bluuebunny/crossref_metadata_2025 huggingface dataset:
Use of a best-practice advisory to increase survivorship clinic referrals.
Authors: Kircher Sheetal Mehta , Slocum Megan , Garcia Sofia F. , Veneruso Aubri , Patel Alpa , Kinahan Karen , Gradishar William John , Jain Sarika , Flaum Lisa E. , Santa-Maria Cesar , Penedo Frank J.
Published: March 2017

53

Background: The American College of Surgeons Commission on Cancer require accredited institutions to give patients a survivorship care plan (SCPs) within six months of completing curative intent therapy. However, only a minority are receiving SCP’s. Some institutions have survivorship clinics to deliver comprehensive care, including SCP’s. Insufficient referrals to such clinics are a common barrier due to survivorship not being integrated into oncology workflows. To address this, we developed and implemented a best practice advisory (BPA) alert within our EMR to identify eligible patients and facilitate referrals to the survivorship clinic. Methods: Our pilot included breast cancer patients within medical oncology. The BPA electronic alert criteria included: stage 0-III, new patient encounter within 12 months, no SCP completed or previous referral. Upon triggering, the BPA asks “Does your patient require a SCP?” followed by 3 options: 1) SCP needed- an automatic order is generated, if signed, the BPA will not fire again, if unsigned, it will fire at the next encounter (no sooner than 30 days) and will continue until an order is placed or the response “ SCP not needed” is selected. 2) SCP not needed- the BPA will never trigger again for that patient. 3) Don’t know/still on treatment-the BPA will re-fire in 30 days. Data on frequency of BPA firing and number of referrals was compared 90 days prior and post implementation. Chi-square analysis was used. Results: Between 4/1/2015-3/31/2016, 902 patients were seen with stage 0-III breast cancer at Northwestern. Ninety days prior to implementation of the BPA, 30 patients (3.3%) were referred by 8 oncology providers. In the 90 days following implementation, the BPA fired 845 times (48.5% option 1, 24.8% option 2, 26.6% option 3) and 198 patients (22%) were referred. The difference was statistically significant ( χ2 = 141.7, p < 0.0001). Conclusions: The implementation of BPAs within an EMR is an effective way to increase referrals to a survivorship clinic, thus increasing the number of patients given SCPs. Challenges identified were having enough staff availible to deal with a rapid increase in referrals, need for refinement of BPA criteria to more precisely identify eligible patients, and provider burden.
Growing a cancer survivorship care plan program.
Authors: Sutherby (Bennett) Claire Michelle
Published: March 2017

58

Background: More than 15.5 million cancer survivors live in the United States. This number is expected to be over 20 million by 2026. Cancer survivors have increased risk of morbidity; therefore, preventive and on-going medical treatment requires close monitoring and coordination. The Institute of Medicine’s (IOM) 2005 report, Cancer Patient to Cancer Survivor: Lost in Transition, recommended health providers raise awareness of cancer survivors’ needs and establish cancer survivorship as a distinct phase of care. The IOM also recommended patients who complete primary treatment are provided a comprehensive summary and plan that is effectively explained. A survivorship care plan maps out and improves care related to accessibility of past diagnosis and treatment history, surveillance guidelines, and potential long term side effects. In 2012, the Commission on Cancer (CoC) added Standard 3.3 Survivorship Care Planto the program standards. This met the IOM’s objective of addressing potential patients that get “lost” as they transition from care they received during treatment through phases of their life or disease. Methods: The Cancer Committee within a CoC certified organization developed multiple strategies to address the IOM and CoC standards. Strategies included a process to disseminate a comprehensive care summary for cancer patients who are completing primary treatment, adoption of the American Society of Clinical Oncology’s Treatment Summary and Survivorship Care Plan template, and adding a survivorship nurse navigator to the interprofessional treatment team. The survivorship nurse navigator monitors and reviews survivorship care plans with patients, advises when to seek treatment for symptoms, discusses surveillance guidelines, navigates patients through therapies, and educates on prevention and screening. Results: Evaluation for quality of life and compliance with individualized surveillance guidelines is ongoing. Conclusions: The oncology nurse navigator role is uniquely positioned to lead care coordination and improve outcomes through the continuum of care. Providing patients with a summary of their treatment and a plan moving forward may decrease stress related to the transition from active treatment to survivorship.
Living with and beyond cancer: What can be achieved by multi-organization collaboration.
Authors: Cunningham Nicola , Stanway Susannah Jane , Wiseman Theresa , Taylor Claire , Noble Jillian Louise , Doyle Natalie
Published: March 2017

