Defining Essential Elements of Caregiver Support in Gynecologic Cancers Using the Modified Delphi Method

PURPOSE

Family caregivers are instrumental to patients with gynecologic cancer and can be deeply affected by the demands of caregiving. Our aims were as follows: (1) increase awareness of unmet needs of caregivers and (2) identify and prioritize the unmet needs of caregivers and essential support services to be provided in gynecologic cancer centers.

METHODS

From July 2017 to June 2018, a 16-person steering committee and 40 stakeholders, including caregivers, patients, and clinicians, participated in a modified Delphi approach to generate, review, and prioritize a set of essential elements for caregiver support. Stakeholders prioritized caregiver needs and brainstormed, discussed, and prioritized essential support services to meet those needs, using three rounds of a consensus-building protocol. Basic descriptive statistics were performed to feed means and rankings back to stakeholders before each round.

RESULTS

The top three caregiver needs were as follows: (1) to obtain information about their loved one's cancer, (2) how to provide support and comfort to their loved one, and (3) how to maintain their own emotional health and well-being. Fifteen essential elements of support for caregivers of patients with gynecologic cancer were identified and ranged from elements currently attainable (eg, information on managing symptoms, skilled-care training, a point person to help navigate the system) to more aspirational elements (eg, integrative services to promote caregiver well-being).

CONCLUSION

To ensure comprehensive quality care, clinicians and health care providers should strive to provide caregivers with the identified essential elements of support. Health care settings should work to incorporate caregiver needs into cancer care delivery.

Exploration of a new model of care in a psychiatry unit

The model established at Orillia Soldiers Memorial Hospital involves family physicians as the most responsible physician. They act as "admission gatekeeper" for all unattached patients who are admitted to the psychiatry in-patient unit. A PubMed, EBSCO, OVID Medline, Embase, CINAHL, and Web of Science database review of the last 10 years (2006-2016) was undertaken. A satisfaction survey was undertaken. An intensive literature review found this model to be unique. The model has proved to be extremely efficient and cost-effective.

Elective chemotherapy admission pilot and work-flow improvements to reduce excess days

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Background: The Inpatient (Inpt) Oncology Service at University Hospitals Seidman Cancer Center, a large urban academic NCI Comprehensive Cancer Center was charged with identifying opportunities to link patient (pt) quality improvement and decreased length of stay (LOS) in pts admitted for elective chemotherapy (EC). Historically, EC admissions were delayed due to pt variables, inpt bed availability, and chemotherapy order entry errors. Often chemotherapy was not initiated until late evening on day of admission, resulting in increased LOS. Safety concerns associated with late starts included fewer pharmacy resources, lower nurse/pt ratio, and no onsite APRN. Methods: A 2-month pilot was conducted, using an intervention group (IG) and control (C) group representing usual care (UC). The IG group was a subset with oropharyngeal pts and C group, all other EC admissions. Pre-registration and bed placement processes were reviewed. Workflow changes for IG included chemotherapy order set entered in electronic medical record 48 hours before admission, labs drawn day before admission, and weekly huddle including admitting, inpt and outpatient (Outpt) teams to review upcoming week’s admissions. IG pts were pre-scheduled for am admission. Inpt oncology services incorporated admissions into morning workflow. Census was taken above cap to accommodate IG patients. Time parameters were tracked from point of pt arrival in Admitting to initiation of EC. Results: There were 32 pts in the 2-month pilot study; 14 in the IG and 9 in UC. Mean admit time was 0900 (range 0730-1030) for IG and 1200 noon (range 1000-1600) for UC. Initiation of EC before 1500 occurred in 93% of IG compared to 11% of UC pts. This resulted in an average decreased LOS for IG of 1.1 day compared to UC. Pt and family comments included appreciation of predictable admit time and LOS. Conclusions: Because of the 8-week pilot success, these EC workflow changes have been implemented across Oncology services. Weekly huddles and coordination of clinical services across inpt and outpt settings continue to show advantage of proactive planning and troubleshooting before the day of EC admission. More importantly, EC pt safety and experience has improved with these work-flow changes.

Introduction to the DAPPLE Air Pollution Project

The Dispersion of Air Pollution and its Penetration into the Local Environment (DAPPLE) project brings together a multidisciplinary research group that is undertaking field measurements, wind tunnel modelling and computer simulations in order to provide better understanding of the physical processes affecting street and neighbourhood-scale flow of air, traffic and people, and their corresponding interactions with the dispersion of pollutants at street canyon intersections. The street canyon intersection is of interest as it provides the basic case study to demonstrate most of the factors that will apply in a wide range of urban situations. The aims of this paper are to introduce the background of the DAPPLE project, the study design and methodology for data collection, some preliminary results from the first field campaign in central London (28 April-24 May 2003) and the future for this work. Updated information and contact details are available on the web site at http://www.dapple.org.uk.

