide non-invasive ventilation services to people with neuromuscular disorders, recruited from participants at a 2017 sleep medicine conference. Interviews were conducted during 1 October 2017 - 31 May 2018.

MAIN OUTCOME MEASURES

Major themes identified by an iterative, semantic, and inductive analysis.

RESULTS

A total of 28 participants attended the four focus group sessions and five individual interviews; fourteen each from New Zealand and Australia, seventeen women and eleven men, eighteen physicians and ten other clinicians. Two major themes were identified: decision making for current practice, and resource constraints. Participants noted variable use of clinical guidelines and limited training to meet the needs of people with neuromuscular disorders who require non-invasive ventilation. They described a lack of dedicated funding, unstructured care pathways, equipment supply levels that do not meet need, low staff-to-patient ratios and staff shortages, and the inability to deliver quality multidisciplinary care. The need for clinical guidelines and service specifications was highlighted as requisite for reducing variation in clinical care.

CONCLUSIONS

Systemic factors influence the needs-based provision of non-invasive ventilation for people with neuromuscular disorders. Development of clinical guidelines for Australia and New Zealand, dedicated funding for respiratory services for people with neuromuscular disorders, and specialist clinician training are important for equitable and high quality non-invasive ventilation care.

Screening and treatment of pre-bariatric surgical patients with obesity related sleep disordered breathing

BACKGROUND

There is a significant burden of sleep disordered breathing (SDB) in patients living with severe and complex obesity undergoing pre-bariatric surgery assessment. This longitudinal observational study evaluated the burden of obesity hypoventilation syndrome (OHS) in this cohort of patients and the therapeutic compliance of patients commenced on positive airway pressure treatment.

METHODS

All pre-bariatric surgery patients referred to the sleep clinic for review after an abnormal screening study between 2018 and 2022 were included. We collected data on their sleep study results, anthropometrics, co-morbid medical conditions, clinical observations, spirometry and arterial blood gas (ABG). Patients commenced on therapy were followed-up longitudinally and compliance data collected via remote monitoring.

RESULTS

A total of 116 patients were included [age: mean ± standard deviation (SD) 48.8±10.8 years; body mass index (BMI) 49.2±8.5 kg/m2; Epworth Sleepiness Scale (ESS) 8.7±5.1 points]. Fifteen patients (12.9% of cohort) were diagnosed with hypercapnic respiratory failure (pH 7.40±0.02; pO2 11.00±1.04 kPa; pCO2 6.15±0.08 kPa). Compared to eucapnic obstructive sleep apnoea (OSA) patients, they were older (51.1 vs. 48.5 years; P=0.311), had a higher BMI (51.5 vs. 48.9 kg/m2; P=0.266), more likely to be female (66.7% vs. 53.5%; P=0.275) and had a higher ESS score (10.4 vs. 8.5 points; P=0.177). On binomial regression analysis insulin dependent diabetes was the only patient characteristic of significance with prevalence increased in patients with OHS (26.7% vs. 8.9%; P=0.042). Forced vital capacity (FVC) and oxygen saturation (SpO2) cut-offs demonstrated high specificity (96.8%) but low sensitivity (13.3%) to diagnosed hypercapnia. Fifty percent of the patients with hypercapnia required bi-level ventilation. On follow-up 44.9% of patients were compliant with therapy (>4 hours usage/night).

CONCLUSIONS

In minimally symptomatic patients living with severe and complex obesity who have an abnormal overnight oximetry, over 1 in 10 demonstrated chronic respiratory failure. Clinic spirometry and daytime SpO2 excluded those with hypercapnia. Overall adherence to prescribed therapy is low. Screening, appropriate pre-operative optimisation and peri-operative planning are important in preventing complications in this patient cohort.

Drivers and barriers to COVID-19 vaccination in Australians with cancer

PURPOSE

To understand the drivers and barriers for COVID-19 vaccination in people with cancer in Australia.

METHODS

A cross-sectional, online survey, distributed nationally following the establishment of community vaccination programs, wider availability of COVID-19 vaccines and emergence of new variants. Consisting of 21 questions, the survey was designed to determine the behavioural and social drivers of vaccination, participant demographics, underlying disease and treatment, and vaccination status. It was open from the 10th of August 2021 to the 7th of September 2021, recruiting people who had a previous history of cancer (diagnosed or treated in the past 5 years).