59

Background: The London Cancer Alliance (LCA), created in 2011, is an integrated cancer system consisting of 14 NHS organisations serving a population of 5.7 million. The multi-professional Survivorship Pathway Group has 18 members including a service user. The purpose of the group is to provide expert clinical leadership for the development and implementation of the pathways to imbed the Recovery Package (Holistic needs assessment (HNA)/care plan, treatment summaries, health and well-being events, cancer care reviews), treatment and management of the consequences of cancer into standard practice of cancer care. Methods: Data is collected quarterly for each NHS organisations’- HNA and care plan, treatment summaries, health and well-being events against defined metrics. Data Collection is in its fourth year. To support the implementation, guidelines have been developed, support and information provided and educational fora run. Results: The number of HNAs completed within 31 days of diagnosis from 487 to 2646 (an increase of 543%) and for HNAs completed within 6 weeks of completing treatment from 185 to 905 (an increase of 489%) (RM Partners Overall 2016) since Q2 2013/14 until Q2 2015/16. The group have mapped service availability across the LCA and developed robust survivorship pathways for lymphedema, complementary services, sexual consequences, GI consequences, onco-fertility, allied health professional rehabilitation and health and wellbeing events. Guidelines have also been developed and published on survivorship, lymphoedema, health and well-being events, gastro-intestinal and sexual consequences, complementary therapies, developing patient information leaflets, gaining patient and carer feedback. Furthermore, over 15 fora have been run on diverse topics. Conclusions: Collaborative working across London organisations has proved to be feasible and productive. The impact of the group has been demonstrated through the significant uptake in implementation of the Recovery Package. Future directions include an improvement in collection of HCP agreed data sets, the embedding of treatment summary templates into Trust cancer data systems, and further role out of electronic HNA.
Development and implementation of an electronic measurement process for survivorship care plan dissemination and compliance.
Authors: Leighton Patricia , Hoopes Stephanie , Weathers Jo Maria , Perkins Leann , McCormick Douglas , Franco Regina A , O'Rourke Mark Allen
Published: March 2017

67

Background: Cancer programs must comply with survivorship care plan (SCP) delivery by 2018 to maintain or achieve Commission on Cancer (CoC) accreditation. Barriers to measuring and tracking SCP compliance include insufficient staffing to facilitate the documentation and input of data, lack of electronic medical record automation methods, lack of interoperability and electronic health record reporting processes. In June 2016, The Greenville Health System-GHS Cancer Institute Center for Integrative Oncology and Survivorship-CIOS developed a process to record, measure and track the number of SCP delivery visits delivered to Cancer Survivors. Methods: A patient who attends an SCP visit sees a provider in collaboration with a nurse navigator. The provider explains the elements within the patient’s SCP document. A copy is provided to the patient. The SCP document is embedded within the providers note for the SCP visit. To document the visit and delivery of the SCP, the nurse navigator clicks the “complete SCP visit” button located in the patient’s EMR. The SCP button also identifies the name of the provider and whether the SCP was complete or incomplete. This action in the EMR enables the creation of reports that record and document SCP delivery. Results: Four weeks were chosen during the initial implementation period to evaluate use of the SCP delivery button. For each visit provided, the SCP delivery button was clicked documenting the delivery of the SCP. The weekly data for #SCP deliveries documented and total #SCP visits are: Week 1, 17 of 22 (77%); Week 2, 16 of 17 (94%); Week 3, 13 of 13 SCP (100%); Week 4, 12 of 12 SCP (100%). Of the 64 SCP’s, 42 were complete and 22 incomplete. Conclusions: The development of the electronic measurement process for survivorship care plan delivery has significantly increased efficiency of reporting and has decreased time spent on chart audits.
Social support at diagnosis and noninitiation, discontinuation, and nonadherence to adjuvant hormonal therapy in the Pathways Study.
Authors: Kroenke Candyce , Hershman Dawn L. , Adams Sara , Kwan Marilyn L. , Kushi Lawrence H.
Published: March 2017

7

Background: Exceedingly little research has examined associations between social support and adherence to adjuvant hormonal therapy (AHT) in breast cancer patients. We evaluated associations of social support and noninitiation and discontinuation of, and nonadherence to, AHT in a large, Northern California cohort. Methods: This study included 3,382 women from the Pathways Study who were diagnosed with stages I-III hormone receptor positive breast cancer from 2006-2013 and responded to the Medical Outcomes Study social support survey approximately two months following diagnosis. We used logistic regression to evaluate associations between social support and noninitiation ( < 2 consecutive prescription fills within the first year after diagnosis). Among those who initiated treatment, we used proportional hazards regression to evaluate associations of social support, discontinuation ( > 90 day gap), and nonadherence ( < 80% medical possession ratio) to treatment. Results: Of those who initiated treatment (79%), approximately one fourth either discontinued AHT or were nonadherent. In multivariable-adjusted analyses, adjusted for sociodemographic characteristics, disease severity, other treatment, and presence of comorbidity, women with low (OR = 1.31, 95% CI: 1.06-1.62) and moderate (OR = 1.18, 95% CI: 0.96-1.46) levels of social support were more likely not to initiate AHT treatment, compared to those with high support. Emotional/informational support, tangible support, and positive interaction were each significantly related to noninitiation; affection was not. Of those who initiated treatment, women with low (HR = 1.30, 95% CI: 1.07-1.58) or moderate (HR = 1.19, 95% CI: 0.98-1.44) levels of support were more likely to discontinue treatment. Furthermore, women with low (HR = 1.37, 95% CI: 1.11-1.88) or moderate (HR = 1.24, 95% CI: 1.01-1.52) support had higher nonadherence to treatment. Conclusions: Hormone receptor positive breast cancer patients with low levels of social support had higher noninitiation and discontinuation of, and nonadherence to, AHT. Information on social support may help clinicians determine who is at greater risk of AHT nonadherence.
Integration of survivorship care plans into standard care: A quality improvement project.
Authors: Deslauriers Patricia , Subbiah Shanmuga , Fall-Dickson Jane M.
Published: March 2017

