Search

Objectives: This trial examines the impact of the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum on surgical residents' knowledge, cross-cultural care, skills, and beliefs., Background: Cross-cultural training of providers may reduce health care outcome disparities, but its effectiveness in surgical trainees is unknown., Methods: PACTS focuses on developing skills needed for building trust, working with patients with limited English proficiency, optimizing informed consent, and managing pain. The PACTS trial was a randomized crossover trial of 8 academic general surgery programs in the United States: The Early group ("Early") received PACTS between periods 1 and 2, while the Delayed group ("Delayed") received PACTS between periods 2 and 3. Residents were assessed preintervention and postintervention on Knowledge, Cross-Cultural Care, Self-Assessed Skills, and Beliefs. χ 2 and Fisher exact tests were conducted to evaluate within-intervention and between-intervention group differences., Results: Of 406 residents enrolled, 315 were exposed to the complete PACTS curriculum. Early residents' Cross-Cultural Care (79.6%-88.2%, P <0.0001), Self-Assessed Skills (74.5%--85.0%, P <0.0001), and Beliefs (89.6%-92.4%, P =0.0028) improved after PACTS; knowledge scores (71.3%-74.3%, P =0.0661) were unchanged. Delayed resident scores pre-PACTS to post-PACTS showed minimal improvements in all domains. When comparing the 2 groups in period 2, Early residents had modest improvement in all 4 assessment areas, with a statistically significant increase in Beliefs (92.4% vs 89.9%, P =0.0199)., Conclusions: The PACTS curriculum is a comprehensive tool that improved surgical residents' knowledge, preparedness, skills, and beliefs, which will help with caring for diverse patient populations., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Proper alignment and sizing are critical to the performance of a successful total ankle arthroplasty. While it is common practice in preoperative planning prior to total knee and total hip arthroplasty, preoperative computer templating has not been well established in the setting of total ankle arthroplasty. A retrospective review of all total ankle arthroplasties performed during a 10-year period by a single fellowship-trained orthopaedic surgeon was conducted. Computer templating was utilized for all preoperative Anterior to Posterior (AP) and lateral standing radiographs, and templated component sizes were compared to the operative reports and postoperative radiographs to determine the precision of the available templates. Statistical analysis was performed with Interclass Correlation Coefficients (ICC) and descriptive statistical tests. Seventy patients with a mean age of 64.8 years (range, 48-87) and mean BMI of 30.34 (range, 19.1-55.6) were included. The ICC demonstrated that both the AP (ICC 0.80 - 95% CI 0.679-0.876) and lateral (ICC 0.786 - 95% CI 0.655-0.867) radiographs provided accurate tibial total ankle arthroplasty component templating. Similarly, the AP (ICC 0.842 - 95% CI 0.745-0.902) and lateral (ICC 0.809 - 95% CI 0.692-0.881) radiographs provided accurate talar templating. No differences were observed when comparing AP to lateral radiographs in percentage of correct component templating: tibial AP 61.4% vs lateral 58.6%, p = .119 and talar component AP 57.1% vs lateral 45.7%, p = .176. These study findings demonstrate that preoperative templating for total ankle arthroplasties is accurate in determining appropriate implant sizing. Accurate templating is an absolute necessity for future templating studies., (Copyright © 2024 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Despite use of standardized electronic health record templates, the structure of discharge summaries may hinder communication from inpatient settings to primary care providers (PCPs). We developed an enhanced electronic discharge summary template to improve PCP satisfaction with written discharge summaries targeting diagnoses, medication reconciliation, laboratory test results, specialist follow-up, and recommendations., Methods: Resident template usage was measured using statistical process control charts. PCP reviewers' discharge summary satisfaction was surveyed using 5-point Likert scales analyzed using the Mann-Whitney U test. Residents were surveyed for satisfaction., Results: Resident template usage increased from 61% initially to 72% of discharge summaries at 6 months. The PCP reviewers reported increased satisfaction for summaries using the template compared with those without (4.3 vs 3.9, P = .003). Surveyed residents desired template inclusion in the default electronic discharge summary (93%)., Conclusions: This system-level resident-initiated quality improvement initiative created a novel discharge summary template that achieved widespread usage among residents and significantly increased outpatient PCP satisfaction., Competing Interests: The authors declare no conflicts of interest.

The Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum was developed to improve surgical resident cultural dexterity, with the goal of promoting health equity by developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care through structured educational interventions for surgical residents. Funded by the National Institute of Health (NIH)'s National Institute on Minority Health and Health Disparities, PACTS addresses surgical disparities in patient care by incorporating varied educational interventions, with investigation of both traditional and nontraditional educational outcomes such as patient-reported and clinical outcomes, across multiple hospitals and regions. The unique attributes of this multicenter, multiphased research trial will not only impact future surgical education research, but hopefully improve how surgeons learn nontechnical skills that modernize surgical culture and surgical care. The present perspective piece serves as an introduction to this multifaceted surgical education trial, highlighting the rationale for the study and critical curricular components such as key stakeholders from multiple institutions, multimodal learning and feedback, and diverse educational outcomes., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The majority of non-metastatic breast cancer patients in sub-Saharan Africa are recommended to have mastectomy. The impact of mastectomy on a predominantly young African patient population requires evaluation. The BREAST-Q is a validated patient-reported outcome measure of quality-of-life following breast surgery that has been translated into 30 languages-none in Africa. This study aimed to translate and assess the psychometric properties of the mastectomy module of the BREAST-Q for use in Nigeria., Methods: The BREAST-Q mastectomy module was translated from English to Yoruba and its psychometric properties assessed using best practice guidelines. Translation was performed in 4 steps: forward translation (x2), back translation, back translation review, and cognitive interviews with post-mastectomy patients. The translated BREAST-Q instrument was administered to post-mastectomy patients (n = 21) alongside the EORTC-QLQ BR23 to evaluate construct validity. Test-retest reliability was evaluated using intraclass correlation coefficients (ICC); surveys were re-administered 4 weeks apart., Results: The translation process identified English phrases not amenable to direct translation, including "emotionally healthy" and descriptions of pain ("nagging," "throbbing," "sharp"). Translations were amended to reflect local context and question intent. During cognitive interviews, patients provided suggestions to simplify complex phrases, e.g. "discomfort in your breast area.". Internal consistency within scales was over 0.70 for psychosocial wellbeing (α = 0.84-0.87), sexual wellbeing (α = 0.98-0.99), physical wellbeing in chest (α = 0.84-0.86), and satisfaction with care (α = 0.89-0.93). ICC for test-retest reliability was moderate (0.46-0.63)., Conclusions: The Yoruba version of the BREAST-Q mastectomy module presents a unique opportunity to adequately capture the experiences of Nigerian women post mastectomy. This instrument is being used in a pilot study of Nigerian patients to identify targets for intervention to improve the patient experience and compliance with breast cancer surgery., (© 2024. The Author(s).)

Competency-based medical education (CBME) is the future of medical education and relies heavily on high quality assessment. However, the current assessment practices employed by many general surgery graduate medical education training programs are subpar. Assessments often lack reliability and validity evidence, have low faculty engagement, and differ from program to program. Given the importance of assessment in CBME, it is critical that we build a better assessment system for measuring trainee competency. We propose that an ideal system of assessment is standardized, evidence-based, comprehensive, integrated, and continuously improving. In this article, we explore these characteristics and propose next steps to achieve such a system of assessment in general surgery., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Force transmission at integrin-based adhesions is important for cell migration and mechanosensing. Talin is an essential focal adhesion (FA) protein that links F-actin to integrins. F-actin constantly moves on FAs, yet how Talin simultaneously maintains the connection to F-actin and transmits forces to integrins remains unclear. Here we show a critical role of dynamic Talin unfolding in force transmission. Using single-molecule speckle microscopy, we found that the majority of Talin are bound only to either F-actin or the substrate, whereas 4.1% of Talin is linked to both structures via elastic transient clutch. By reconstituting Talin knockdown cells with Talin chimeric mutants, in which the Talin rod subdomains are replaced with the stretchable β-spectrin repeats, we show that the stretchable property is critical for force transmission. Simulations suggest that unfolding of the Talin rod subdomains increases in the linkage duration and work at FAs. This study elucidates a force transmission mechanism, in which stochastic molecular stretching bridges two cellular structures moving at different speeds., (© 2023. The Author(s).)

Purpose: To determine whether treatment of anal high-grade squamous intraepithelial lesions (HSIL), vs active monitoring, is effective in reducing incidence of anal cancer in persons living with HIV, the US National Cancer Institute funded the Phase III ANal Cancer/HSIL Outcomes Research (ANCHOR) clinical trial. As no established patient-reported outcomes (PRO) tool exists for persons with anal HSIL, we sought to estimate the construct validity and responsiveness of the ANCHOR Health-Related Symptom Index (A-HRSI)., Methods: The construct validity phase enrolled ANCHOR participants who were within two weeks of randomization to complete A-HRSI and legacy PRO questionnaires at a single time point. The responsiveness phase enrolled a separate cohort of ANCHOR participants who were not yet randomized to complete A-HRSI at three time points: prior to randomization (T1), 14-70 (T2), and 71-112 (T3) days following randomization., Results: Confirmatory factor analysis techniques established a three-factor model (i.e., physical symptoms, impact on physical functioning, impact on psychological functioning), with moderate evidence of convergent validity and strong evidence of discriminant validity in the construct validity phase (n = 303). We observed a significant moderate effect for changes in A-HRSI impact on physical functioning (standardized response mean = 0.52) and psychological symptoms (standardized response mean = 0.60) from T2 (n = 86) to T3 (n = 92), providing evidence of responsiveness., Conclusion: A-HRSI is a brief PRO index that captures health-related symptoms and impacts related to anal HSIL. This instrument may have broad applicability in other contexts assessing individuals with anal HSIL, which may ultimately help improve clinical care and assist providers and patients with medical decision-making., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Purpose: There is an urgent need to address the growing global cancer burden in the context of complex disaster events, which both disrupt access to oncology care and facilitate carcinogenic exposures. Older adults (65 years and older) are a growing population with multifaceted care needs, making them especially vulnerable to disasters. The objective of this scoping review is to characterize the state of the literature concerning older adult cancer-related outcomes and oncologic care after a disaster event., Methods: A search was conducted in PubMed and Web of Science. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews, articles were extracted and screened for inclusion. Eligible articles were summarized using descriptive and thematic analyses., Results: Thirty-five studies met all criteria for full-text review. The majority focused on technological disasters (60%, n = 21), followed by climate-amplified disasters (28.6%, n = 10) and geophysical disasters (11.4%, n = 4). Thematic analysis classified the current evidence into three major categories: (1) studies concerned with carcinogenic exposure and cancer incidence related to the disaster event, (2) studies examining changes in access to cancer care and cancer treatment disruptions as a result of the disaster event, and (3) studies exploring the psychosocial experiences of patients with cancer affected by a disaster event. Few studies focused on older adults specifically, and most of the current evidence focuses on disasters in the United States or Japan., Conclusion: Older adult cancer outcomes after a disaster event are understudied. Current evidence suggests that disasters worsen cancer-related outcomes among older adults by disrupting continuity of care and access to timely treatment. There is a need for prospective longitudinal studies following older adult populations postdisaster and studies focused on disasters in low- and middle-income country contexts.