RESULTS

A total of 1506 responses were included in the final analysis. Overall, 87.8% reported a positive attitude toward vaccination and 83.1% had received at least one dose of a COVID-19 vaccine. Perceived risk of COVID-19 infection (for self and others) and engagement with a trusted health professional were key drivers for vaccination, while concerns about vaccine development, safety and side effects were barriers. Concerns about vaccination mostly stemmed from a place of misinformation, rather than a broader disregard of vaccines. Just over a third (497, 34.3%) of the respondents were concerned that the vaccine would impact their cancer treatment.

CONCLUSION

Overall, participants had positive attitudes toward COVID-19 vaccination and thought it was safe. Findings supported the role of health professionals and cancer organisations as trusted information providers and calls for more, credible information to help people with cancer make informed decisions about the COVID-19 vaccine.

Return to work in head and neck cancer survivors: a systematic review

PURPOSE

Cancer survivors face higher rates of unemployment compared with individuals without a history of cancer. Compared to other cancer types, head and neck cancer (HNC) survivors face unique disease and treatment-specific issues that may limit return to work (RTW). This review aimed to determine employment outcomes of HNC survivors post-treatment and identify factors associated with RTW.

METHODS

A systematic search was conducted in MEDLINE, CINAHL and PsycINFO in December 2021. Inclusion criteria included adults (≥ 18 years); completed treatment for HNC; data available on RTW post-treatment. Both quantitative and qualitative studies were considered. Studies were critically appraised and data synthesised narratively.

RESULTS

Twenty-nine publications were included: 22 quantitative, four qualitative and three mixed methods. The proportion of HNC survivors who RTW ranged from 32 to 90%, with participants taking 3.6-11 months to RTW. Working in a professional role and having a supportive work environment were positively associated with RTW.

CONCLUSIONS

The proportion of HNC survivors who RTW varies significantly which may be due to the heterogeneity between the studies including difference in clinical characteristics of the participants and/or sample size. Future studies that are longitudinal, adequately powered and measure a range of clinical and demographic variables are needed to better understand the RTW experience and assist development of effective RTW strategies.

IMPLICATIONS FOR CANCER SURVIVORS

This review suggests potential areas for intervention, including enhanced symptom management and engaging with employers to foster supportive work environments to support RTW of HNC survivors.

A pilot randomized trial comparing CPAP vs bilevel PAP spontaneous mode in the treatment of hypoventilation disorder in patients with obesity and obstructive airway disease

STUDY OBJECTIVES

Both obesity and airways disease can lead to chronic hypercapnic respiratory failure, which can be managed with positive airway pressure (PAP) therapy. The efficacy of PAP has been studied in obesity hypoventilation syndrome as well as in chronic hypercapnic chronic obstructive pulmonary disease patients, but not in patients where both obesity and airway obstruction coexist. This pilot study aims to compare the efficacy of continuous positive airway pressure vs bilevel positive airway pressure spontaneous mode in the treatment of hypoventilation disorder with obesity and obstructive airways disease.

METHODS

We sequentially screened PAP-naïve patients with stable chronic hypercapnic respiratory failure (PaCO₂ > 45 mm Hg), obesity (body mass index > 30 kg/m²), and obstructive airways disease. Participants were randomized to continuous positive airway pressure or bilevel positive airway pressure spontaneous mode treatment for 3 months. Participants were blinded to their PAP allocation. Change in awake PaCO₂ was the primary endpoint. Secondary endpoints included change in lung function, daytime sleepiness, sleep quality, quality of life, PAP adherence, and neurocognitive function.

RESULTS

A total of 32 individuals were randomized (mean ± SD: age 61 ± 11 years, body mass index 43 ± 7 kg/m², PaCO₂ 54 ± 7 mm Hg, forced expiratory volume in 1 second 1.4 ± 0.6L, apnea-hypopnea index 59 ± 35 events/h). Sixteen participants in each PAP group were analyzed. Bilevel positive airway pressure yielded a greater improvement in PaCO₂ compared to continuous positive airway pressure (9.4 mm Hg, 95% confidence interval, 4.3-15 mm Hg). There were no significant differences in PAP adherence, sleepiness, sleep quality, or neurocognitive function between the two therapies.

CONCLUSIONS

Although both PAP modalities improved hypercapnic respiratory failure in this group of individuals, bilevel positive airway pressure spontaneous mode showed greater efficacy in reducing PaCO₂.