70

Background: American College of Surgeons’ Commission on Cancer accredited programs are required to provide Survivorship Care Plans (SCPs) to cancer survivors after initial cancer treatment. A critical need exists to evaluate SCP patient outcomes. The primary purpose of this quality improvement project was to integrate SCP into standard care for adult stage I, II, and III breast and colon cancer patients. Secondary aims were to examine the hypothesis that the SCP will improve participants’ knowledge base regarding their cancer, health promotion and disease prevention, satisfaction with delivery of health care, quality of life, and adherence to follow-up and surveillance testing. Methods: The IRB approved study was conducted at a hospital-based Medical Oncology Clinic (MOC) in the Western US. A pre/post design was used. Sociodemographic, Medical Outcomes Study Form-36 (MOS-SF-36), Patient Satisfaction Questionnaire Short Form-PSQ-18 (PSQ-SF-18), and Patient Knowledge of Disease Questionnaire (PKDQ) data were collected pre/post SCP. At the follow-up visit, MOS-SF-36, PSQ-SF-18, PKDQ, and open-ended evaluative questionnaire (OEEQ) data were collected. Results: Forty-two subjects were enrolled. The sample is primarily female (n = 36; 86%), Caucasian (n = 41; 97.6%), Hispanic (n = 36; 85.7%), non-high school graduates (n = 26; 61%), and unemployed/retired (n = 32; 78%). Annual incomes were primarily less than $20K (n = 32; 78%). Paticipants were post-treatment for breast cancer (n = 36) or colon cancer (n = 6). 100% of the participants returned for follow-up visits with only 2 (4.8%) delayed. There were significant increases in knowledge (p < 0.001). There were no statistically significant changes in the MOS-SF-36 ant the PSQ-SF-18. Themes in the OEEQ captured satisfaction with the provision of the SCP, changes in health promotion and disease prevention habits. Conclusions: This pilot study supports the hypothesis that SCPs improve adherence to follow-up and patient knowledge, especially in a unique setting of a low socio-economic, ethnically diverse population. A larger study is needed to show statistically significant improvements in health-related quality of life and satisfaction with delivery of health care.
Attendance to Hodgkin lymphoma survivorship care clinics in the Netherlands.
Authors: Nijdam Annelies , de Weijer Roel J. , Janus Cecile P.M. , Clevers-Petersen Eefke J. , Roesink Judith M. , Lugtenburg Pieternella J. , van 't Veer Mars B. , Aleman Berthe M.P. , Raemaekers John M. M. , Van Leeuwen Flora
Published: March 2017

71

Background: Survivors of Hodgkin lymphoma (HL) are at risk for late adverse effects of treatment. The Dutch BETER consortium, consisting of healthcare providers, researchers and patient representatives, has set up survivorship care clinics where HL survivors are screened for late effects. Methods: In order to assess patient characteristics and clinical attendance rates, descriptive statistics were calculated for data on HL survivors who were invited to attend the BETER clinics in the University Medical Center Utrecht (UMCU) and Erasmus University Medical Center (EMC). Results: Overall 291 survivors were invited to attend one of the two BETER clinics. Median age at invitation was 46 years (interquartile range IQR: 40-55 years), median age at HL diagnosis 29 years (IQR: 22-37 years) and median time since diagnosis 16 years (IQR: 11-22 years). Survivors were referred to the BETER clinic by the general EMC/UMCU outpatient clinics where they were still under surveillance (42%) or invited by phone (37%) or letter (20%). While 79% of survivors responded to the invitation, only 53% of all patients actually visited the BETER clinic. Most common reasons to not attend were: undergoing surveillance or treatment for late effects elsewhere (91%) and unwillingness to attend (8%; e.g. due to financial or emotional burden). Ninety-eight% of survivors who were still under surveillance in EMC/UMCU hospitals attended the BETER clinic, as opposed to only 19% of survivors who were no longer under surveillance. Survivors initially invited by letter were more likely to attend (38%) than those who were first contacted by phone (11%). Age at invitation and age at HL diagnosis were similar in those who did and did not attend. Similar data for another 3 clinics are being collected and will be presented at the ASCO Survivorship Symposium. Conclusions: These preliminary data show that only half of HL survivors who were invited, attended a BETER clinic. Unfortunately, survivors who were no longer under medical surveillance were less likely to attend, especially when first contacted by phone. Future, more detailed, evaluation of (non-)attendance in more BETER clinics may reveal the need for additional implementation measures to improve the BETER survivorship care program.
Evaluating preliminary outcomes among primary care and oncology providers who participated in the cancer survivorship e-learning series for primary care providers.
Authors: Pratt-Chapman Mandi , Villalobos Aubrey , Harvey Allison , Roccio Ashley
Published: March 2017

