Active Treatment to Survivorship Care: A Mixed-Methods Study Exploring Resource Needs and Preferences of Young Adult Cancer Survivors in Transition

Purpose: The purpose of this study was to identify resource needs and preferences of young adult cancer survivors (YAs) during the transition from active treatment to survivorship care to inform tailored care tools to support YAs during this period. Methods: A mixed methods study following a sequential explanatory approach was conducted among YAs between the ages of 15 and 39. Online surveys were distributed to assess participant information and resource needs, and responses were further explored during virtual focus group and interview discussions. Frequencies and proportions were calculated to identify quantitative resource needs, and a descriptive qualitative approach was used to gather and analyze qualitative data. Results: Thirty-one participants completed the online surveys, and 27 participated in qualitative data collection. The top resource needs identified in the surveys and discussed in focus groups and interviews were (1) fear of recurrence, (2) sleep and fatigue, (3) anxiety, (4) nutrition, (5) physical activity, and (6) finances. Emergent themes identified during transcript analyses included the need for (1) tailored, customizable resources, (2) connection with other survivors, (3) tools to guide conversations about cancer, (4) clarity in what to expect during treatment and survivorship, and (5) consistent and equitable care in YA oncology. Conclusions: Participants identified six important information needs in addition to an overarching need for tailored support and equitable distribution of resources while transitioning into early survivorship. Thus, tailored interventions are needed to enhance the distribution of YA-centered resources, improve equity in YA cancer care, and connect YAs with peer survivors.

Knowledge, Attitudes, and Resources of Frontline Oncology Support Personnel Regarding Financial Burden in Patients With Cancer

PURPOSE

Financial navigation services support patients with cancer and address the direct and indirect financial burden of cancer diagnosis and treatment. These services are commonly delivered through a variety of frontline oncology support personnel (FOSP) including navigators, social workers, supportive care providers, and other clinic staff, but the perspective of FOSPs is largely absent from current literature on financial burden in oncology. We surveyed a national sample of FOSPs to understand their perspectives on patient financial burden, resource availability, and barriers and facilitators to assisting patients with cancer-related financial burden.

METHODS

We used Qualtrics online survey software and recruited participants using multiple professional society and interest group mailing lists. Categorical responses were described using frequencies, distributions of numeric survey responses were described using the median and IQR, and two open-ended survey questions were categorized thematically using a priori themes, allowing additional emergent themes.

RESULTS

Two hundred fourteen FOSPs completed this national survey. Respondents reported a high awareness of patient financial burden and felt comfortable speaking to patients about financial concerns. Patient assistance resources were commonly available, but only 15% described resources as sufficient for the observed needs. A substantial portion of respondents reported moral distress related to this lack of resources.

CONCLUSION

FOSPs, who already have requisite knowledge and comfort in discussing patient financial needs, are a critical resource for mitigating cancer-related financial burden. Interventions should leverage this resource but prioritize transparency and efficiency to reduce the administrative and emotional toll on the FOSP workforce and reduce the risk of burnout.

Multidimensional financial hardship among uninsured and insured young adult patients with metastatic breast cancer

BACKGROUND

Little is known about the heterogeneous nature of financial hardship in younger patients with metastatic disease and the extent to which insurance protects against it. We examine the association between insurance status and multidimensional indicators of financial hardship in a national sample of women with metastatic breast cancer.

METHODS

We conducted a national, retrospective online survey in partnership with the Metastatic Breast Cancer Network. Eligible participants were ≥18 years, diagnosed with metastatic breast cancer, and able to respond in English. We estimated multivariate generalized linear models predicting two distinct dimensions of financial hardship-financial insecurity (the ability to afford care and living costs) and financial distress (the extent of emotional/psychological distress experienced due to costs)-as a function of insurance status.

RESULTS

Participants responded from 41 states (N = 1054; median age: 44 years). Overall, 30% were uninsured. Financial insecurity was more frequently reported by uninsured respondents. In adjusted analyses, uninsured participants were more likely than insured participants to report contact by debt collectors (adjusted risk ratio [aRR]: 2.38 [2.06, 2.76]) and being unable to meet monthly expenses (aRR: 2.11 [1.68, 2.66]). Financial distress was reported more frequently by insured participants. For example, insured participants were more likely to worry about future financial problems due to cancer and distress about lack of cost transparency. After adjustment, uninsured participants remained about half as likely as insured participants to report financial distress.

CONCLUSIONS

Young adult women with metastatic cancer reported a high burden of financial toxicity. Importantly, insurance does not protect against financial distress; however, the uninsured are the most materially vulnerable.

Mechanical excitation and marginal triggering during avalanches in sheared amorphous solids

We study plastic strain during individual avalanches in overdamped particle-scale molecular dynamics (MD) and mesoscale elastoplastic models (EPM) for amorphous solids sheared in the athermal quasistatic limit. We show that the spatial correlations in plastic activity exhibit a short length scale that grows as t^{3/4} in MD and ballistically in EPM, which is generated by mechanical excitation of nearby sites not necessarily close to their stability thresholds, and a longer lengthscale that grows diffusively for both models and is associated with remote marginally stable sites. These similarities in spatial correlations explain why simple EPMs accurately capture the size distribution of avalanches observed in MD, though the temporal profiles and dynamical critical exponents are quite different.

Collective chemotaxis in a Voronoi model for confluent clusters

Collective chemotaxis, where single cells cannot climb a biochemical signaling gradient but clusters of cells can, has been observed in different biological contexts, including confluent tissues where there are no gaps or overlaps between cells. Although particle-based models have been developed that predict important features of collective chemotaxis, the mechanisms in those models depend on particle overlaps, and so it remains unclear if they can explain behavior in confluent systems. Here, we develop an open-source code that couples a two-dimensional Voronoi simulation for confluent cell mechanics to a dynamic chemical signal that can diffuse, advect, and/or degrade and use the code to study potential mechanisms for collective chemotaxis in cellular monolayers. We first study the impact of advection on collective chemotaxis and delineate a regime where advective terms are important. Next, we investigate two possible chemotactic mechanisms, contact inhibition of locomotion and heterotypic interfacial tension, and demonstrate that both can drive collective chemotaxis in certain parameter regimes. We further demonstrate that the scaling behavior of cluster motion is well captured by simple analytic theories.

