Interventions for improving psychosocial care and support in routine oncology practice.

A cancer diagnosis may have a significant impact on an individual and those around them. This is not always recognised in routine oncology practice, and information provision for patients on psychosocial difficulties may be delivered in an ad-hoc manner. Unresolved social difficulties may undermine patients’ abilities to deal with the larger stressors of the disease and its treatment, increasing the burden on patients and services. The overall aim of the work presented in this thesis was to explore implementation of a programme of social difficulties assessment, which utilised the Social Difficulties Inventory (SDI-21) and included staff training and provision of information to patients. Pilot randomised controlled trials (RCTs) were conducted to explore the role of two components of this programme in managing social difficulties. The first was a study-specific information resource, which was developed, evaluated, and its impact on processes of care, patient behaviours and well-being assessed through the pilot RCT. Secondly, an assessment method, incorporating training for nurses in utilising the SDI-21, was evaluated in the second RCT. Both RCTs were used to calculate estimates of effect sizes to inform future trials of these interventions. The information resource was not widely used. Qualitative data suggested various reasons for this, including that patients are faced with an often overwhelming amount of information. Difficulties in implementing the assessment process were experienced in the second RCT, confounded by issues with recruitment. Qualitative data provided depth of understanding around implementation issues and highlighted key considerations for future trials. Small effect sizes were observed for both interventions. Development of a full RCT cannot be recommended based on the findings presented here, and alternative trial designs (e.g. quasi-experimental, service improvement models) should be considered

Development of an Item Pool for a Needs-Based Measure of Quality of Life of Carers of a Family Member with Dementia.

BACKGROUND AND OBJECTIVES: This paper describes the development of an item pool for a needs-based self-report outcome measure of the impact of caring for a relative, friend or neighbour with dementia on carer quality of life. The aims are to give a detailed account of the steps involved and describe the resulting item pool. METHODS: Seven steps were followed: generation of an initial item set drawing on 42 needs-led interviews with carers; a content and face validity check; assessment of psychometric potential; testing of response formats; pre-testing through cognitive interviews with 22 carers; administration rehearsal with two carers; and final review. RESULTS: An initial set of 99 items was refined to a pool of 70 to be answered using a binary response format. Items were excluded due to overlap with others, ceiling effects, ambiguity, dependency on function of the person with dementia or two-part phrasing. Items retained covered a breadth of areas of impact of caring and were understandable and acceptable to respondents. CONCLUSIONS: The resulting dementia carer-specific item pool reflects the accounts of a diverse sample of those who provide care for a person with dementia, allowing them to define the nature of the impact on their lives and resulting in a valid, acceptable set of items.Jan Oyebode, Penny Wright, Simon Pini, Mike Horton, each declare that this work was supported by the Medical Research Council (MRC) and the National Institute for Health Research (NIHR). Grant title: HQLC Dementia Carers Instrument Development: DECIDE (MR/M025179/1) and that the grant is registered on the UK Research and Innovation Gateway: http://gtr.ukri.org/projects?ref=MR/M025179/1 . They also declare that they have received financial support for travel to meetings for the study, manuscript preparation or other purposes from the grant funder as part of the award only. In addition, Penny Wright has declared that she is the principal investigator and was the main applicant for the funding that was received from the MRC and NIHR, and Jan Oyebode has declared her position as a coinvestigator. The following authors have no conflicts of interest to declare: Emma Ingleson, Molly Megson, Linda Clare, Hareth Al-Janabi, Carol Brayne

Dementia Carers Instrument Development (DECIDE) - Qualitative interview data

This dataset contains qualitative interview transcripts, obtained from 41 of 42 semi-structured interviews with a purposively diverse sample of primary carers aged ≥16 years, supporting a partner or family member who had a diagnosis of dementia and living in the community. Participants included 28 females, and 14 males (aged 31-83). The sample included 22 carers who were husband or wife of the person with dementia, and 20 who were daughters, sons, daughter-in-laws or granddaughters. Specific diagnoses of the person with dementia included Alzheimer's disease, vascular dementia, or other. Open questions were used to explore carers’ experiences, thoughts, and feelings related to challenging and rewarding experiences and events. Socratic questioning was employed, through asking carers to reflect on why particular experiences of care made them feel or think as they did. In this way, we aimed to uncover underlying needs that were impacted upon by the carer experience and generate nuanced contextualized accounts of how caring impacted on carers’ lives

Daratumumab, Cyclophosphamide, Bortezomib, Lenalidomide, and Dexamethasone as Induction and Extended Consolidation Improves Outcome in Ultra-High-Risk Multiple Myeloma