78

Background: The American Cancer Society estimates there are 15.5 million cancer survivors in the U.S. and projects this number will rise. Survivors are at increased risk for a variety of issues due to cancer and its treatment including long-term and late effects. In recent years, there has also been increased focused on ensuring coordinated care for survivors to address these and other issues. Methods: Launched in 2013, the E-Learning Series evaluation employs self-report pre/post surveys using a 5-point Likert scale of agreement. In an initial analysis conducted with available data, participants who took more than one module were represented more than once in the total sample. Independent samples t-tests and Mann Whitney U tests were used for tests of significance for comparisons between PCP and oncology providers. Results: Of the respondents (n = 1,662), PCPs were represented on average 30% across modules. Both PCP and oncology providers reported knowledge gains across modules from pre (Mean pre-range for PCP = 2.96-3.71, SD = 0.797-1.022; Mean pre-range for oncology = 3.28-3.92, SD = 0.717-0.964) to post (Mean post-range for PCP = 4.05-4.44, SD = 0.568-0.716; Mean post-range for oncology = 4.28-4.49, SD = 0.525-0.611). Mean change scores for PCPs ranged from 0.66-1.15 (SD = 0.671-1.093) and for oncology providers change scores ranged from 0.58-1.04 (SD = 0.700-0.967). Related to shared-care model, differences in perceived knowledge gain about treatment late effects were statistically significant (p = 0.001) between PCPs (change score mean = 0.92, SD = 0.975) and oncology providers (change score mean = 0.58, SD = 0.799). Differences were also seen in rehabilitation module, with PCPs indicating gain in ability to identify appropriate interventions (p = 0.047). Conclusions: Initial results indicate the E-Learning Series is effective in improving knowledge about needs of survivors as well as recommended care practices among providers.
The effects of global and targeted advance care planning efforts at a national comprehensive cancer center.
Authors: Zachariah Finly , Emanuel Lindsay , Ito-Hammerling Gayle , Wong-Toh Judy , Morse Denise , Klein Linda , Loscalzo Matthew J. , Garcia Nellie , Buga Sorin , Lew Michael , Horak David , Banerjee Chandana , Mooney Stefanie , Alvarnas Joseph C.
Published: March 2017

79

Background: Advance Care Planning is a central component of patient centered care and helps assure treatment aligns with a patient’s goals, values, and priorities. Various studies demonstrate advance care planning decreases stress and anxiety, increases satisfaction, improves awareness and implementation of a patient’s end of life wishes, and reduces costs in select populations. At City of Hope (COH) National Medical Center, we made concerted efforts over the last four years to improve the overall number of advance directives(ADs), and have additionally focused on improving AD capture rates in clinically relevant populations (patients undergoing surgery, those with metastatic disease, and those undergoing hematologic transplant). Methods: The Department of Supportive Care Medicine with executive team endorsement and in collaboration with medical oncology, hematology, anesthesia, surgery, nursing, marketing, and informatics created a patient-centric advance care planning program. We developed disease specific workflows, created multi-lingual AD workshops in the Sheri & Les Biller Patient and Family Resource Center, changed policy to provide complimentary patient/caregiver and staff notarizations for ADs, leveraged the electronic medical record (assured providers were able to document discussions, know when ADs were absent, and easily retrieve ADs when present), deploy AD specific screening questions, and most recently created a culturally sensitive branding campaign coined “Plan Today for Tomorrow.” Results: The rate of advance directive capture for all patients new to COH has continuously improved from 12% in 2012 to 22% in 2016. In transplant patients, AD capture rate increased to 63%. In a pilot for bladder cancer patients undergoing cystectomy, ADs were increased to 68%, and in the pre-anesthesia testing clinic, ADs were increased to 35%. Conclusions: We have made significant strides in the capture of advance directives at City of Hope with markedly higher capture rates in selectively targeted, clinically relevant populations. We anticipate improved patient centric care as a result, with the unintended consequence of cost savings and decreased resource utilization.
Use of a web-based app to improve breast cancer symptom management and aromatase inhibitor adherence.
Authors: Graetz Ilana , McKillop Caitlin N , Stepanski Edward J. , Vidal Gregory A. , Schwartzberg Lee Steven
Published: March 2017