Lessening the Impact of Financial Toxicity (LIFT): a protocol for a multi-site, single-arm trial examining the effect of financial navigation on financial toxicity in adult patients with cancer in rural and non-rural settings

BACKGROUND

Almost half of the patients with cancer report cancer-related financial hardship, termed "financial toxicity" (FT), which affects health-related quality of life, care retention, and, in extreme cases, mortality. This increasingly prevalent hardship warrants urgent intervention. Financial navigation (FN) targets FT by systematically identifying patients at high risk, assessing eligibility for existing resources, clarifying treatment cost expectations, and working with patients and caregivers to develop a plan to cope with cancer costs. This trial seeks to (1) identify FN implementation determinants and implementation outcomes, and (2) evaluate the effectiveness of FN in improving patient outcomes.

METHODS

The Lessening the Impact of Financial Toxicity (LIFT) study is a multi-site Phase 2 clinical trial. We use a pre-/post- single-arm intervention to examine the effect of FN on FT in adults with cancer. The LIFT trial is being conducted at nine oncology care settings across North Carolina in the United States. Sites vary in geography (five rural, four non-rural), size (21-974 inpatient beds), and ownership structure (governmental, non-profit). The study will enroll 780 patients total over approximately 2 years. Eligible patients must be 18 years or older, have a confirmed cancer diagnosis (any type) within the past 5 years or be living with advanced disease, and screen positive for cancer-related financial distress. LIFT will be delivered by full- or part-time financial navigators and consists of 3 components: (1) systematic FT screening identification and comprehensive intake assessment; (2) connecting patients experiencing FT to financial support resources via trained oncology financial navigators; and (3) ongoing check-ins and electronic tracking of patients' progress and outcomes by financial navigators. We will measure intervention effectiveness by evaluating change in FT (via the validated Comprehensive Score of Financial Toxicity, or COST instrument) (primary outcome), as well as health-related quality of life (PROMIS Global Health Questionnaire), and patient-reported delayed or forgone care due to cost. We also assess patient- and stakeholder-reported implementation and service outcomes post-intervention, including uptake, fidelity, acceptability, cost, patient-centeredness, and timeliness.

DISCUSSION

This study adds to the growing evidence on FN by evaluating its implementation and effectiveness across diverse oncology care settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04931251. Registered on June 18, 2021.

Adaptation of a financial toxicity intervention for scale-up to diverse contexts: Core functions of Lessening the Impact of Financial Toxicity (LIFT)

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Background: Rural and non-English speaking populations experience a disproportionate burden of financial toxicity and access to services for their cancer care. Lessening the Impact of Financial Toxicity (LIFT) is an intervention designed to address financial toxicity (FT) through financial navigation (FN). FN identifies patients at risk for FT, assesses eligibility for financial support, clarifies costs, and develops strategies to cope with costs. LIFT was successful in reducing financial toxicity in preliminary studies among English-speaking patients with high levels of FT in a single large academic cancer center. To benefit diverse patients with FT in cancer programs across the US, there is a need to adapt LIFT. Adapting LIFT requires distinguishing between its core functions— the components of LIFT key to its effectiveness and implementation, and its forms— the activities that comprise LIFT, facilitate its implementation, and may be adapted to accommodate new populations and contexts. We completed the first stage of adaptation, identifying LIFT core functions. Methods: We conducted interviews with individuals responsible for LIFT’s design and implementation. Interview questions were based on Kirk’s methods for identifying core functions and were recorded and transcribed verbatim. Using a codebook based on the Model for Adaptation Design and Impact, we coded interview transcripts and identified themes related to how LIFT engaged cancer program staff in FN (implementation core functions) and decreased FT (intervention core functions). Results: Eight interview participants filled various roles in designing and implementing LIFT (e.g., P.I.s; FNs). LIFT intervention core functions include a systematic way of cataloging knowledge, resources, and tracking patient information; using patient-specific needs to guide access to resources; ongoing, dynamic assistance and strong one-on-one relationships between navigators and patients; and removing common barriers to accessing resources. Conclusions: We identified core functions key to LIFT’s effectiveness and implementation. Next steps include identifying systematic differences between LIFT’s original context and population and new ones. Successfully adapting LIFT has the potential to extend its benefits to diverse patients in cancer programs throughout the US, such as Spanish-speaking patients served by rural community cancer programs.

Core functions of a financial navigation intervention: An in-depth assessment of the Lessening the Impact of Financial Toxicity (LIFT) intervention to inform adaptation and scale-up in diverse oncology care settings

Background

Lessening the Impact of Financial Toxicity (LIFT) is an intervention designed to address financial toxicity (FT) and improve cancer care access and outcomes through financial navigation (FN). FN identifies patients at risk for FT, assesses eligibility for financial support, and develops strategies to cope with those costs. LIFT successfully reduced FT and improved care access in a preliminary study among patients with high levels of FT in a single large academic cancer center. Adapting LIFT requires distinguishing between core functions (components that are key to its implementation and effectiveness) and forms (specific activities that carry out core functions). Our objective was to complete the first stage of adaptation, identifying LIFT core functions.

Methods

We reviewed LIFT's protocol and internal standard-operating procedures. We then conducted 45-90 min in-depth interviews, using Kirk's method of identifying core functions, with key LIFT staff (N = 8), including the principal investigators. Interviews focused on participant roles and intervention implementation. Recorded interviews were transcribed verbatim. Using ATLAS.ti and a codebook based on the Model for Adaptation Design and Impact, we coded interview transcripts. Through thematic analysis, we then identified themes related to LIFT's intervention and implementation core functions. Two report back sessions with interview participants were incorporated to further refine themes.