Background: Patient-reported outcome measures for sexual health were often designed for research studies that included only heterosexual, partnered, and cisgender participants; as such, they may have limited applicability for clinical use among sexual and gender minority (SGM) individuals or those without a partner., Aim: We aimed to conduct cognitive interviews with SGM persons and heterosexual women to determine the readability, comprehension, and applicability of questionnaire items to assess sexual function among diverse sexual and gender identities., Methods: We conducted 4 rounds of cognitive interviews with 52 participants (28 SGM; 24 cisgender, heterosexual) who provided feedback on the comprehension and wording of questionnaire items and response scales. We used items from the Female Sexual Function Index (FSFI) and focused on establishing content validity of a modified measure. Participants made recommendations for changes to the questionnaire, which was iteratively revised between interview rounds. Two independent coders analyzed the transcripts using structural coding based on 5 predefined codes: satisfaction with item, specificity/language change needed, missing/suggested item, patient definitions of concepts, and confusion with item., Outcomes: Content validity., Results: After 3 rounds of cognitive interviews and revisions to the questionnaire, participants found the final version acceptable and understandable, thereby reaching thematic saturation and establishing content validity of the modified FSFI. Modifications included the following: replacing all instances of "sexual stimulation" and "intercourse" with "sexual activity (alone or with a partner)," broadening the definition of "vaginal penetration" beyond penile-vaginal penetration, and adding skip logic to include the option "no sexual activity." Participants identified missing concepts important to their sexual health, such as use of an external lubricant., Clinical Implications: The FSFI and similar questionnaires need to be adapted to broader clinical practice populations such that all persons' experiences are accurately reflected and assessed, ensuring that sexual health needs can be met more inclusively., Strength and Limitations: A strength of the study was using cognitive interviews engaging patient perspectives, which is considered the gold standard for establishing content validity. One limitation is that participants included predominantly White and highly educated women., Conclusion: Feedback from interviews supports modifying FSFI items and further psychometric testing, and future studies should evaluate the measure among racially and educationally diverse groups., (© The Author(s) 2023. Published by Oxford University Press on behalf of The International Society of Sexual Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

National and state data show low adoption of childhood COVID-19 vaccinations, despite emergency use authorizations and availability. We conducted 24 in-depth, semi-structured interviews with Black and Latino parents in New York City (15 in English, 9 in Spanish), who were undecided or somewhat likely to vaccinate their 5 to 11-year-old children in early 2022. The interviews explored the evolution of parental perceptions on childhood COVID-19 vaccines, and were analyzed using a matrix-driven rapid approach to thematic analysis. We present our findings as themes oriented around trust at three levels of the social ecological model. In summary, we found that structural positionality and historical traumas of participants seeded mistrust in institutions and government. This led to parental reliance on personal observations, conversations, and norms within social groups for vaccine decision-making. Our findings also describe key features of trust-building, supportive conversations that shaped the thinking of undecided parents. This study demonstrates how relational trust becomes a key factor in parental vaccine decision-making, and suggests the potential power of community ambassador models of vaccination promotion for increasing success and rebuilding trust with members of the "movable middle."