89

Background: For postmenopausal women with hormone receptor-positive breast cancer, long-term use of aromatase inhibitors (AI) significantly reduces the risk of cancer recurrence and improves disease free and overall survival. Despite the known benefits of AIs, many patients are nonadherent due to adverse side effects. We conducted a pilot randomized controlled trial of a web-enabled application (app) to provide real-time monitoring and better management of treatment-related adverse symptoms among patients with hormone-receptor positive breast cancer and a new AI prescription. Methods: Eligible patients who agreed to participate were randomized into either: App: had access to the app and received weekly reminders to use it; or Usual Care: had access to the app but did not receive reminders. Concerning responses and trends triggered email alerts to the patient’s providers, who then could review responses to manage ongoing treatment and make therapeutic adjustments. The main analyses compared overall AI adherence using the Morisky Medication Adherence Scale and quality of life using the Functional Assessment of Cancer Therapy Endocrine Symptoms (FACT-ES). Results: We enrolled 44 patients, 21 in the App and 23 in the Usual Care groups; 83% of patients approached agreed to participate, 23% were African-American, and 32% were over the age of 65. Overall, 74% of participants in the App group used the app at least once per week compared with 38% in the Usual Care group (p<0.01). Reported AI adherence at 8 weeks after initiation was significantly higher among App compared with the Usual care group at 8 weeks (100% vs. 72%, p=0.01). Using a differences-in-differences analysis, we found a substantially larger decrease in quality of life in the Usual Care group compared with the App (-11.5 vs. -3.9, p=0.191), although this difference did not reach statistical significance. Conclusions: App use with weekly reminders significantly improved short-term AI adherence. If short-term gains in adherence persist, this low-cost intervention could improve survival outcomes for women with hormone-receptor positive breast cancer.
Breast cancer care redesign as an approach to streamline survivorship care: Outcomes and challenges.
Authors: Post Kathryn Elizabeth , Smith Barbara L. , Taghian Alphonse G. , Isakoff Steven J. , Peppercorn Jeffrey M. , Moy Beverly
Published: March 2017

9

Background: Optimal follow up care for the 3.1 million breast cancer (BC) survivors in the United States has not been definitively determined. ASCO and NCCN recommend that early stage BC patients have a history and physical by their oncology or primary care provider every 3 to 6 months in the first three years post treatment. Additional visits have not been shown to improve outcomes. However, many patients are seen more frequently, leading to increased healthcare costs. In this context, we developed and implemented a BC care redesign algorithm (BCCRA) to reduce redundant follow up. Methods: The BCCRA multidisciplinary team recommended BC survivors be seen by an oncology provider every 6 months for the first five years post treatment and annually thereafter. Retrospective chart review was conducted to evaluate BCCRA adherence from November 2014 to November of 2015. Patients were deemed ineligible if there was a medically necessary reason for visits outside of the BCCRA such as reconstruction, ongoing treatment or clinical trial participation. Eligible charts were analyzed for adherence. For survivors who did not adhere, charts were analyzed for outcome of additional visits. Results: 116 patient charts reviewed and 72 (62.1%) were deemed ineligible. Of the remaining 44 survivors, 26 (59.1 %) adhered and 18 (40.91%) did not adhere. Of the 18 survivors who did not adhere, six had visits due to clinical concern and 12 had visits due to patient or provider preference. Of the 6 patients who had visits for clinical concern, 4 resulted in a change in the patient’s medical management (CMM). Of the 12 patients who had visits due to patient/provider preference, 2 resulted in a CMM. Conclusions: Despite buy-in from a motivated multidisciplinary team, there were challenges to implementing the BCCRA. 62.1% of patients were ineligible and there was a significant proportion of patients/providers who chose more frequent visit schedules. However, the BCCRA had 59.1% adherence which could result in cost reduction and increased flexibility in oncologists’ schedules. Further evaluation of the model is needed to validate these claims.
A multisite cancer survivorship clinical placement program for primary care practitioners (PCPs).
Authors: Jefford Michael , Wiley Georgina , Piper Amanda , Evans Judy , Nolte Linda , Drosdowsky Allison , Simkiss Liz , Whitfield Kathryn , Cairns Julie , Raco Giovanna , Mann Bruce , Shanahan Kerry , Pitcher Meron , Bell Bianca
Published: March 2017

95

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.
Primary care physicians experiences of caring for cancer survivors: Toward developing a primary care-responsive cancer survivorship research agenda.
Authors: O'Malley Denalee M. , Davis Stacy N. , Crabtree Benjamin F , Hudson Shawna V.
Published: March 2017

97

Background: Understanding of the ecology of primary care can inform efforts that aim to build primary care capacity to address cancer survivorship issues. This study describes the experiences of primary care physicians (PCPs) delivering care to cancer survivors. Methods: Semi-structured in-depth interviews were conducted with PCPs (n=30) across two NCI-funded studies of cancer survivorship in primary care. PCPs were recruited from primary care practices enrolled in a qualitative case study of cancer survivorship in patient centered medical homes (R01 CA176545; n=21) and from a sample recruited for the formative development of a primary care mHealth and health coaching interventions for cancer survivors (R01 CA176838; n=9). Interviews averaged 30 minutes, were audio-recorded and transcribed verbatim. A multi-step immersion/crystallization approach was used to identify emergent themes using Atlas.ti. Results: PCPs stated that their role in cancer survivorship care varies widely and is often shaped by patient characteristics. These characteristics include: patient expectations of the PCPs role; the patient’s ability to provide clinical details about their cancer and its treatment; and the status of patient relationship with cancer treatment team. PCPs described having incomplete information and recounted experiences of cancer survivors presenting for visits motivated by fear of disease recurrence. PCPs described the tensions around having to make decisions about further additional testing versus offering support about recurrence of fears with incomplete clinical information. PCPs also expressed a need for basic clinical information and surveillance plans to be integrated into existing systems of care (e.g. electronic medical record systems and registries), citing immunization schedules as a potential model. Conclusions: The lack of clinical information to inform cancer survivors’ care remains a critical challenge to PCPs. Survivorship care plans are a proposed strategy to rectify informational deficits; however, further evaluation of how effectively care plans integrate into primary care systems and processes are needed.
Understanding primary care provider (PCP) experiences with survivorship care plans (SCPs) and informational needs when caring for cancer survivors.
Authors: Garces Natalie , Eaton Tara , Robinson Myra M , York Beth , Bailey-Dorton Chasse Margot , Brick Wendy G.
Published: March 2017

