Lung cancer diagnosed following an emergency admission: mixed methods study of the management, outcomes and needs and experiences of patients and carers

Background In the UK, although 40% of patients with lung cancer are diagnosed following an emergency admission (EA), data is limited on their needs and experiences as they progress through diagnostic and treatment pathways. Methods Prospective data collection using medical records, questionnaires and in-depth interviews. Multivariate logistic regression explored associations between diagnosis following EA and aspects of interest. Questionnaire responses with 95% confidence intervals were compared with local and national datasets. A grounded theory approach identified patient and carer themes. Results Of 401 patients, 154 (38%) were diagnosed following EA; 37 patients and six carers completed questionnaires and 13 patients and 10 carers were interviewed. Compared to those diagnosed electively, EA patients adjusted results found no difference in treatment recommendation, treatment intent or place of death. Time to diagnosis, review, or treatment was 7–14 days quicker but fewer EA patients had a lung cancer nurse present at diagnosis (37% vs. 62%). Palliative care needs were high (median [IQR] 21 [13–25] distressing or bothersome symptoms/issues) and various information and support needs unmet. Interviews highlighted in particular, perceived delays in obtaining investigations/specialist referral and factors influencing success or failure of the cough campaign. Conclusions Presentation as an EA does not appear to confer any inherent disadvantage regarding progress through lung cancer diagnostic and treatment pathways. However, given the frequent combination of advanced disease, poor performance status and prognosis, together with the high level of need and reported short-fall in care, we suggest that a specialist palliative care assessment is routinely offered

Lung cancer diagnosed following an emergency admission: exploring patient and carer perspectives on delay in seeking help

Purpose Compared to others, patients diagnosed with lung cancer following an emergency, unplanned admission to hospital (DFEA) have more advanced disease and poorer prognosis. Little is known about DFEA patients’ beliefs about cancer and its symptoms or about their help-seeking behaviours prior to admission. Methods As part of a larger single-centre, prospective mixed-methods study conducted in one University hospital, we undertook qualitative interviews with patients DFEA and their carers to obtain their understanding of symptoms and experiences of trying to access healthcare services before admission to hospital. Interviews were recorded and transcribed. Framework analysis was employed. Results Thirteen patients and 10 carers plus 3 bereaved carers took part in interviews. Three patient/carer dyads were interviewed together. Participants spoke about their symptoms and why they did not seek help sooner. They described complex and nuanced experiences. Some (n = 12) had what they recalled as the wrong symptoms for lung cancer and attributed them either to a pre-existing condition or to ageing. In other cases (n = 9), patients or carers realised with hindsight that their symptoms were signs of lung cancer, but at the time had made other attributions to account for them. In some cases (n = 3), a sudden onset of symptoms was reported. Some GPs (n = 6) were also reported to have made incorrect attributions about cause. Conclusion Late diagnosis meant that patients DFEA needed palliative support sooner after diagnosis than patients not DFEA. Professionals and lay people interpret health and illness experiences differently

Teaching CONSULT: Consultation with Novel methods & Simulation for UME Longitudinal Training.

Introduction: An important area of communication in healthcare is the consultation. Existing literature suggests that formal training in consultation communication is lacking. We aimed to conduct a targeted needs assessment of third-year students on their experience calling consultations, and based on these results, develop, pilot, and evaluate the effectiveness of a consultation curriculum for different learner levels that can be implemented as a longitudinal curriculum. Methods: Baseline needs assessment data were gathered using a survey completed by third-year students at the conclusion of the clinical clerkships. The survey assessed students’ knowledge of the standardized consultation, experience and comfort calling consultations, and previous instruction received on consultation communication. Implementation of the consultation curriculum began the following academic year. Second-year students were introduced to Kessler’s 5 Cs consultation model through a didactic session consisting of a lecture, viewing of “trigger” videos illustrating standardized and informal consults, followed by reflection and discussion. Curriculum effectiveness was assessed through pre- and post- curriculum surveys that assessed knowledge of and comfort with the consultation process. Fourth-year students participated in a consultation curriculum that provided instruction on the 5 Cs model and allowed for continued practice of consultation skills through simulation during the Emergency Medicine clerkship. Proficiency in consult communication in this cohort was assessed using two assessment tools, the Global Rating Scale and the 5 Cs Checklist. Results: The targeted needs assessment of third-year students indicated that 93% of students have called a consultation during their clerkships, but only 24% received feedback. Post-curriculum, second-year students identified more components of the 5 Cs model (4.04 vs. 4.81, p<0.001) and reported greater comfort with the consultation process (0% vs. 69%, p<0.001). Post- curriculum, fourth-year students scored higher in all criteria measuring consultation effectiveness (p<0.001 for all) and included more necessary items in simulated consultations (62% vs. 77%, p<0.001). Conclusion: While third-year medical students reported calling consultations, few felt comfortable and formal training was lacking. A curriculum in consult communication for different levels of learners can improve knowledge and comfort prior to clinical clerkships and improve consultation skills prior to residency training

Teaching CONSULT: Consultation with Novel Methods and Simulation for UME Longitudinal Training.