Purpose. To evaluate patient perceptions of a Web-based decision aid for the treatment of localized prostate cancer. Methods. We assessed patient perceptions of a multicomponent, Web-based decision aid with a preference elicitation/values clarification exercise using adaptive conjoint analysis, the generation of a summary report, and provision of information about localized prostate cancer treatment options. Using a think-aloud approach, we conducted 21 cognitive interviews with prostate cancer patients presented with the decision aid prior to seeing their urologist. Thematic content analysis was used to examine patient perceptions of the tool's components and content prior to engaging in shared decision making with their clinician. Results. Five themes were identified: 1) patients had some negative emotional reactions to the tool, pointing out what they perceived to be unnecessarily negative framing and language used; 2) patients were forced to stop and think about preferences while going through the tool and found this deliberation to be useful; 3) patients were confused by the tool; 4) patients tried to discern the intent of the conjoint analysis questions; and 5) there was a disconnect between patients' negative reactions while using the tool and a contrasting general satisfaction with the final "values profile" created by the tool. Conclusions. Studies are needed to explore the disconnect between patients' expressing negative reactions while going through some components of decision aids but satisfaction with the final output. In particular, we hypothesize that this effect might be explained by cognitive biases such as choice-supportive bias, hindsight bias, and the "IKEA effect." This is one of the first projects to elicit patient reactions while they were completing a decision aid, and we recommend further similar, qualitative postprocess evaluation studies., Highlights: We explored perceptions of a decision aid with education about localized prostate cancer treatment and preference elicitation using adaptive conjoint analysis.Patients found the tool useful but were also confused by it, tried to discern the intent of the questions, and expressed negative emotional reactions.In particular, there was a disconnect between patients' negative reactions while using the tool and general satisfaction with the final values profile generated by the tool, which is an area for future research., Competing Interests: The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Andrew J. Vickers is a co-inventor of the 4Kscore, a commercially available reflex test for predicting prostate biopsy. He receives royalties from sales of the test. He owns stock options in Opko, which offers the test. The remaining authors have nothing to disclose. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Financial support for this quality improvement project was provided by the Movember Foundation. The authors’ work on this article was supported through a National Institute of Health/National Cancer Institute Cancer Center Support Grant (P30-CA008748) to Memorial Sloan Kettering Cancer Center. S.V.C. was further supported by a National Institutes of Health/National Cancer Institute Transition Career Development Award (K22-CA234400). The funding agreement ensured the authors’ independence in designing the project, interpreting the data, writing, and publishing the report. This work was previously presented at the Society for Medical Decision Making (SMDM) virtual meeting 2020., (© The Author(s) 2023.)

Objective: To examine by age, the veterans' report on whether components of age-friendly health systems were discussed during primary care visits., Data Sources and Study Setting: Veterans Affairs (VA) Survey of Healthcare Experience of Patients from October 2015 to September 2019., Study Design: Cross-sectional survey of VA users by age group (18-44 years, 45-64 years, 65+ years; N = 1,042,318). We used weighted logistic regression models to evaluate disparities in whether veterans discussed with anyone in their provider's office: health goals, depression symptoms, stress, personal problems, and medications. Models were adjusted for socio-demographic characteristics (sex, socioeconomic status, education, rurality) and comorbidity., Data Collection/extraction Method: Surveys were administered by mail and online. Additional veteran characteristics were extracted from VA administrative data., Principal Findings: In unadjusted analyses, VA users age 18-44 had a higher (-8.2%; CI: -9.0, -7.3) and users aged 45 to 64 had lower (4.0%; CI: 3.7, 4.3) predicted, probably discussing health goals compared to age 65+. Fewer VA users age 65+ reported discussing depression symptoms, personal problems, and stress than other age groups, whereas more VA users age 65+ discussed medications. Results were unchanged after adjusting for socio-demographics and comorbidity., Conclusions: Delivery of goal-concordant care relies on understanding the needs of individual patients. Lower rates of discussing what matters and mood represent potential missed opportunities to deliver age-friendly care for older veterans., (Published 2022. This article is a U.S. Government work and is in the public domain in the USA.)

Background: The COVID-19 pandemic has led to the rapid expansion of telehealth service delivery. We explored the experiences of a multidisciplinary palliative care team delivering telepalliative care for oncology inpatients during a 10-weeks COVID-19 surge in New York City., Methods/participants: We conducted semi-structured qualitative interviews with a targeted sample, employing a phenomenological approach with applied thematic text analysis. An interdisciplinary coding team iteratively coded data using a mix of a priori and inductive codes. Team members first independently reviewed each category, then met to reach consensus on recurring themes. The sample (n = 11) included a chaplain (n = 1), social worker (n = 1), pharmacist (n = 1), physicians (n = 3), physician assistant (n = 1), and nurse practitioners (n = 4)., Results: Participants described multidimensional clinician distress as a primary experience in delivering telepalliative care during the COVD-19 surge, characterized by competing loyalties (e.g., institutional obligations, ethical obligations to patients, resentment and distrust of leadership) and feelings of disempowerment (e.g., guilt in providing subpar support, decisional regret, loss of identity as a provider). Participants provided explicit recommendations to improve telepalliative care delivery for acute oncology inpatients in the future., Conclusion: Palliative care clinicians experienced personal and professional distress providing inpatient telepalliative care during this COVID-19 surge. Clinician strain providing telehealth services must be explored further as the pandemic and utilization of telehealth evolves. Telepalliative care planning must include attention to clinician wellbeing to sustain the workforce and promote team cohesion, and a focus on infrastructure needed to deliver high-quality, holistic care for oncology patients and their families when in-person consultation is impossible.