98

Background: Survivorship advocate organizations, including the Commission on Cancer and the American College of Surgeons, have proposed SCPs as one solution to help meet the post-treatment needs of cancer survivors and improve coordination of care between provider types. Though there have been a few recent studies investigating PCP evaluation of SCPs and their survivorship informational needs, widespread incorporation of PCP and other provider types’ perspectives on survivorship care planning and SCPs is lacking. Methods: Levine Cancer Institute emailed 598 surveys to PCPs and obstetrics and gynecology (OBGYN) providers affiliated with Carolinas HealthCare System. 159 surveys were returned (26.6% response rate) between February and August 2016. Results: Nearly half of providers reported having received a SCP (42.4%, 67 of 158) and the vast majority of those who did (95.5%, 64 of 67) found them useful. Providers stated that the most useful parts of the SCP for their practice needs were the surveillance recommendations (50.0%) and the treatment summary (45.3%). Respondents indicated the most challenging part of caring for cancer survivors is knowing the recommended surveillance tests/schedule/who is the responsible provider to order tests (53.8%) and knowing what late-effects of treatment to look out for (20.2%). The majority (77.7%) of providers reported using Up-to-Date to guide them in their care of patients who have completed cancer treatment. Providers indicated that guidelines for identifying and managing late (44.9%) and lingering (32.7%) effects of treatment would be the most helpful resources in caring for cancer survivors. Finally, providers reported interest in attending future CME conferences on surveillance (73.4%), managing late (57.8%) and lingering (54.1%) effects, and integrative and alternative therapies (24.8%). Conclusions: Preliminary findings from this internal survey suggest PCPs and OBGYNs may find SCPs useful and may need additional resources to guide their care of cancer survivors. We recommend formal study of preferences for SCP content among these understudied provider groups in the coordination of survivorship care.
A Contemporary Medicolegal Analysis of Implanted Devices for Chronic Pain Management
Authors: Abrecht Christopher R. , Greenberg Penny , Song Ellen , Urman Richard D. , Rathmell James P.
Published: March 2017

BACKGROUND:

Analysis of closed malpractice claims allows the study of rare but serious complications and likely results in improved patient safety by raising awareness of such complications. Clinical studies and closed claims analyses have previously reported on the common complications associated with intrathecal drug delivery systems (IDDS) and spinal cord stimulators (SCS). This study provides a contemporary analysis of claims from within the past 10 years.

METHODS:

We performed a closed claims analysis for a period January 1, 2009 to December 31, 2013 for cases with pain medicine as the primary service. These cases were identified using the Controlled Risk Insurance Company (CRICO) Comparative Benchmarking System (CBS), a database containing more than 300,000 malpractice claims from more than 400 academic and community institutions, representing approximately 30% of malpractice cases in the United States. The clinical narratives, which included medical files, claims files, depositions, and expert witness testimony, were reviewed by the authors, as were the CRICO coded variables, which included algorithmically determined contributing factors to the patient injury.

RESULTS:

Intrathecal drug delivery systems represented 17 of the closed claims; spinal cord stimulators represented 11 of the closed claims. The most common chronic pain diagnoses for which a device was implanted included failed back surgery syndrome and spasticity. The average total incurred for pain medicine claims was $166,028. Damaging events included IDDS refill errors (eg, subcutaneous administration of medication, reprogramming errors), intraoperative nerve damage, and postoperative infection (eg, epidural abscess, meningitis). High-severity outcomes included nerve damage (eg, paraplegia) and death. Medium-severity outcomes included drug reactions (eg, respiratory arrest from opioid overdose) and the need for reoperation. For both IDDS and SCS, deficits in technical skill were the most common contributing factor to injury, followed by deficits in clinical judgment, communication, and documentation.

CONCLUSIONS:

Implanted devices used for pain management involve a significant risk of morbidity and mortality. Proper education of providers and patients is essential. Providers must acquire the technical skills required for the implantation and refilling of these devices and the clinical skills required for the identification and management of complications such as intrathecal granuloma. Proper patient selection and clear communication between the provider and the patient about these possible complications are of paramount importance.
Tanshinone IIA Attenuates Sevoflurane Neurotoxicity in Neonatal Mice
Authors: Xia Yimeng , Xu Heng , Jia Chenfei , Hu Xiaodong , Kang Yu , Yang Xiaoxuan , Xue Qingsheng , Tao Guorong , Yu Buwei
Published: March 2017

BACKGROUND:

Sevoflurane is the most widely used inhalational anesthetic in pediatric medicine. Despite this, sevoflurane has been reported to exert potentially neurotoxic effects on the developing brain. Clinical interventions and treatments for these effects are limited. Tanshinone IIA (Tan IIA), extracted from Salvia miltiorrhiza (Danshen), has been documented to alleviate cognitive decline in traditional applications. Therefore, we hypothesized that preadministration of Tan IIA may attenuate sevoflurane-induced neurotoxicity, suggesting that Tan IIA is a new and promising drug capable of counteracting the effects of cognitive dysfunction produced by general anesthetics.