Results

Six intervention core functions (i.e., what makes LIFT effective) and five implementation core functions (i.e., what facilitated LIFT's implementation) were identified to be sufficient to reduce FT. Intervention core functions included systematically cataloging knowledge and tracking patient-specific information related to eligibility criteria for FT relief. Repeat contacts between the financial navigator and participant created an ongoing relationship, removing common barriers to accessing resources. Implementation core functions included having engaged sites with the resources and willingness necessary to implement FN. Developing navigators' capabilities to implement LIFT-through training, an established case management system, and connections to peer navigators-were also identified as implementation core functions.

Conclusion

This study adds to the growing evidence on FN by characterizing intervention and implementation core functions, a critical step toward promoting LIFT's implementation and effectiveness.

Abstract PR07: Racial differences in financial toxicity among metastatic breast cancer patients

Background: Awareness of the significant financial burden and distress that cancer patients experience (i.e., “financial toxicity”) is gaining traction in the oncology community. While racial differences in cancer care are well documented, less is known about racial variations in the financial impact of cancer care, particularly among patients with costly incurable disease. Using data from a national survey of racially diverse patients with metastatic breast cancer, we examined racial/ethnic patterns in financial burden due to cancer.

Methods: We partnered with the Metastatic Breast Cancer Network to conduct a 20-minute online survey of metastatic breast cancer patients over a 2-week period in 2018. Study participants responded to items assessing sociodemographic characteristics, communication with providers regarding costs, financial distress, strategies for managing cancer-related costs, and emotional well-being. We evaluated and compared financial outcomes among Hispanics, non-Hispanic Blacks, and non-Hispanic Whites.

Results: Our analysis included 1,119 respondents from 41 states, including 214 Hispanics (19%), 130 non-Hispanic Blacks (12%), and 775 non-Hispanic Whites (69%). Compared with non-Hispanic Whites, Hispanics were more likely to report refusing or delaying treatment due to costs (81% vs. 41%, p<.001), applying for disability (66% vs. 35.1%, p<.001), avoiding treatment for other medical problems (54% vs. 34%, p<.001), and skipping payments on non-medical bills (70% vs. 13%, p<.001). Non-Hispanic Blacks were more likely than non-Hispanic Whites to report refusing or delaying treatment due to costs (91% vs. 41%, p<.001), skipping payments on non-medical bills (32% vs. 13%, p<.001), and being contacted by a collections agency (87% vs. 46%, p<.001). In contrast, non-Hispanic Whites more often reported skipping a vacation to help manage their cancer care costs than Hispanics and non-Hispanic Blacks (46.1% vs. 36.4% vs. 13.8%, respectively, p<.05). Moreover, compared with non-Hispanic Whites and Blacks, Hispanics reported more severe financial distress associated with uncertainty about the cost of their cancer care (6.6% vs. 8.5% vs 47.4%, respectively, p<.001).

Conclusions: Racial/ethnic differences exist in financial burden among metastatic breast cancer patients, with patients of color experiencing more financial harm than their White counterparts. Given the negative impact of financial strain on patient well-being and treatment decision-making, and longstanding disparities in cancer outcomes, equity must be a guiding principle in strategies aimed at addressing financial toxicity in cancer patients.

This abstract is also being presented as Poster B024.

Citation Format: Cleo A. Samuel, Jennifer C. Spencer, Michelle L. Manning, Donald L. Rosenstein, Katherine E. Reeder-Hayes, Jean B. Sellers, Stephanie B. Wheeler. Racial differences in financial toxicity among metastatic breast cancer patients [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr PR07.

Abstract B024: Racial differences in financial toxicity among metastatic breast cancer patients

This abstract is being presented as a short talk in the scientific program. A full abstract is printed in the Proffered Abstracts section (PR07) of the Conference Proceedings.

Citation Format: Cleo A. Samuel, Jennifer C. Spencer, Michelle L. Manning, Donald L. Rosenstein, Katherine E. Reeder-Hayes, Jean B. Sellers, Stephanie B. Wheeler. Racial differences in financial toxicity among metastatic breast cancer patients [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B024.

Cytokinetic bridge triggers de novo lumen formation in vivo

Multicellular rosettes are transient epithelial structures that serve as intermediates during diverse organ formation. We have identified a unique contributor to rosette formation in zebrafish Kupffer's vesicle (KV) that requires cell division, specifically the final stage of mitosis termed abscission. KV utilizes a rosette as a prerequisite before forming a lumen surrounded by ciliated epithelial cells. Our studies identify that KV-destined cells remain interconnected by cytokinetic bridges that position at the rosette's center. These bridges act as a landmark for directed Rab11 vesicle motility to deliver an essential cargo for lumen formation, CFTR (cystic fibrosis transmembrane conductance regulator). Here we report that premature bridge cleavage through laser ablation or inhibiting abscission using optogenetic clustering of Rab11 result in disrupted lumen formation. We present a model in which KV mitotic cells strategically place their cytokinetic bridges at the rosette center, where Rab11-associated vesicles transport CFTR to aid in lumen establishment.

Reducing Cancer-related Financial Toxicity through Financial Navigation: Results from a Pilot Intervention

Our purpose was to pilot a novel patient-centered financial navigation (FN) intervention to decrease the burden of financial toxicity (FT) among uninsured and underinsured patients with cancer treated at the North Carolina Cancer Hospital (NCCH). Methods: Participants were recruited by cancer clinic nurses and social workers at the NCCH. Eligible patients scored less than 22 points (indicating significant FT) on the COmprehensive Score for financial Toxicity (COST) instrument. Fifty patients were enrolled in the intervention, which included an intake assessment of financial needs and vulnerability, initial one-on-one consultation with a trained financial navigator (i.e., financial counselor or social worker), triage to financial support services matching patients' needs, and multiple follow-up appointments. Navigator recommendations were based upon a detailed review of patients' financial status, billing information, insurance, and other indicators used to refer patients to appropriate financial and social services resources offered by the hospital, government, nonprofits and private corporations. Following the initial appointment, patients were given a checklist of resources they were eligible for and the required paperwork to complete applications. During follow-up appointments, application status was reviewed, and practical assistance was provided. Patients were re-contacted at 2-week intervals to assess progress toward financial assistance goals. Outcome data collection included pre/post-intervention COST scores, patient satisfaction with the intervention, and intervention fidelity and retention. Results: The first fifty patients approached all screened positive for FT (COST < 22). Baseline COST scores ranged from 0–19. Results indicated a significant improvement in COST scores following the FN intervention (average increase = 6.86, 95% CI = 4.30–9.42), P < 0.0001). Post-intervention questionnaires indicated excellent patient satisfaction and retention with the FN intervention, and navigator logs indicated high fidelity to the intervention protocol. Conclusions: A novel FN intervention was feasible, acceptable, and effective in reducing FT among uninsured and underinsured oncology patients.