In April 2020, the Department of Veterans Affairs responded to the COVID-19 pandemic and escalating unsheltered homelessness in Los Angeles by sanctioning a tent turned tiny shelter encampment at the West Los Angeles Veterans Affairs medical center. Initially, staff offered linkages to on-campus VA healthcare. However, as many Veterans living in the encampment struggled to avail themselves of these services, our "encampment medicine" team was launched to provide on-site care coordination and healthcare at the tiny shelters. This case study showcases the team's engagement with a Veteran experiencing homelessness struggling with opioid use disorder and depicts how this co-located, comprehensive care team allowed for trusting care relationships formed with, and empowerment of the Veterans living in the encampment. The piece highlights a healthcare model that engages with persons experiencing homelessness on their own terms while building trust and solidarity, focuses on the sense of community that formed in the tiny shelter encampment, and gives recommendations for how homeless services might adapt to use the strengths of this unique community.

Objectives: The Anal Cancer High-grade squamous intraepithelial lesions (HSIL) Outcomes Research (ANCHOR) Health-Related Symptom Index (A-HRSI) is a 25-item measure that assesses physical symptoms and impacts, and psychological symptoms. To promote generalizability and equity in the capture of these concepts in Spanish-speaking participants, we linguistically validated a Spanish version of A-HRSI., Methods: Following independent forward translation and reconciliation of A-HRSI from English to Spanish, two rounds of cognitive interviews were completed with ANCHOR participants who had been diagnosed with anal HSIL in the prior nine months and preferred delivery of their healthcare in Spanish. Interviews were coded to highlight any items and concepts that were reported as being difficult for any reason by ≥ 3 participants, with such items revised during a research team panel discussion and tested in a second round of interviews if applicable., Results: Seventeen participants representing 8 nationalities were enrolled (Round 1 n=10, Round 2 n=7); 7 participants reported not completing high school (41.2%). No difficulties were reported with respect to the theoretical concepts measured by A-HRSI. We made modifications to the Spanish translation of eight items and two response option terms in cases where participants had difficulty understanding a term, experienced problems in discriminating between terms, or preferred the use of an alternative term to represent the concept(s)., Conclusion: The Spanish version of A-HRSI is a linguistically valid tool that can be used to assess physical symptoms, impacts, and psychological symptoms related to anal HSIL. Language is a tremendous barrier to enrolling patients to clinical trials. The anal cancer high-grade squamous intraepithelial lesions (HSIL) outcomes research [ANCHOR] trial is a randomized clinical trial that recently established that the treatment of anal HSIL, versus active monitoring, is effective in reducing incidence of anal cancer in persons living with HIV (PLWH). The ANCHOR Health-Related Symptom Index (A-HRSI) is a 25-item patient-reported outcomes measure that was developed to assess physical symptoms, physical impacts, and psychological symptoms related to anal HSIL. As approximately 10% of ANCHOR participants preferred the delivery of their healthcare in Spanish, the purpose of the present study was to linguistically validate a Spanish version of A-HRSI. Based on feedback from interviews with 17 participants from the ANCHOR trial who had been diagnosed with anal HSIL in the prior nine months and preferred delivery of their healthcare in Spanish, we made modifications to the Spanish translation of eight items and two response option terms in cases where participants had difficulty understanding a term, experienced problems in discriminating between terms, or preferred the use of an alternative term to represent the concept(s). The Spanish version of A-HRSI is a linguistically valid tool that can be used to assess physical symptoms, impacts, and psychological symptoms related to anal HSIL as part of clinical trials or routine care., (© 2022. The Author(s).)

Background: The importance of deriving benefit and meaning has been identified among cancer caregivers, but this has yet to be examined in the context of rare cancers. We sought to characterize unmet needs and experiences of caregivers of patients with Erdheim-Chester disease (ECD) and other histiocytic neoplasms (HN) and to identify factors associated with finding benefit and meaning-making in providing care for patients with rare cancers., Methods: Caregivers of patients with ECD and other HN completed quantitative surveys. Linear univariable regression modeling examined associations between unmet needs, social and family support, and intolerance of uncertainty with benefit finding and meaning-making. A subset participated in qualitative interviews assessing experiences of rare cancer caregiving that were analyzed with applied thematic analysis (NCT039900428)., Findings: Of caregivers ( N  = 92, M  = 54 years old, 68% female) of patients with ECD (75%) and other HN (25%), 78% reported moderately or severely unmet support needs, most frequently informational (58%) and psychological/emotional (66%) needs. Caregivers with unmet informational, psychological/emotional, and social support needs, difficulty tolerating uncertainty, a longer duration of the patient's illness, lower social support, more family conflict, and higher anxiety and depression symptoms demonstrated less benefit finding and meaning-making ( p s <.05). Qualitative interviews ( N  = 19) underscored information and support needs and the capacity to derive meaning from caregiving., Interpretation: Rare cancer caregivers report numerous unmet information and support needs, needs that arise from disease rarity itself and which are associated with diminished capacity for deriving benefit and meaning from caregiving. Findings highlight targets for interventions to improve support for caregivers with HN and other rare cancers., Funding: NIH P30 CA008748 (PI: Craig Thompson, MD), NIH T32 CA009461 (H.M.; PI: Jamie Ostroff, PhD), Frame Family Fund (E.L.D.), Applebaum Foundation (E.L.D.)., Competing Interests: Dr. Applebaum receives support from Blue Note Therapeutics. Dr. Diamond discloses unpaid editorial support from Pfizer Inc and serves on an advisory board for Day One Therapeutics and Springworks Therapeutics, both outside the submitted work and serves on the Histiocytosis Association Board of Trustees (unpaid) and Erdheim-Chester Disease Global Alliance -Medical Advisory Board (unpaid)., (© 2022 The Authors.)