Introduction: An important area of communication in healthcare is the consultation. Existing literature suggests that formal training in consultation communication is lacking. We aimed to conduct a targeted needs assessment of third-year students on their experience calling consultations, and based on these results, develop, pilot, and evaluate the effectiveness of a consultation curriculum for different learner levels that can be implemented as a longitudinal curriculum. Methods: Baseline needs assessment data were gathered using a survey completed by third-year students at the conclusion of the clinical clerkships. The survey assessed students’ knowledge of the standardized consultation, experience and comfort calling consultations, and previous instruction received on consultation communication. Implementation of the consultation curriculum began the following academic year. Second-year students were introduced to Kessler’s 5 Cs consultation model through a didactic session consisting of a lecture, viewing of “trigger” videos illustrating standardized and informal consults, followed by reflection and discussion. Curriculum effectiveness was assessed through pre- and post- curriculum surveys that assessed knowledge of and comfort with the consultation process. Fourth-year students participated in a consultation curriculum that provided instruction on the 5 Cs model and allowed for continued practice of consultation skills through simulation during the Emergency Medicine clerkship. Proficiency in consult communication in this cohort was assessed using two assessment tools, the Global Rating Scale and the 5 Cs Checklist. Results: The targeted needs assessment of third-year students indicated that 93% of students have called a consultation during their clerkships, but only 24% received feedback. Post-curriculum, second-year students identified more components of the 5 Cs model (4.04 vs. 4.81, p<0.001) and reported greater comfort with the consultation process (0% vs. 69%, p<0.001). Post- curriculum, fourth-year students scored higher in all criteria measuring consultation effectiveness (p<0.001 for all) and included more necessary items in simulated consultations (62% vs. 77%, p<0.001). Conclusion: While third-year medical students reported calling consultations, few felt comfortable and formal training was lacking. A curriculum in consult communication for different levels of learners can improve knowledge and comfort prior to clinical clerkships and improve consultation skills prior to residency training

Comparison of oyster aquaculture methods and their potential to from coastal ecosystems

© The Author(s), 2021. This article is distributed under the terms of the Creative Commons Attribution License. The definitive version was published in Mara, P., Edgcomb, V. P., Sehein, T. R., Beaudoin, D., Martinsen, C., Lovely, C., Belcher, B., Cox, R., Curran, M., Farnan, C., Giannini, P., Lott, S., Paquette, K., Pinckney, A., Schafer, N., Surgeon-Rogers, T., & Rogers, D. R. Comparison of oyster aquaculture methods and their potential to from coastal ecosystems. Frontiers in Marine Science, 8,(2021): 633314, https://doi.org/10.3389/fmars.2021.633314.Coastal ecosystems are impacted by excessive nutrient inputs that cause degradation of water quality and impairments of ecosystem functioning. Regulatory and management efforts to enhance nutrient export from coastal ecosystems include sustainable oyster aquaculture that removes nitrogen in the form of oyster biomass and increases particulate export to underlying sediments where increased organic material may enhance microbial denitrification. To better understand the impacts of oyster aquaculture on nitrogen removal, we examined bacterial processes in sediments underlying three of the most common aquaculture methods that vary in the proximity of oysters to the sediments. Sediment samples underlying sites managed with these different aquaculture methods were examined using the 16S rRNA gene to assess microbial community structure, gene expression analyses to examine nitrogen and sulfur cycling genes, and nitrogen gas flux measurements. All sites were located in the same hydrodynamic setting within Waquoit Bay, MA during 2018 and 2019. Although sediments under the different oyster farming practices showed similar communities, ordination analysis revealed discrete community groups formed along the sampling season. Measured N2 fluxes and expression of key genes involved in denitrification, anaerobic ammonium oxidation (anammox), and dissimilatory nitrate reduction to ammonium (DNRA) increased during mid-summer and into fall in both years primarily under bottom cages. While all three oyster growing methods enhanced nitrogen removal relative to the control site, gene expression data indicate that the nitrogen retaining process of DNRA is particularly enhanced after end of July under bottom cages, and to a lesser extent, under suspended and floating bags. The choice of gear can also potentially increase processes that induce nitrogen retention in the form of ammonia in the underlying sediments over time, thus causing deviations from predicted nitrogen removal. If nitrogen removal is a primary objective, monitoring for these shifts is essential for making decisions about siting and size of aquaculture sites from year to year.This work was supported by the National Oceanic and Atmospheric Administration and National Estuarine Research Reserve System Science Collaborative, award NAI4NOS4190145 (subaward 3004686666) to DR and VE

Associations of prostate tumor immune landscape with vigorous physical activity and prostate cancer progression

Background: Vigorous physical activity has been associated with lower risk of fatal prostate cancer. However, mechanisms contributing to this relationship are not understood. Methods: We studied 117 men with prostate cancer in the University of North Carolina Cancer Survivorship Cohort (UNC CSC) who underwent radical prostatectomy, and 101 radiation-treated prostate cancer patients in FASTMAN. Structured questionnaires administered in UNC CSC assessed physical activity. In both studies, digital image analysis of H&amp;E-stained tissues was applied to quantify Tumor Infiltrating Lymphocytes (TILs) in segmented regions. Nanostring gene expression profiling in UNC CSC and microarray in FASTMAN were performed on tumor tissue and a 50-gene signature utilized to predict immune cell types. Results: Vigorous recreational activity, reported by 34 (29.1%) UNC men, was inversely associated with TILs abundance. Tumors of men reporting any vigorous activity versus none showed lower gene expression-predicted abundance of Th, exhausted CD4 T cells and macrophages. T cell subsets, including Treg, Th, Tfh, exhausted CD4 T cells, and macrophages were associated with increased risk of biochemical recurrence, only among men with ERG-positive tumors. Conclusions: Vigorous activity was associated with lower prostate tumor inflammation and immune microenvironment differences. Macrophages and T cell subsets, including those with immunosuppressive roles and those with lower abundance in men reporting vigorous exercise, were associated with worse outcomes in ERG-positive prostate cancer. Impact: Our novel findings contribute to our understanding of the role of the tumor immune microenvironment in prostate cancer progression, and may provide insight into how vigorous exercise could affect prostate tumor biology.<br/

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research