CLINICAL TRIAL REGISTRATION

Registry: Australian New Zealand Clinical Trials Registry; Name: Nocturnal ventilatory support in obesity hypoventilation syndrome; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12605000096651; Identifier: ACTRN12605000096651.

CITATION

Zheng Y, Yee BJ, Wong K, Grunstein R, Piper A. A pilot randomized trial comparing CPAP vs bilevel PAP spontaneous mode in the treatment of hypoventilation disorder in patients with obesity and obstructive airway disease. J Clin Sleep Med. 2022;18(1):99-107.

Telehealth in cancer care: during and beyond the COVID-19 pandemic

The COVID‐19 pandemic has precipitated the rapid uptake of telehealth in cancer care and in other fields. Many of the changes made in routine clinical practice could be embedded beyond the duration of the pandemic. This is intended as a practical guide to cancer clinicians and others in establishing and improving the quality of consultations performed by telehealth.

Facilitators and barriers to shared primary and specialist cancer care: a systematic review

PURPOSE

To care for the growing population of cancer survivors, health services worldwide must reconsider how to deliver care to people living with and beyond a cancer diagnosis. Shared care, defined as cancer care that is shared between specialist and primary care providers, is one model that has been investigated; however, practical guidance to support implementation is lacking. This systematic review aimed to explore facilitators and barriers to implementing shared cancer care and to develop practice and policy recommendations to support implementation.

METHODS

A systematic literature search was conducted in June 2019 across MEDLINE, Embase, Emcare, and PsycINFO databases. Quantitative and qualitative data relevant to the review question were extracted and synthesized following a mixed methods approach.

RESULTS

Thirteen papers were included in the review, 10 qualitative and three quantitative. Included articles were from Australia (n = 8), the USA (n = 3), and one each from the UK and the Netherlands. Sixteen themes were developed under four categories of patient, healthcare professional, process, and policy factors. Key themes included the perceived need for primary care provider training, having clearly defined roles for each healthcare provider, providing general practitioners with diagnostic and treatment summaries, as well as protocols or guidelines for follow-up care, ensuring rapid and accurate communication between providers, utilizing electronic medical records and survivorship care plans as communication tools, and developing consistent policy to reduce fragmentation across services.

CONCLUSION

Recommendations for practice and policy were generated based on review findings that may support broader implementation of shared cancer care.

Clinical placement program in cancer survivorship for primary care providers 2017-2019

PURPOSE

The growing population of cancer survivors indicates an increasing role for primary care practitioners (PCPs). Building on two pilot initiatives, we sought to demonstrate feasibility of a state-wide program of short observational placements for PCPs and identify changes in knowledge and confidence to deliver survivorship care.

METHODS

Placements were offered at hospitals with oncology departments across Victoria, Australia. Participants attended a multidisciplinary team meeting and a minimum of two outpatient clinics. Participation targets included at least 70 general practitioners (GPs), 15 practice nurses (PNs) and 15 allied health professionals (AHPs). Mixed methods evaluation included pre- and post-placement surveys.

RESULTS

The program was successfully delivered across eight sites; 148 PCPs enrolled, 58 PCPs withdrew and ultimately 90 PCPs (53 GPs, 15 PNs and 22 AHPs) completed a total of 224 placements. Ninety-two percent (81/89) of participants reported increased knowledge and confidence regarding survivorship care, 87% (78/89) agreed they had opportunities to enhance clinical relationships with specialist teams and 93% (83/89) agreed the program was relevant to their practice.

CONCLUSIONS

Building on previous pilots, this third iteration demonstrated the program is sustainable across multiple health services and geographical locations. PCPs reported increased knowledge and confidence regarding survivorship care and that the program provided opportunities to strengthen relationships between primary care and cancer specialists.

IMPLICATIONS FOR CANCER SURVIVORS

A placement program within tertiary cancer centres offers a feasible, transferable model to build PCP knowledge and confidence to deliver appropriate and quality survivorship care.

Return to Work in Survivors of Human Papillomavirus-Associated Oropharyngeal Cancer: An Australian Experience

PURPOSE

Human papillomavirus (HPV)-associated oropharyngeal cancer (OPC) commonly affects people of working age, yet there is limited data regarding the return-to-work experience in this cohort. This study aimed to investigate the proportion of survivors currently working after completion of radiation therapy and to explore potential facilitators and barriers to working after treatment.