The Development and Psychometric Validation of the Diabetes Impact and Device Satisfaction Scale for Individuals with Type 1 Diabetes

BACKGROUND

With the rapid development of new insulin delivery technology, measuring patient experience has become especially pertinent. The current study reports on item development, psychometric validation, and intended use of the newly developed Diabetes Impact and Device Satisfaction (DIDS) Scale.

METHOD

The DIDS Scale was informed by a comprehensive literature review, and field tested as part of two focus groups. The finalized measure was used at baseline and 6 months post-assessment with a large US cohort. Exploratory factor analyses (EFAs) were conducted to determine and confirm factor structure and item selection. Internal reliability, test-retest reliability, and convergent/divergent validity of the emerged factors were tested with demographics, diabetes-specific information, and diabetes behavioral and satisfaction measures.

RESULTS

In all, 778 participants with type 1 diabetes (66% female, mean age 47.13 ± 17.76 years, 74% insulin pump users) completed surveys at both baseline and post-assessment. EFA highlighted two factors-Device Satisfaction (seven items, Cronbach's α = 0.85-0.90) and Diabetes Impact (four items, Cronbach's α = 0.71-0.75). DIDS Scale demonstrated good concurrent validity and test-retest reliability.

CONCLUSION

The DIDS Scale is a novel and a brief assessment tool with robust psychometric properties. It is recommended for use across all insulin delivery devices and is considered appropriate for use in longitudinal studies. Future studies are recommended to evaluate the performance of DIDS Scale in diverse populations with diabetes.

Cancer-related financial burden among patients with metastatic breast cancer

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Background: Recent data suggest that the adverse financial impact of cancer is an underappreciated source of potential harm to patients, also known as “financial toxicity”. Little is known about the financial impact of cancer in patients with widespread, incurable disease, despite the relatively high cost of their care. We conducted a national survey of patients with metastatic breast cancer to address this gap. Methods: We partnered with the Metastatic Breast Cancer Network to field an online survey of metastatic breast cancer patients over a fourteen-day period using Qualtrics. The survey required approximately 20 minutes to complete, and participants were offered a $10 Amazon gift card. Survey items included sociodemographic information, health insurance status, cost-related communication with providers, post-treatment financial burden, financial coping strategies, and emotional well-being. We report financial outcomes stratified by health insurance status, as insurance is an important protective mechanism against health-related financial shocks. Results: 1,513 participants responded from 41 states. More than a third of these women (35%) were uninsured. Uninsured individuals more often reported refusing or delaying treatment due to cost (98% vs. 41% of insured, p < .001) and were also more likely to report skipping non-medical bills (40% vs. 16%, p < .001), stopping work after diagnosis (65% vs. 46%, p < .001), or being contacted by a collections agency (77% vs. 36%, p < .001). Despite this, insured participants reported higher cost-related emotional distress, including being “quite a bit” or “very” stressed about not knowing cancer costs (53% vs. 32%, p < .001) and about financial stress on their family due to their cancer (52% vs. 27%, p < .001). Conclusions: Metastatic breast cancer patients reported an unprecedented level of cancer-related financial harm and significant worry about the financial legacy left behind in the wake of their illness. Health insurance expansion is a necessary, but insufficient strategy to address this financial burden; additional interventions to prevent and mitigate cancer-related financial harm are urgently needed.

Health system stakeholder perceptions of financial assistance programs at a comprehensive cancer center

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Background: Cancer-related financial burden is a growing problem that has been linked to psychosocial distress, treatment delays and non-adherence, and excess mortality risk. Comprehensive cancer centers often provide financial support resources to mitigate financial burden, but the scope of these services and the processes involved are poorly understood. We conducted an in-depth qualitative analysis of key health system stakeholders to understand these processes and identify areas for improvement. Methods: Semi-structured interviews were conducted with 12 stakeholders involved in the financial assistance process at a public comprehensive cancer center. Interviews elicited descriptions of programs, perceived strengths and weakness, and the stakeholders' roles in helping patients obtain financial assistance. A codebook was developed inductively and interviews were coded in duplicate, with codes added as new themes emerged. Coded data were used to develop and revise a system-wide process map of financial support resources. Results: Stakeholders described numerous resources for financial assistance, both internal (e.g., Charity Care) and external (e.g., manufacturer assistance). Although participants described feeling pride at helping patients obtain assistance, numerous barriers were identified, including delays in processing applications, duplicative processes, insufficient time to address patients' concerns, lack of dedicated staff to address the complexity of navigating resources, and perception that existing resources are inadequate to meet patient needs. Conclusions: Processes required to obtain financial support for cancer patients often place a high administrative burden on patients who must proactively seek resources, understand complex eligibility criteria and complete multiple, often overlapping applications, even within comprehensive cancer center environments. Dedicated financial navigators may assist patients in accessing existing available resources, and health systems should consider moving beyond patient-activated pathways of access to financial support to avoid exacerbating disparities for the most vulnerable patients.

Oncology navigators' perceptions of cancer-related financial burden and financial assistance resources

INTRODUCTION

As the cost of cancer treatment continues to rise, many patients are faced with significant emotional and financial burden. Oncology navigators guide patients through many aspects of care and therefore may be especially aware of patients' financial distress. Our objective was to explore navigators' perception of their patients' financial burden and their role in addressing financial needs.

MATERIALS AND METHODS

We conducted a real-time online survey of attendees at an oncology navigators' association conference. Participants included lay navigators, oncology nurse navigators, community health workers, and social workers. Questions assessed perceived burden in their patient population and their role in helping navigate patients through financial resources. Answers to open-ended questions are reported using identified themes.