Localization of the m2 muscarinic acetylcholine receptor protein and mRNA in cortical neurons of the normal and cholinergically deafferented rhesus monkey

The m2 muscarinic acetylcholine receptor in the cerebral cortex has traditionally been thought of as an autoreceptor located on cholinergic fibers that originate from neurons in the nucleus basalis of Meynert. We now provide evidence for widespread localization of the m2 receptor in noncholinergic neurons and fibers of the cerebral cortex. The cellular and subcellular distribution of the m2 receptor protein and mRNA were examined in normal monkeys and in monkeys in which the cortical cholinergic afferents were selectively lesioned by injection of the specific immunotoxin, anti-p75NTR-saporin into the nucleus basalis. Both in normal and immunolesioned monkeys, the m2 mRNA and protein were localized in pyramidal and nonpyramidal neurons. In pyramidal neurons, membrane-associated receptor immunoreactivity was found exclusively in dendritic spines receiving asymmetric synapses, indicating that the m2 receptor may modulate excitatory neurotransmission at these sites. In nonpyramidal neurons, the m2 immunoreactivity was present along the cytoplasmic surface of membranes in cell bodies, dendrites and axons. Both in pyramidal and nonpyramidal neurons of normal and lesioned monkeys, the m2 receptor was located peri- and extra-synaptically, suggesting that it may be contacted by acetylcholine via volume transmission. The localization of the m2 receptor in cortical neurons and the sparing of m2 immunoreactivity in lesioned monkeys indicates that the m2 receptor is synthesized largely within the cortex and/or is localized to noncholinergic terminals of either intrinsic or extrinsic origin. These findings open the possibility that the loss of the m2 receptor in Alzheimer's disease may in part be due to degenerative changes in m2 positive neurons of the cortex rather than entirely due to the loss of autoreceptors.

A new sodium channel alpha-subunit gene (Scn9a) from Schwann cells maps to the Scn1a, Scn2a, Scn3a cluster of mouse chromosome 2

We have used a total of 27 AXB/BXA recombinant inbred mouse strains to determine the chromosomal location of a newly identified gene encoding an alpha-subunit isoform of the sodium channel from Schwann cells, Scn9a. Linkage analysis established that Scn9a mapped to the proximal segment of mouse chromosome 2. The segregation of restriction fragment length polymorphisms in 145 progeny from a Mus spretus x C57BL/6J backcross indicates that Scn9a is very tightly linked to Scn1a (gene encoding the type I sodium channel alpha-subunit of the brain) and forms part of a cluster of four Scna genes located on mouse chromosome 2.

Examination of the esterified fatty acids from mouse erythrocyte and synaptosomal membrane phospholipids and their distribution between the various phospholipid types

Esterified fatty acids from mouse erythrocyte and synaptosomal membranes were characterised by fused-silica capillary gas-liquid chromatography and gas chromatography-mass spectrometry. Structural information was obtained from the mass spectra of a number of derivatives including trimethylsilyl (TMS), methyl and picolinyl esters together with the TMS ethers of glycols derived from the unsaturated acids. In addition to previously characterised acids, small concentrations of several acids previously unreported from these membranes were identified. These included branched chain acids and several unsaturated acids.

Direct measurement of propranolol bioavailability during accumulation to steady-state

1. A high performance liquid chromatographic method for the determination of propranolol in human plasma and blood has been developed and used to confirm that cumulation occurred during chronic oral administration, steady-state being achieved within 48 h of beginning 80 mg of the drug every 8 h. 2. The method was adapted to measure [H3]-propranolol and native drug in the same blood sample and was applied to determine simultaneously the disposition of i.v. ([H3]-propranolol) and orally (non-labelled) administered drug after single oral dose of 80 mg and when steady-state had been established on an 80 mg, 8-hourly regimen. 3. Using this approach it was possible to show that a reduced oral clearance at steady-state was associated with a smaller reduction in systemic (i.v.) clearance and no change in liver blood flow. A direct estimate of bioavailability was also possible and was found to be increased at steady-state compared with a single oral dose. 4. We conclude that the accumulation of propranolol during the attainment of steady-state is due to a reduction in intrinsic clearance, resulting in reduced presystemic hepatic extraction.