METHODS:

To test this hypothesis, neonatal C57 mice (P6) were exposed to 3% sevoflurane for 2 hours with or without Tan IIA pretreatment at a dose of 10 mg/kg or 20 mg/kg for 3 consecutive days. Cognitive behavior tests such as open field tests and fear conditioning were performed to evaluate locomotor and cognitive function at P31 and P32. At P8, other separate tests, including TdT mediated dUTP Nick End Labeling (TUNEL) assay, immunohistochemistry, Western blotting, enzyme-linked immunosorbent assay, and electron microscopy, were performed. The mean differences among groups were compared using 1-way analysis of variance followed by Bonferroni post hoc multiple comparison tests.

RESULTS:

Repeated exposure to sevoflurane leads to significant cognitive impairment in mice, which may be explained by increased apoptosis, overexpression of neuroinflammatory markers, and changes in synaptic ultrastructure. Interestingly, preadministration of Tan IIA ameliorated these neurocognitive deficits, as shown by increased freezing percentages on the fear conditioning test (sevoflurane+Tan IIA [20 mg/kg] versus sevoflurane, mean difference, 19, 99% confidence interval for difference, 6.4–31, P < .0001, n = 6). The treatment also reduced the percentage of TUNEL-positive nuclei (sevoflurane versus sevoflurane+Tan IIA [20 mg/kg], 2.6, 0.73–4.5, P = .0004, n = 6) and the normalized expression of cleaved caspase-3 (sevoflurane versus sevoflurane+Tan IIA [20 mg/kg], 0.27, 0.02–0.51, P = .0046, n = 5). Moreover, it attenuated the production of the neuroinflammatory mediators interleukin (IL)-1β and IL-6 (normalized sevoflurane versus sevoflurane+Tan IIA [20 mg/kg]: IL-1β: 0.75, 0.47–1.0; P < .0001; IL-6: 0.66, 0.35–0.97; P < .0001; n = 10 per group). Finally, based on measurements of postsynaptic density, the treatment preserved synaptic ultrastructure (sevoflurane+Tan IIA [20 mg/kg] versus sevoflurane, 42, 20–66; P < .0001; n = 12 per group).

CONCLUSIONS:

These results indicate that Tan IIA can alleviate sevoflurane-induced neurobehavioral abnormalities and may decrease neuroapoptosis and neuroinflammation.
Evaluation of Lung Function and Clinical Features of the Ultrasound-Guided Stellate Ganglion Block With 2 Different Concentrations of a Local Anesthetic: A Randomized Controlled Trial
Authors: Kim Won-Joong , Park Hahck Soo , Yi Myung Sub , Koo Gill-Hoi , Shin Hwa-Yong
Published: March 2017

BACKGROUND:

One possible complication of stellate ganglion block (SGB) is respiratory compromise. No study has yet addressed the comparison of its effect on lung function and clinical features, including Horner’s syndrome, changes in temperature, sensory and motor functions, and adverse events of lower versus higher concentrations (LC and HC, respectively) of local anesthetics in an ultrasound-guided SGB.

METHODS:

Fifty patients were randomized into 1 of 2 groups: the LC group (5 mL of 0.5% mepivacaine) and the HC group (5 mL of 1% mepivacaine). One anesthesiologist performed a C6- SGB under ultrasound guidance. Our primary objective was to compare LC and HC of a local anesthetic in terms of its effect on lung function, and the secondary objective was to compare the clinical features between LC and HC of a local anesthetic. Lung function was compared between the 2 groups using the Mann-Whitney U test.

RESULTS:

The forced vital capacity at 20 minutes post-SGB was not significantly different between the HC and the LC groups (P = .360); the median difference (95% confidence intervals [CI]) was 1 (−1 to 8). Other parameters of lung function were comparable with the forced vital capacity. Patients in the HC group had significantly greater sensory changes than those in the LC group (% decrease compared with the unblocked side); 95.4 ± 2.1 (CI: 91.11–99.73) vs 87.3 ± 3.5 (CI: 80.12–94.49).

CONCLUSIONS:

Lung function between the LC and HC groups after SGB did not differ significantly. Clinical features between the 2 groups also did not differ clinically, except that patients in the HC group had significantly greater sensory loss in the C6 dermatomes.
From the Archives to the Streets
Authors: Hendrickson Burleigh
Published: March 2017

In the spring of 1968, activists across the globe took to the streets and clashed with authorities to protest neo-imperialism, oppressive regimes, and the postcolonial order of things. While there is no shortage of archival material documenting this type of activism during France's mai 68, this is often not the case for similar activism in places like Tunisia and Senegal. This article discusses the importance of personal archives and oral histories for analyzing lesser-known activism of the 1960s and 1970s in the former French empire. On the one hand, oral histories can help clarify archival material; on the other hand, they can further muddy politically charged narratives where past, present, and future collide. Through an analysis of interviews conducted with 1968 participants in France, Tunisia, and Senegal, I uncover the promises and perils of expanding conventional notions of the archive for the study of the “global 1960s.”