RESULTS

Seventy-eight respondents participated in the survey, reporting that on average 75% of their patients experienced some degree of financial toxicity related to their cancer. Only 45% of navigators felt the majority of these patients were able to get some financial assistance, most often through assistance with medical costs (73%), subsidized insurance (36%), or non-medical expenses (31%). Commonly identified barriers for patients obtaining assistance included lack of resources (50%), lack of knowledge about resources (46%), and complex/duplicative paperwork (20%).

CONCLUSION

Oncology navigators reported a high burden of financial toxicity among their patients but insufficient knowledge or resources to address this need. This study underscores the importance of improved training and coordination for addressing financial burden, and the need to address community and system-level barriers.

Functional phases and angular momentum characteristics of Tkatchev and Kovacs

Understanding the technical requirements and underlying biomechanics of complex release and re-grasp skills on high bar allows coaches and scientists to develop safe and effective training programmes. The aim of this study was to examine the differences in the functional phases between the Tkatchev and Kovacs skills and to explain how the angular momentum demands are addressed. Images of 18 gymnasts performing 10 Tkatchevs and 8 Kovacs at the Olympic Games were recorded (50 Hz), digitised and reconstructed (3D Direct Linear Transformation). Orientation of the functional phase action, defined by the rapid flexion to extension of the shoulders and extension to flexion of the hips as the performer passed through the lower vertical, along with shoulder and hip angular kinematics, angular momentum and key release parameters (body angle, mass centre velocity and angular momentum about the mass centre and bar) were compared between skills. Expected differences in the release parameters of angle, angular momentum and velocity were observed and the specific mechanical requirement of each skill were highlighted. Whilst there were no differences in joint kinematics, hip and shoulder functional phase were significantly earlier in the circle for the Tkatchev. These findings highlight the importance of the orientation of the functional phase in the preceding giant swing and provide coaches with further understanding of the critical timing in this key phase.

Using Telehealth to Train Providers of a Cancer Support Intervention

BACKGROUND

Group interventions are effective for addressing the transition from cancer treatment to survivorship but are not widely available outside of urban areas. In addition, minimal training is available for group facilitators outside of the mental healthcare discipline. Telehealth as a medium can facilitate conversation and interactive learning and make learning accessible to individuals in areas that lack resources for traditional classroom teaching. Little is known, however, regarding the feasibility and acceptability of a telehealth training program for group leaders. This project aimed to investigate the utility of a telehealth training program for the delivery of a copyrighted, manualized psychosocial group intervention, Cancer Transitions: Moving Beyond Treatment.

MATERIALS AND METHODS

Nine group leaders attended one in-person orientation, four telehealth training classes, and four telehealth supervision sessions, completing self-report measures of content knowledge, quality satisfaction, and self-confidence. Following the completion of their last Cancer Transitions facilitation, group leaders participated in a focus group to provide qualitative feedback regarding their experiences in training for and leading the respective groups in eight urban and rural North Carolina communities.

RESULTS

Group leaders rated the training program highly across the domains of content knowledge, quality satisfaction, and self-confidence. Satisfaction with the technology itself was equivocal.

CONCLUSIONS

Telehealth represents a feasible avenue for training and supporting leaders of psychosocial interventions. In addition, telehealth is particularly well suited to the need for training group leaders in areas outside urban centers or academic communities.

Measurement of correlations between low-frequency vibrational modes and particle rearrangements in quasi-two-dimensional colloidal glasses

We investigate correlations between low-frequency vibrational modes and rearrangements in two-dimensional colloidal glasses composed of thermosensitive microgel particles, which readily permit variation of the sample packing fraction. At each packing fraction, the particle displacement covariance matrix is measured and used to extract the vibrational spectrum of the "shadow" colloidal glass (i.e., the particle network with the same geometry and interactions as the sample colloid but absent damping). Rearrangements are induced by successive, small reductions in the packing fraction. The experimental results suggest that low-frequency quasilocalized phonon modes in colloidal glasses, i.e., modes that present low energy barriers for system rearrangements, are spatially correlated with rearrangements in this thermal system.

Vibrational modes identify soft spots in a sheared disordered packing

We analyze low-frequency vibrational modes in a two-dimensional, zero-temperature, quasistatically sheared model glass to identify a population of structural "soft spots" where particle rearrangements are initiated. The population of spots evolves slowly compared to the interval between particle rearrangements, and the soft spots are structurally different from the rest of the system. Our results suggest that disordered solids flow via localized rearrangements that tend to occur at soft spots, which are analogous to dislocations in crystalline solids.

Rate-dependent shear bands in a shear-transformation-zone model of amorphous solids

We use shear transformation zone (STZ) theory to develop a deformation map for amorphous solids as a function of the imposed shear rate and initial material preparation. The STZ formulation incorporates recent simulation results [T. K. Haxton and A. J. Liu, Phys. Rev. Lett. 99, 195701 (2007)] showing that the steady state effective temperature is rate dependent. The resulting model predicts a wide range of deformation behavior as a function of the initial conditions, including homogeneous deformation, broad shear bands, extremely thin shear bands, and the onset of material failure. In particular, the STZ model predicts homogeneous deformation for shorter quench times and lower strain rates, and inhomogeneous deformation for longer quench times and higher strain rates. The location of the transition between homogeneous and inhomogeneous flow on the deformation map is determined in part by the steady state effective temperature, which is likely material dependent. This model also suggests that material failure occurs due to a runaway feedback between shear heating and the local disorder, and provides an explanation for the thickness of shear bands near the onset of material failure. We find that this model, which resolves dynamics within a sheared material interface, predicts that the stress weakens with strain much more rapidly than a similar model which uses a single state variable to specify internal dynamics on the interface.