New York City was a "global COVID-19 hotspot" in spring 2020. Many health teams rapidly transitioned to telehealth platforms. Little is known about the experiences of inpatient palliative care services who delivered telehealth services during the pandemic. This study was aimed to explore the experiences of an interdisciplinary palliative care team in meeting the holistic needs of oncology inpatients via telehealth over a 10-week period during the first COVID-19 surge. A targeted sample of interdisciplinary palliative specialists at an urban comprehensive cancer center participated in in-depth interviews that explored participants' experiences delivering physical, psychosocial, and spiritual care via telehealth. An interdisciplinary coding team followed a rigorous thematic text analysis approach and met regularly to reach consensus on emerging themes. Eleven palliative specialists from six disciplines (chaplaincy, medicine, nursing, pharmacy, physician assistant, and social work) participated. Seventy-three percent reported not receiving telehealth training prior to COVID-19 and 64% were "not at all" or "somewhat comfortable" delivering telepalliative care. Several themes were identified, including the barriers related to telehealth, the impact of telehealth on the quality of relationships with patients, their families, and coworkers, and the changes in perceived self-efficacy of fulfilling job responsibilities. Telehealth use has increased significantly during COVID-19, requiring further evaluation of its utility. Participants reported both positive and negative inpatient telepalliative care experiences associated with various domains of professional functioning, such as communication, relationships with key stakeholders, and self-efficacy. Enhanced telehealth training and support must be improved to sustain the palliative workforce and promote high-quality patient and family care in the future., (© Society of Behavioral Medicine 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

To address ambulatory care sensitive hospitalisations in heart failure (HF), we implemented a quality improvement initiative to reduce admissions and improve guideline-directed medical therapy (GDMT) prescription, through proactive integration of remote patient monitoring-home telehealth (RPM-HT) and pharmacist consultations. Each enrolled patient (n=38) was assigned an RPM-HT registered nurse (RN), cardiology licensed independent provider (provider), and, if referred, a clinical pharmacy specialist (pharmacist). The RN called patients weekly and for changes detected by RPM-HT, while the pharmacist worked to optimise GDMT. The RN and pharmacist communicated clinical status changes to the provider for expedited management. Process measures were the percentage of outbound RN weekly calls missed per enrolled patient; the weekly percentage of provider interventions missed; and the number of initiative-driven diuretic changes. Outcome measures included eligible GDMT medications prescribed, optimisation of those medications, and the pre-post difference in emergency department (ED) visits/hospitalisations. After a 4-week run-in period, RN weekly calls missed per enrolled patient decreased from a mean of 21.4% (weeks 5-15) to 10.2% (weeks 16-23). Weekly missed provider interventions decreased from a mean of 15.1% (weeks 1-15) to 3.4% (weeks 16-23), with special cause variation detected. The initiative resulted in 43 diuretic changes in 21 patients. Among 34 active patients, 65 ED visits (0.16 per person-month) occurred in 12 months pre intervention compared with 8 ED visits (0.04 per person-month) for 6 intervention months (p<0.001). Among 16 patients referred to pharmacist, the per cent of eligible GDMT medications prescribed increased by 17.1% (p<0.001); the number of patients receiving all eligible medications increased from 3 to 11 (p=0.008). Similarly, the per cent optimisation of GDMT doses increased by 25.3% (p<0.001), with the number of patients maximally optimised on GDMT increasing from 1 to 6 (p=0.06). We concluded that a cardiology, RPM-HT RN and pharmacist team improved prescription of GDMT and may have reduced HF admissions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: High levels of moral distress in nursing professionals, of which oncology nurses are particularly prone, can negatively impact patient care, job satisfaction, and retention., Aim: "Positive Attitudes Striving to Rejuvenate You: PASTRY" was developed at a tertiary cancer center to reduce the burden of moral distress among oncology nurses., Research Design: A Quality Improvement (QI) initiative was conducted using a pre- and post-intervention design, to launch PASTRY and measure its impact on moral distress of the nursing unit, using Hamric's Moral Distress Scale-Revised (MDS-R.) This program consisted of monthly 60-minute sessions allowing nurses to address morally distressing events and themes, such as clinicians giving "false hope" to patients or families. The PASTRY program sessions were led by certified clinicians utilizing strategies of discussion and mind-body practices., Participants: Clinical nurses working on an adult leukemia/lymphoma unit., Ethical Considerations: This was a QI initiative, participation was voluntary, MDS-R responses were collected anonymously, and the institution's Ethics Committee oversaw PASTRY's implementation., Findings: While improvement in moral distress findings were not statistically significant, the qualitative and quantitative findings demonstrated consistent themes. The PASTRY program received strong support from nurses and institutional leaders, lowered the nursing unit's moral distress, led to enhanced camaraderie, and improved nurses' coping skills., Discussion: Measurement of moral distress is innately challenging due to its complexity. This study reinforces oncology nurses have measurable moral distress. Interventions should be implemented for a safe and healing environment to explore morally distressing clinical experiences. Poor communication among multidisciplinary team members is associated with moral distress among nurses. Programs like PASTRY may empower nurses to build support networks for change within themselves and institutions., Conclusion: This QI initiative shows further research on moral distress reduction should be conducted to verify findings for statistical significance and so that institutional programs, like PASTRY, can be created.