Au printemps 1968, des militants autour du monde ont affronté les forces de l'ordre dans la rue pour protester contre le néo-impérialisme et les régimes postcoloniaux oppressifs. Tandis qu'il y a beaucoup d'archives sur ce type de militantisme dans le mai 68 français, ce n'est pas le cas pour les mouvements en Tunisie et au Sénégal. Cet article vise à capter l'importance des archives privées et de l'histoire orale pour l'analyse des mouvements minorés aux années 1960 dans l'ancien empire français. D'une part, l'histoire orale peut clarifier le contenu des archives ; d'autre part, elle sert à embrouiller les récits politiques où le passé, le présent et le futur se heurtent. L'analyse des entretiens menés en France, en Tunisie et au Sénégal dévoile des avantages et des pièges associés à l'expansion de la notion traditionnelle des archives pour l'étude des « années 68 ».
TOPLESS mediates brassinosteroid control of shoot boundaries and root meristem development in Arabidopsis thaliana
Authors: Espinosa-Ruiz Ana , Martínez Cristina , de Lucas Miguel , Fàbregas Norma , Bosch Nadja , Caño-Delgado Ana I. , Prat Salomé
Published: March 2017

The transcription factor bri1-EMS-SUPRESSOR1 (BES1) is a master regulator of brassinosteroid (BR)-regulated gene expression. BES1 together with BRASSINAZOLE-RESISTANT1 (BZR1) drive activated or repressed expression of several genes, and have a prominent role in negative regulation of BR synthesis. Here, we report that BES1 interaction with TOPLESS (TPL), via its ERF-associated amphiphilic repression EAR motif, is essential for BES1-mediated control of organ boundary formation in the SAM and the regulation of the quiescent center (QC) cell division in roots. We show that TPL binds via BES1 to the promoters of the CUC3 and BRAVO targets and suppresses their expression. Ectopic expression of TPL leads to similar organ boundary defects and alterations in the QC cell division rate as the bes1-d mutation, while bes1-d defects are suppressed by the dominant interfering tpl-1 protein, with these effects respectively correlating with changes in CUC3 and BRAVO expression. Together, our data unveil a pivotal role of the co-repressor TOPLESS in the shoot and root meristems, which relies on its interaction with BES1 and regulation of BES1 target gene expression.
Massive ear keloids: Natural history, evaluation of risk factors and recommendation for preventive measures – A retrospective case series
Authors: Tirgan Michael
Published: March 2017

Keloid disorder (KD) is an inherited wound healing ailment, frequently seen among Africans /African Americans and Asians.  Genetics of this disorder continues to be obscure and poorly understood.  Clinical manifestation of KD is quite variable and very diverse, spanning from individuals with one or very few small keloidal lesions, to those with numerous and very large lesions covering large portion of their skin. Ears are common locations for development of keloids.  Ear piercing is by far the leading triggering factor for ear keloid formation in genetically predisposed individuals. Although there are numerous publications about ear and earlobe keloids, there is a void in medical literature about massive ear keloids.  This paper focuses on the natural history of massive ear keloids and risk factors that lead to formation of these life-changing and debilitating tumors and recommendations for prevention.
Journal Scan
Authors: Welyczko Nikki
Published: March 2017

Nikki Welyczko, Teacher Fellow and Principal Lecturer for Adult Nursing at the Faculty of Health and Life Sciences, De Montfort University, provides a brief overview of recently published nursing and health articles
Engaging fathers: Acknowledging the barriers
Authors: Bateson Karen , Darwin Zoe , Galdas Paul , Rosan Camilla
Published: March 2017

Engaging fathers has the potential to benefit the entire family through promoting fathers' wellbeing directly; building on fathers' vital capacity to support mothers' psychological wellbeing; maternal health behaviours; and promoting children's mental health and development. Benefits to a child's development include positive impacts on cognitive development, educational attainment, social competence, positive self-esteem and reduced incidence of emotional and behavioural problems. However, the barriers to father-inclusive practice are numerous and include personal, organisational, strategic and societal factors. This article reviews the need to work more closely and fruitfully with fathers, and acknowledges some of the barriers.
Postnatal depression: Student health visitors' perceptions of their role in supporting fathers
Authors: Oldfield Veronique , Carr Helen
Published: March 2017

A qualitative, interpretative phenomenological analysis (IPA) study was undertaken to explore student health visitors' perceptions of their role in supporting fathers when their partner has had postnatal depression (PND). Purposive sampling was used to ensure participants were chosen based on their ability to answer the research question. Data collection included one-to-one, semi-structured interviews with student health visitors/newly qualified health visitors, which were then transcribed and analysed by the researcher. Themes from the data were identified during analysis. The findings demonstrate that student health visitors felt that paternal mental health was not addressed in their training and they did not feel able to adequately support fathers in practice. Participants searched for a solution to how health visitors can be more inclusive of fathers and how to support both parents in the postnatal period when the mother has got PND.