Strain localization in a shear transformation zone model for amorphous solids

We model a sheared disordered solid using the theory of shear transformation zones (STZs). In this mean-field continuum model the density of zones is governed by an effective temperature that approaches a steady state value as energy is dissipated. We compare the STZ model to simulations by Shi [Phys. Rev. Lett. 98, 185505 (2007)], finding that the model generates solutions that fit the data, exhibit strain localization, and capture important features of the localization process. We show that perturbations to the effective temperature grow due to an instability in the transient dynamics, but unstable systems do not always develop shear bands. Nonlinear energy dissipation processes interact with perturbation growth to determine whether a material exhibits strain localization. By estimating the effects of these interactions, we derive a criterion that determines which materials exhibit shear bands based on the initial conditions alone. We also show that the shear band width is not set by an inherent diffusion length scale but instead by a dynamical scale that depends on the imposed strain rate.

Steady-state, effective-temperature dynamics in a glassy material

We present a shear-transformation-zone (STZ)-based analysis of numerical simulations by Haxton and Liu [Phys. Rev. Lett. 99, 195701 (2007)]. The extensive Haxton and Liu (HL) data sharply test the basic assumptions of the STZ theory, especially the central role played by the effective disorder temperature as a dynamical state variable. We find that the theory survives these tests, and that the HL data provide important and interesting constraints on some of its specific ingredients. Our most surprising conclusion is that, when driven at various constant shear rates in the low-temperature glassy state, the HL system exhibits a classic glass transition, including super-Arrhenius behavior, as a function of the effective temperature.

Serratia marcescens transmission in a pediatric intensive care unit: a multifactorial occurrence

BACKGROUND

Fourteen patients in the pediatric cardiac intensive care unit (CICU) had > or =1 positive culture for a single strain of Serratia marcescens from April through December 1995 (study period).

OBJECTIVES

To identify risk factors for S marcescens infection or colonization in a pediatric CICU.

METHODS

Retrospective case-control study. Assessment of CICU infection control practices and patient exposure to CICU health care workers (HCWs). Epidemiologic-directed cultures of the environment and HCWs' hands were obtained.

SETTING

Pediatric CICU.

PATIENTS

Fourteen patients in the pediatric CICU had > or =1 positive culture for a single strain of S marcescens from April through December 1995 (study period). CICU patients who did not have S marcescens infection or colonization during the study period were randomly selected as controls.

RESULTS

A case patient was more likely than a noncase patient to have exposure to a single HCW (odds ratio [OR], 19.5; 95% CI, 2.6-416; P<.003); however, this association was not adequately explained by epidemiologic or microbiologic studies. Interviews suggested that during the outbreak period, handwashing frequency among HCWs might have been reduced because of severe hand dermatitis.

CONCLUSIONS

A combination of factors, including breaks in aseptic technique, reduced frequency of handwashing among HCWs before and between caring for patients, decreased attention to infection control practices, and environmental contamination may have indirectly contributed to this S marcescens infections outbreak.

Nosocomial respiratory syncytial virus infections: the cost-effectiveness and cost-benefit of infection control

OBJECTIVE

To determine the cost-effectiveness and cost-benefit of an infection control program to reduce nosocomial respiratory syncytial virus (RSV) transmission in a large pediatric hospital.

DESIGN

RSV nosocomial infection (NI) was studied for 8 years, before and after intervention with a targeted infection control program. The cost-effectiveness of the intervention was calculated, and cost-benefit was estimated by a case-control comparison.

SETTING

Children's Hospital of Philadelphia, a 304-bed pediatric hospital.

PATIENTS

All inpatients with RSV infection, both community- and hospital-acquired.

INTERVENTION

Consisted of early recognition of patients with respiratory symptoms, confirmation of RSV infection by laboratory testing, establishing cohorts of patients and nursing staff, gown and glove barrier precautions, and monitoring and education of staff.

OUTCOME MEASURES

The incidence density of RSV NI before and after the intervention was calculated as the rate per 1000 patient days-at-risk for infection. Intervention costs included laboratory testing, isolation, and administration of the program. The cost of RSV NI was estimated by comparing hospital charges for 30 cases and matched uninfected controls.

RESULTS

A total of 148 patients acquired NI (88 before and 60 after the intervention). The Mantel-Haenszel stratified relative risk for NI in the period before the infection control program, compared with the postintervention period, was.61 (95% confidence interval:.53-.69). By applying the preintervention stratum-specific rates of infection to the days-at-risk in the postintervention period, an estimated 100 NIs would have been expected, which in comparison to the 60 NIs observed, yielded an estimated program effectiveness of 10 RSV NIs prevented per season. The total cost of the program per season was $15 627 or $1,563/NI prevented. In comparison, the mean cost to the hospital was $9,419/case of RSV NI, resulting in a cost-benefit ratio of 1:6.

CONCLUSIONS

A targeted infection control intervention was cost-effective in reducing the rate of RSV NI. For every dollar spent on the program, approximately $6 was saved.

The judicious use of antibiotic agents in common childhood respiratory illness

Increased bacterial resistance is caused most frequently by the widespread use of antimicrobial agents. Antimicrobial agents are often used inappropriately to treat common respiratory illnesses in children. This article discusses the judicious use of antimicrobials in the common cold, otitis media, acute sinusitis, pharyngitis, and bronchitis.

Patient density, nurse-to-patient ratio and nosocomial infection risk in a pediatric cardiac intensive care unit

BACKGROUND

An investigation of a Serratia marcescens outbreak in a pediatric cardiac intensive care unit (CICU) suggested that understaffing or overcrowding might have been underlying risk factors.

OBJECTIVE

To assess the effect of fluctuations in CICU nurse staffing levels and patient census on CICU nosocomial infection rate (NIR).

METHODS

The monthly CICU nursing hours, patient days and nosocomial infections were obtained from retrospective review of administrative, patient and microbiology records during December, 1994, through December, 1995 (study period). The NIR and nursing hours:patient day ratio were then calculated. The correlations between NIR vs. nursing hours, patient days and nursing hours:patient day ratio were determined.

RESULTS

The median monthly CICU NIR was 6.9 (range, 0 to 15.2) infections per 1000 patient days; the median number of hours worked per month by CICU registered nurses was 7754 (range, 7133 to 8452) hours; the median number of patient days treated per month was 507 (range, 381 to 590) patient days; and the median monthly nursing hours:patient day ratio was 15.2:1 (range, 13.2:1 to 19.9:1). The strongest linear correlation was observed between the monthly NIR and patient days (r = 0.89, P = 0.0001). There was an inverse correlation between the monthly NIR and nursing hours:patient day ratio (r = -0.77, P = 0.003).