METHODS

A cross-sectional, single-institutional study was undertaken at the Peter MacCallum Cancer Centre, a comprehensive cancer center in Melbourne, Victoria, Australia. Eligible participants were 18 to 65 years old at diagnosis, were employed at or within the 3 months before diagnosis, and had completed curative treatment for HPV-associated OPC ≥4 months before enrollment. Participants completed a paper-based survey to assess baseline demographics, employment status, and quality of life (QOL; Functional Assessment of Cancer Therapy Head and Neck). Open-ended questions explored factors affecting return to work. Associations between current employment status and various disease, treatment, and demographic variables and with QOL were examined. Free-text items were analyzed by summarizing content analysis.

RESULTS

Of 93 participants approached, 68 responded (73.1%). Mean age was 54.1 years (range, 39-64 years), and 89.7% were male. Most participants (67.6%) had stage II disease and were treated with chemoradiation (85.3%). Mean time after treatment was 2.6 years (range, 0.3-9.1 years). Fifty-eight of 68 participants (85.3%) were working at enrollment; median time to return to work was 6.0 months (interquartile range, 4-10 months); 45 (77.6%) were in the same role and 35 (60.3%) worked the same number of hours. Ten participants were not working, 3 had retired, 5 reported persistent and significant treatment toxicity preventing employment. Survivors currently working reported higher physical, functional, and global QOL scores. Access to leave and support from treating doctors were facilitators for return to work, whereas fatigue was frequently reported as a barrier to returning to work.

CONCLUSION

With time, the majority of participants with HPV-associated OPC will return to work after radiation therapy. Attention to symptom management and support from the workplace may enable more successful return to work.

Identifying the most prevalent unmet needs of cancer survivors in Australia: A systematic review

Understanding the unmet needs of cancer survivors is crucial to inform health service planning and optimize survivorship care. This systematic review sought to identify the most prevalent unmet needs of cancer survivors in Australia, and to determine personal, disease, and treatment-related variables correlated with unmet needs. Seventeen studies were included in the review. Substantial heterogeneity across the included studies precluded statistical pooling of the data; narrative synthesis and vote counting were used to synthesize results. Unmet needs were ranked by the number of endorsements (n) each item received. The most frequently reported unmet needs of Australian cancer survivors are for help with psychosocial issues, including fear of cancer recurrence (n = 14; 14-42%), uncertainty about the future (n = 9; 12-26%), worry about partners, friends, and families (n = 8; 12-26%), help to reduce stress (n = 8; 12-34%), and sexual changes (n = 7; 11-29%). Survivors also needed more help with physical issues, including fatigue (n = 7; 10-27%) and usual activities (n = 6; 13-27%), and expressed supportive care unmet needs, including for affordable hospital car parking (n = 7; 12-26%), information about available services (n = 7; 11-33%), and peer support (n = 6; 13-26%). Anxiety, depression, and lower overall and physical quality of life were significantly correlated with greater unmet needs, as were younger age and more advanced disease.

Obesity Hypoventilation Syndrome: Early Detection of Nocturnal-Only Hypercapnia in an Obese Population

STUDY OBJECTIVES

Hypoventilation in obesity is now divided into five stages; stage 0 (pure obstructive sleep apnea; OSA), stages I/II (obesity-related sleep hypoventilation; ORSH) and stages III/IV (awake hypercapnia, obesity hypoventilation syndrome; OHS). Hypercapnia during the day may be preceded by hypoventilation during sleep. The goal of this study was to determine the prevalence and to identify simple clinical measures that predict stages I/II ORSH. The effect of supine positioning on selected clinical measures was also evaluated.

METHODS

Ninety-four patients with a body mass index > 40 kg/m² and a spirometric ratio > 0.7 were randomized to begin testing either in the supine or upright seated position on the day of their diagnostic sleep study. Arterialized capillary blood gases were measured in both positions. Oxygen saturation measured by pulse oximetry was also obtained while awake. Transcutaneous CO₂ monitoring was performed during overnight polysomnography.

RESULTS

Stages I/II ORSH had a prevalence of 19% in an outpatient tertiary hospital setting compared with 61%, 17%, and 3% for stages 0, III/IV, and no sleep-disordered breathing respectively. Predictors for sleep hypoventilation in this group were an awake oxygen saturation of ≤ 93% (sensitivity 39%, specificity 98%, positive likelihood ratio of 22) and a partial pressure of carbon dioxide ≥ 45 mmHg (sensitivity 44%, specificity 98%, positive likelihood ratio of 24) measured in the supine position.