Purpose: The multicenter OPTIMUM (MUKnine) phase II trial investigated daratumumab, low-dose cyclophosphamide, lenalidomide, bortezomib, and dexamethasone (Dara-CVRd) before and after autologous stem-cell transplant (ASCT) in newly diagnosed patients with molecularly defined ultra–high-risk (UHiR) multiple myeloma (NDMM) or plasma cell leukemia (PCL). To provide clinical context, progression-free survival (PFS) and overall survival (OS) were referenced to contemporaneous outcomes seen in patients with UHiR NDMM treated in the recent Myeloma XI (MyeXI) trial.Methods: Transplant-eligible all-comers NDMM patients were profiled for UHiR disease, defined by presence of ≥2 genetic risk markers t(4;14)/t(14;16)/t(14;20), del(1p), gain(1q), and del(17p), and/or SKY92 gene expression risk signature. Patients with UHiR MM/PCL were offered treatment with Dara-CVRd induction, V-augmented ASCT, extended Dara-VR(d) consolidation, and Dara-R maintenance. UHiR patients treated in MyeXI with carfilzomib, lenalidomide, dexamethasone, and cyclophosphamide, or lenalidomide, dexamethasone, and cyclophosphamide, ASCT, and R maintenance or observation were identified by mirrored molecular screening. OPTIMUM PFS at 18 months (PFS18m) was compared against MyeXI using a Bayesian framework, and patients were followed up to the end of consolidation for PFS and OS.Results: Of 412 screened NDMM OPTIMUM patients, 103 were identified as UHiR or PCL and subsequently treated on trial with Dara-CVRd; 117 MyeXI patients identified as UHiR formed the external comparator arm, with comparable clinical and molecular characteristics to OPTIMUM. Comparison of PFS18m per Bayesian framework resulted in a 99.5% chance of OPTIMUM being superior to MyeXI. At 30 months' follow-up, PFS was 77% for OPTIMUM versus 39.8% for MyeXI, and OS 83.5% versus 73.5%, respectively. Extended post-ASCT Dara-VRd consolidation therapy was highly deliverable, with limited toxicity.Conclusion: Our results suggest that Dara-CVRd induction and extended post-ASCT Dara-VRd consolidation markedly improve PFS for UHiR NDMM patients over conventional management, supporting further evaluation of this strategy.</p

Using the Theoretical Domains Framework (TDF) to understand adherence to multiple evidence-based indicators in primary care : a qualitative study

BACKGROUND: There are recognised gaps between evidence and practice in general practice, a setting posing particular implementation challenges. We earlier screened clinical guideline recommendations to derive a set of 'high-impact' indicators based upon criteria including potential for significant patient benefit, scope for improved practice and amenability to measurement using routinely collected data. Here, we explore health professionals' perceived determinants of adherence to these indicators, examining the degree to which determinants were indicator-specific or potentially generalisable across indicators. METHODS: We interviewed 60 general practitioners, practice nurses and practice managers in West Yorkshire, the UK, about adherence to four indicators: avoidance of risky prescribing; treatment targets in type 2 diabetes; blood pressure targets in treated hypertension; and anticoagulation in atrial fibrillation. Interview questions drew upon the Theoretical Domains Framework (TDF). Data were analysed using framework analysis. RESULTS: Professional role and identity and environmental context and resources featured prominently across all indicators whilst the importance of other domains, for example, beliefs about consequences, social influences and knowledge varied across indicators. We identified five meta-themes representing more general organisational and contextual factors common to all indicators. CONCLUSIONS: The TDF helped elicit a wide range of reported determinants of adherence to 'high-impact' indicators in primary care. It was more difficult to pinpoint which determinants, if targeted by an implementation strategy, would maximise change. The meta-themes broadly underline the need to align the design of interventions targeting general practices with higher level supports and broader contextual considerations. However, our findings suggest that it is feasible to develop interventions to promote the uptake of different evidence-based indicators which share common features whilst also including content-specific adaptations

To what extent can behaviour change techniques be identified within an adaptable implementation package for primary care? A prospective directed content analysis

Interpreting evaluations of complex interventions can be difficult without sufficient description of key intervention content. We aimed to develop an implementation package for primary care which could be delivered using typically available resources and could be adapted to target determinants of behaviour for each of four quality indicators: diabetes control, blood pressure control, anticoagulation for atrial fibrillation and risky prescribing. We describe the development and prospective verification of behaviour change techniques (BCTs) embedded within the adaptable implementation packages

Isotropic Brillouin spectra of liquids having an internal degree of freedom

Isotropic Brillouin spectra of the two chemically similar van der Waals glass forming liquids, 1,1(')-di(4-methoxy-5-methylphenyl)cyclohexane (BMMPC) and 1,1(')-bis(p-methoxy-phenyl)cyclohexane (BMPC) and ortho-terphenyl (OTP), were studied in a broad temperature and pressure range in order to characterize the effect of internal relaxations on the damping of longitudinal phonons. Such relaxations are present in BMPC, while in BMMPC and OTP they are strongly hindered. The authors show that in BMPC (with strong internal relaxations) the damping (broadening) of longitudinal phonons (Brillouin peaks) is much stronger than in BMMPC and OTP (with weaker internal relaxations). The contributions of the internal and structural relaxations to the phonon damping can be separated using high pressure, due to their very different pressure dependences. They show that internal relaxations strongly contribute to the damping of longitudinal phonons at all temperatures and should be taken into account in theoretical models describing the Brillouin spectra of supercooled liquids