CONCLUSIONS

The NIR was most strongly correlated with patient census but also was strongly associated with the nursing hours:patient day ratio. These factors may influence the infection rate because of breaks in health care worker aseptic technique or decreased hand washing. Increased patient census alone may increase the risk of cross-transmission of nosocomial infections. As hospitals proceed with cost containment efforts the effect of fluctuations in patient census and nurse staffing on patient outcomes needs evaluation.

Time-till-breakdown and scalp electrical potential maps of long-range apparent motion

A series of psychophysical and electrophysiological experiments is reported using the apparent motion (AM) breakdown effect. Breakdown describes an effect in AM in which, during continuous viewing, the percept of smooth of a single stimulus alternates with the percept of two discrete alternating stimuli. Visual evoked potentials (VEPs) were recorded during periods of motion or breakdown ("nonmotion") in horizontal and vertical displays. VEPs were compared with synthetic VEPs ("composite-flash") produced by adding VEPs to each element of the display recorded in isolation. Subtraction of VEPs was used in an attempt to compare the electrical responses with the processing of information relating to the form of the stimulus, subthreshold motion processing, and suprathreshold motion processing. The results, presented as scalp electrical potential distribution maps, were interpreted as consistent with a central adaptation process underlying the breakdown effect. The results also indicated that the hemispheric asymmetries in AM VEPs described by Manning, Finlay, and Fenelon (1988) were most likely due to the position of the stimuli in the visual field, rather than as a lateralization of motion processes per se. The results also provided evidence that the subthreshold and suprathreshold motion responses to the display were the product of different populations of motion units.

Immunity induced by primary human cytomegalovirus infection protects against secondary infection among women of childbearing age

To determine if immunity to human cytomegalovirus (HCMV) protects women from acquiring HCMV from their children, a blinded, randomized protocol was used to monitor seronegative women who received placebo or Towne vaccine (approximately 500 pfu) and seropositive women. Each group was similar for mean maternal (33 years) and child age (18 months) and duration of viral shedding by the child (15 months). Among 19 placebo recipients, 9 developed primary infection; 8 of 19 vaccines but only 3 of 42 naturally seropositive subjects had evidence of acquiring HCMV from their child. Wild type infection and Towne vaccine induced similar mean lymphoproliferative responses to HCMV antigens, but one dose of Towne vaccine produced mean neutralizing titers 10- to 20-fold lower than those after wild type infection. Thus, a vaccine that induces immune responses equal to those induced by wild type virus may protect healthy women from acquiring HCMV from their children.

Delayed type hypersensitivity to human cytomegalovirus

A skin test for immunity to human cytomegalovirus (HCMV) is described in which skin induration is measured after intradermal injection of antigen derived from heat-inactivated Towne strain HCMV or of envelope prepared from the virus. Randomly selected healthy young adult males and females were prescreened for evidence of past infection with HCMV using serologic tests. Each individual was inoculated with heat inactivated whole virion HCMV antigen prepared from serum-free supernatants of HCMV-infected MRC-5 cells, non-infected MRC-5 cell lysates, and Candida extract. HCMV seropositive individuals developed positive skin reactions to both the Candida extract and the HCMV test antigen. No response was observed at the MRC-5 cell lysate inoculation site. The envelope antigen also elicited a response in seropositive individuals. Seronegative individuals who were negative to the HCMV intradermal antigen at the start of the study developed a positive response 1 week after subcutaneous immunization with live attenuated Towne strain HCMV. This response also correlated with the onset of in vitro proliferation responses to HCMV antigens by peripheral blood lymphocytes obtained from the immunized individuals. Furthermore, skin test and lymphocyte proliferation responses remained positive when tested up to 93 days post-immunization. In guinea pig experiments with HCMV, those animals immunized with purified HCMV or a virus envelope preparation developed strong skin reactions to intradermal injection of each of those antigens. In contrast, no reaction was observed in immune animals, either to viral capsid antigen or uninfected cell-lysate antigen, and no reactions were observed to any HCMV antigen in non-immune animals.

Detection duration thresholds and evoked potential measures of stereosensitivity

Visual evoked potentials have been proposed by some researchers to be more useful than behavioral techniques to evaluate stereo performance in children and certain clinical populations. Stimulus duration detection thresholds, visual evoked potentials, and scalp electrical potential distribution maps to dynamic random dot stereograms were studied. A high degree of correspondence was found between visual evoked potential amplitudes and behaviorally determined detection thresholds. Upper field stimuli had higher detection thresholds and generated lower-amplitude visual evoked potential responses than did centrally presented stimuli. For the most eccentrically presented stimuli, lower detection thresholds were found for stimuli presented in the right visual field than the left visual field. This finding was consistent with the pattern of VEP responses to be lateralized, with higher-amplitude responses recorded over left-hemisphere sites. The study examined a proposal that the major negative component of the stereoscopic visual evoked potential originates in cortical area V1. The results failed to support the proposal and were consistent with the main negative component of the VEP being generated in V2, rather than V1.

Differential motion thresholds to sinusoidal gratings at two eccentricities

Differential motion thresholds were measured at eccentricities of 9 degrees and 16.6 degrees using computer-generated sinusoidal gratings. Three spatial frequencies (0.51, 0.25, and 0.13 cycles/deg) were examined at reference velocities of 2, 4, 8, 16, 32, and 48 deg/sec. Minimum differential velocity thresholds were between 20 and 30% of the reference velocities for the three spatial frequencies at both eccentricities. Increasing eccentricity produced an increase in the velocity at which minimum velocity discrimination occurred. Temporal frequency tuning was between 4 and 8 Hz, regardless of eccentricity.