Background: Transitioning from trainee to attending surgeon requires learners to become educators. The purpose of this study is to evaluate educational strategies utilized by surgeons, define gaps in preparation for operative teaching, and identify opportunities to support this transition., Methods: A web-based, Association of Surgical Education approved survey was distributed to attending surgeons., Results: There were 153 respondents. Narrating actions was the most frequently reported educational model, utilized by 74% of junior faculty [JF] (0-5yrs) and 63% of senior faculty [SF] (>6yrs). Other models used included educational time-outs (29% JF, 27% SF), BID teaching model (36% JF, 51% SF), and Zwisch model (13% JF, 25% SF). Compared with 91% JF, 65% SF reported struggling with instruction (p < 0.001). Five themes emerged as presenting difficulty during the resident to attending transition: lack of relationships, ongoing learning, systems-based, cognitive load, impression management., Conclusions: Our results represent a needs assessment in the transition from learner to educator in the OR., (Published by Elsevier Inc.)

Background: Engagement in physical activity (PA) post-treatment can improve health outcomes and quality of life among cancer survivors. The purpose of this study is to explore United States (US) older adult cancer survivors' (OACS) reasons for engaging in group-based PA classes, to identify themes supporting exercise motivations in the context of cancer recovery., Methods: OACS participating in a fitness program at a large US comprehensive cancer center completed semi-structured interviews. Transcripts were analyzed using modified grounded theory, and demographic data were analyzed descriptively., Results: Modified grounded theory analysis (n = 25; age M = 70.92, SD = 10.82; 9 cancer types) identified individual rationales for exercise grounded in collective experience. Participants' internal motivations for PA are shaped by the desire for control over an uncertain future and post-treatment body, obtained by literally "moving forward" post-cancer; this is supported by external motivations for social connections that present a positive model of survivorship, within a setting that instills confidence and safety., Conclusions: Exercise can be a way for older adults to tap into internal and external motivations that support cancer survivorship. Interventions that make explicit connections between exercise and cancer recovery, facilitate interpersonal interaction, and promote a sense of safety may be the most effective. The concepts identified in this study can inform the development of future interventions to improve long-term behavior change among OACS and evaluate existing PA programs., (© 2021. International Society of Behavioral Medicine.)

Purpose: The COVID-19 pandemic surge in New York City in Spring 2020 resulted in an unprecedented constraint on health care resources. This study aimed to explore the experiences of doctors providing care to oncology patients during this time., Methods: Hospitalists and medical oncologists from two large inpatient services at a dedicated cancer center participated in virtual in-depth interviews exploring how the pandemic affected their practice and to what extent it may have affected decisions for urgent evaluation or hospital admission, interventions, or goals-of-care discussions. Interviews also explored how the pandemic affected each individual physician's psychologic well-being. Transcripts were analyzed by three independent coders in Atlas.ti v. 7.5, using a thematic analysis approach., Results: Eighteen physicians were interviewed (n = 6 GI medical oncologists, n = 6 gynecologic medical oncologists, and n = 6 hospitalists). Analysis identified five major themes related to fear and distress: (1) perceived patient fears of the hospital during COVID-19, leading to avoidance and delay of acute care needs before admission, (2) physicians' fear and distress delivering oncology care during COVID-19, (3) physician distress resulting from ambiguity in decision making, (4) distress and anxiety balancing the need for patient contact with the need to minimize infection risk, and (5) distress regarding impact of uncertainty and acuity of COVID-19 on goals-of-care discussions., Conclusion: Insight into the experiences of physicians providing cancer care during a COVID-19 surge underscores the need for strategies mitigate short-term distress and long-term psychologic impacts. Findings can also inform practitioner training and preparedness for future pandemics in the oncology setting., Competing Interests: Angela GreenHonoraria: Clinical Congress ConsultantsResearch Funding: Mereo BioPharma (Inst) Leonard SaltzResearch Funding: Taiho Pharmaceutical Andrew S. EpsteinOther Relationship: UpToDateNo other potential conflicts of interest were reported.