CONCLUSIONS

ORSH has a similar prevalence to OHS. Awake oxygen saturation and partial pressure of carbon dioxide performed in the supine position may help predict obese patients with sleep hypoventilation without awake hypercapnia.

COMMENTARY

A commentary on this article appears in this issue on page 1455.

CLINICAL TRIAL REGISTRATION

Registry: Australian New Zealand Clinical Trials Registry, Identifier: ACTRN 12615000135516, URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367493&isReview=true, Title: A cross-sectional study to identify obese patients who are at risk for developing obesity hypoventilation syndrome (OHS) by investigating the relationship between daytime measures (including supine hypercapnia, distribution of body fat and lung volumes) with the presence of hypoventilation during sleep.

Role of the vacuolar ATPase in the Alphavirus replication cycle

We have shown that Alphaviruses can enter cells by direct penetration at the plasma membrane (R. Vancini, G. Wang, D. Ferreira, R. Hernandez, and D. Brown, J Virol, 87:4352–4359, 2013). Direct penetration removes the requirement for receptor-mediated endocytosis exposure to low pH and membrane fusion in the process of RNA entry. Endosomal pH as well as the pH of the cell cytoplasm is maintained by the activity of the vacuolar ATPase (V-ATPase). Bafilomycin is a specific inhibitor of V-ATPase. To characterize the roll of the V-ATPase in viral replication we generated a Bafilomycin A1(BAF) resistant mutant of Sindbis virus (BRSV). BRSV produced mature virus and virus RNA in greater amounts than parent virus in BAF-treated cells. Sequence analysis revealed mutations in the E2 glycoprotein, T15I/Y18H, were responsible for the phenotype. These results show that a functional V-ATPase is required for efficient virus RNA synthesis and virus maturation in Alphavirus infection.

A rapid review of needs assessment tools for post-treatment cancer survivors

Relevant, comprehensive and psychometrically rigorous needs assessment tools are needed to ensure appropriate care is delivered to cancer survivors who have completed treatment. The aim of this rapid review was to identify and describe needs assessment tools that are used in cancer survivors post-treatment, assess their psychometric properties and describe their use in clinical care. The electronic databases Medline, Cochrane Library, CINAHL and PsycINFO were searched. Six studies were identified that described five needs assessment tools used in cancer survivors post-treatment. None of these tools covered all domains of unmet need nor demonstrated adequate evidence of all recommended criteria of validity and reliability. Few had been evaluated for use in a clinical environment. Out of the five tools, the Survivor Unmet Needs Survey (SUNS) showed the strongest psychometric properties. There is little empirical evidence available to guide recommendations on the most appropriate process of conducting needs assessment with cancer survivors once they have completed treatment.

A multisite cancer survivorship clinical placement program for primary care practitioners (PCPs)

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Background: Following a successful pilot, a survivorship placement program for PCPs (general practitioners (GPs) and general practice nurses (GPN)) was refined and extended to additional sites. The program aimed to facilitate collaborative learning, with an emphasis on the post treatment phase. Objectives were to improve clinical knowledge of the health needs of survivors and enhance confidence with shared care (ShC). Methods: Four cancer centres participated. Each received an implementation toolkit and videos, developed to promote the role of PCPs in survivorship care. PCPs received pre-placement materials and attended multidisciplinary meetings and specialist clinics for 10 hours. PCPs and hospital-based specialists completed pre and post-placement surveys, assessing perceptions of the program, perceived barriers to ShC, perceived knowledge regarding survivorship issues (9 items), confidence managing survivorship issues (8 items) and with ShC (1). Results: Forty-seven PCPs (32 GPs, 15 GPN) completed placements and pre and post-placement surveys. Median scores for all confidence items and 8 of 9 knowledge items increased; 1 remained the same. Matching of pre and post responses assessed individual changes. Across the 9 knowledge items, 57-86% of PCPs reported an increase; for the 9 confidence items, 68-89% reported improvement (no decreases). Data from specialists is currently available from 1 site; 16 specialists completed the pre- and 14 (88%) the post-survey. The majority of median knowledge and confidence scores were high and remained unchanged. Specialists (n=14, 88%) and PCPs (n=37, 76%) identified the biggest barrier to ShC as ‘lack of systems to support transition of care.’ All PCPs and specialists agreed/strongly agreed the ‘program was relevant to my clinical practice.’ Conclusions: The program enhanced PCP’s knowledge and confidence regarding survivorship care, was highly regarded and identified perceived barriers to ShC.