Time-till-breakdown and VEP measures of short-range apparent motion

Varying short-range apparent motion (AM) stimulus displacements from 2.7 to 21.6 min it was found that VEP amplitudes varied as a function of the limits for short-range AM described using time-till-breakdown as a behavioural measure of AM strength. This VEP amplitude difference was, however, in the reverse direction to that predicted as the "motion" condition elicited lower VEP amplitude responses than the "non-motion" conditions (which did not significantly differ from each other). This direction of VEP amplitude difference was supported by an intensive study of a single subject. The "breakdown effect" enabled VEPs to be gathered during periods in which the subjective experience was of either coherent lateral motion, or breakdown (incoherent motion) without changing any stimulus parameter. The VEP component identified in expt 2, as predicted, was of lower amplitude during motion with respect to periods of breakdown. The results of these experiments are discussed in terms of describing motion and breakdown in short-range AM displays as "coherent" and "incoherent" motion, rather than as "motion" and "non-motion".

Health assessment of the early adolescent. Challenges and clinical issues

Although early adolescence spans only 4 years, it is a critical time in the life of a young person in forming opinions and selecting options. Specific attention to the growing and changing needs of this population is imperative if their health status is to improve.

Difficulties in the definition of 'stereoscotoma' using temporal detection of thresholds of dynamic random dot stereograms

Temporal detection thresholds are reported from two subjects to dynamic random dot stereograms (DRDSs) of both crossed and uncrossed disparity. The stimuli were 1 degree square, of 0.25 degrees disparity and were presented at 81 positions in a 9 degree square central region. In both subjects crossed disparity stimuli were detected at shorter durations. One subject displayed particularly acute stereoscopic vision and presented a pattern of temporal thresholds increasing gradually with eccentricity. The other subject displayed evidence, particularly in response to uncrossed stimuli, of a 'stereo-scotoma' which was not evident in monocular testing or ophthalmologic examination. Criteria used to define 'stereo-scotoma' are discussed. It was concluded that, although left-right field differences may be found with a large subject sample, individual factors may be more important in the distribution of stereo sensitivity throughout the portion of visual field tested.

Motion components of VEPs to the waggon wheel effect

Visual evoked potentials (VEPs) from eight subjects are presented from scalp sites O1, O2, T5, T6, P3 and P4. A spoked wheel was illuminated by a constantly flashing strobe. By adjusting the real angular speed of the wheel the subjective impression was given of; a stationary wheel, a wheel spinning slowly or spinning rapidly clockwise. Two visually identified components, a negativity and a positivity, were found to be of larger amplitude in response to motion. The results were interpreted as consistent with a model of AM proposing motion information to be processed within the visual system.

Visual evoked potentials to stimuli in apparent motion

Following an extensive single subject pilot study 12 Ss viewed a continuously cycling (3 Hz), two stimulus, apparent motion (AM) display. The "AM breakdown effect" was utilised to gather visual evoked potentials (VEPs) from sites O1, O2, T5, T6, P3, and P4 during periods in which the display elicited either: the percept of motion; or the percept of two discrete alternating stimuli. VEPs displayed components of larger amplitude during motion periods in all right (but no left) hemisphere sites during periods 60-82 msec post left field stimulus onset (positive component) and 100-126 msec post right field stimulus onset (negative component). Results were interpreted as indicating initial extraction of motion information within the occipital lobe, with further motion processing taking place in temporal and parietal lobes.

Individual differences in responses of untrained observers to stroboscopic apparent motion

Two large groups of inexperienced subjects (n = 208 and n = 50) and a small group of experienced subjects (n = 5) were tested using time-till-breakdown as a measure of long-range apparent motion across a range of temporal frequencies. One group of inexperienced subjects was retested after one week and demonstrated quite stable patterns of response. Large intersubject variability was observed in terms of the amount of motion seen, with most inexperienced subjects reporting very little apparent motion. A raster display produced a peak frequency 1 Hz higher than a standard tachistoscope display. The role of experience was also examined with a small group of inexperienced subjects (n = 8) tested once daily over five consecutive days. There was high intersubject variability and intrasubject consistency, demonstrating little influence of learning and experience. The results are discussed in terms of current ideas on the breakdown effect.

Effects of movement in the background field on long-range apparent motion

Two experiments are reported using time-till-breakdown as a measure of apparent motion (AM) in untrained subjects. In Experiment 1 centrally viewed dynamic random dot stereograms and non-disparate stimuli in dynamic random dot fields yielded higher optimal frequencies than did a standard binocular condition. In Experiment 2 a higher optimal frequency was observed for disparate dynamic random dot stimuli compared with both standard binocular and non disparate stimuli presented on a static random dot field. Interaction between short- and long-range AM processes is considered in the interpretation of the findings.

Detection threshold differences to crossed and uncrossed disparities

Using a sample of 85 subjects measurements were made of minimum stimulus durations necessary for detection of crossed and uncrossed disparity stimuli which were presented in five positions in the visual field: centre, lower, upper, right, and left field. The results indicated large detection duration differences between the two disparity conditions, with a marked superiority for crossed disparity detection at all positions. A left-right visual field anisotropy was demonstrated for crossed disparity stimuli.

Evoked potentials to dynamic random dot stimuli with varying dot density ratios of disparity to background

A systematic study was made of visual evoked responses to dynamic random dot stimuli containing controllable, monocularly visible contrast cues. Ratios of dot densities for the centrally presented, disparate figure and the background were varied in steps of 1/8 maximum density between 0/8 and 8/8. The figure was either a square or an equivalent area of nebulous shape. A 30-arc min disparity was compared with binocular nondisparate and monocular conditions. Evoked responses (scalp sites 02, 01, T6, T5) were averaged for each of 24 disparity-contrast-shape conditions. At all contrast levels, response amplitudes and latency over the left hemisphere was significantly greater than over the right hemisphere. For 30 arc min disparity, amplitudes in the 8/8 condition were significantly smaller than in conditions where stimulus/background contrast could afford monocular depth cues. Hemisphere amplitude differences diminished as contrast decreased. Factor analyses isolated two overlapping components in the response to disparate stimuli. The earlier, at 236 ms latency, may index the stereoscopic stimulus features. The later, at 295 ms, peaking at maximum contrast and present in all suprathreshold nondisparity conditions, may index contrast features of the stimulus. The results indicate the importance of controlling dot density ratios in electrophysiological studies of the stereoscopic response to random dot stimuli.