Background: Technology acceptability and usage surveys (TAUS) are brief questionnaires that measure technology comfort, typical daily use, and access in a population. However, current measures are not adapted to low- and middle-income country (LMIC) contexts., Objective: The objective of this pilot study was to develop a TAUS that could be used to inform the implementation of a mobile health (mHealth) intervention in Nigeria., Methods: A literature review of validated technology comfort and usage scales was conducted to identify candidate items. The draft measure was reviewed for face validity by an expert panel comprised of clinicians and researchers with cultural, methodological, and clinical expertise. The measure was piloted by radiologists at an oncology symposium in Nigeria., Results: After expert review, the final measure included 18 items organized into 3 domains: (1) comfort with using mobile applications, (2) reliability of internet or electricity, and (3) attitudes toward using computers or mobile applications in clinical practice. The pilot sample (n=16) reported high levels of comfort and acceptability toward using mHealth applications in the clinical setting but faced numerous infrastructure challenges., Conclusions: Pilot results indicate that the TAUS may be a feasible and appropriate measure for assessing technology usage and acceptability in LMIC clinical contexts. Dedicating a domain to technology infrastructure and access yielded valuable insights for program implementation., (©Kathleen A Lynch, Thomas M Atkinson, Adeleye D Omisore, Olusola Famurewa, Olalekan Olasehinde, Oluwole Odujoko, Olusegun I Alatise, Adedeji Egberongbe, T Peter Kingham, Elizabeth A Morris, Elizabeth Sutton. Originally published in JMIR Formative Research (https://formative.jmir.org), 20.04.2022.)

Background: Accurate self-reported symptomatic toxicity documentation via the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) is essential throughout cancer treatment to ensure safety and understand therapeutic efficacy. However, the capture of accurate toxicities from patients undergoing radiation therapy is challenging because this is generally provided only at the time of scheduled visits., Objective: This study seeks to establish the usability and feasibility of a mobile PRO-CTCAE Administration System (mPROS) to capture toxicities related to radiation therapy., Methods: English-speaking adult patients who were undergoing radiation therapy for cancer were enrolled and given a brief demonstration of the Say All Your Symptoms (SAYS) and Symptom Tracking Entry Program (STEP) interfaces of the mPROS app, followed by a patient-use phase where patient actions were observed as they navigated mPROS to enter toxicities. Patient feedback was captured via a semistructured interview and brief questionnaire., Results: We enrolled 25 patients (age: mean 60.7 years; females: n=13, 52%; White patients: n=13; 52%; non-Hispanic patients: n=19, 76%; college graduates: n=17, 68%). Patients almost equally preferred the SAYS (n=14, 56%) or STEP (n=11, 44%) interfaces, with 21 patients (84%) agreeing that they would use mPROS to report their symptoms to their health care team and 19 patients (76%) agreeing that they would recommend mPROS to others., Conclusions: The mPROS app is usable and feasible for facilitating the patient reporting of radiation therapy-related symptomatic toxicities. A revised version of mPROS that incorporates patient input and includes electronic health record integration is being developed and validated as part of a multicenter trial., (©Jody Underwood, Susan McCloskey, Ann Raldow, Amar Kishan, Chad Zalkin, Daniel Navarro, Lisa Scott Holt, Andrew Webb, Kathleen A Lynch, Thomas M Atkinson. Originally published in JMIR Formative Research (https://formative.jmir.org), 12.04.2022.)

Background: Advance care planning, the process through which patient values and goals are explored and documented, is a core quality indicator in cancer care. However, patient values are predominantly elicited at the end of life; patient values earlier in serious illness are not clearly delineated. The objective of this analysis is to assess the content of patient-verified summaries of health-related values among newly diagnosed cancer outpatients in order to develop a theoretical framework to guide future values discussions and optimize person-centered oncologic care., Methods: Values summaries among patients with gastrointestinal (GI) cancers or myelodysplastic syndrome (MDS) were extracted from the medical record. Modified grounded theory analysis included interdisciplinary team coding of values summaries to identify key domains; code categorization; and identification of thematic constructs during successive consensus meetings. A final round of coding stratified themes by disease type., Results: Analysis of 128 patient values summary documents from 67 patients (gastrointestinal [GI] cancers, n = 49; myelodysplastic syndrome [MDS], n = 18) generated 115 codes across 12 categories. Resultant themes demonstrated patients' focus on retaining agency, personhood and interpersonal connection amidst practical and existential disruption caused by cancer. Themes coalesced into a theoretical framework with 5 sequenced constructs beginning with the cancer diagnosis, leading to 3 nesting constructs of individual identity (character), interpersonal (communication) preferences and needs, and social identity (connection), signifying sources of meaning and fulfillment. Values differences between GI cancer and MDS patients-including greater focus on normalcy, prognosis, and maintaining professional life among GI patients-reflected the distinct therapeutic options and prognoses across these disease groups., Conclusions: Patient values reflect goals of meaning-making and fulfillment through individual agency and interpersonal supports in the setting of a newly diagnosed cancer. Early, nurse-led values discussions provide important and patient-specific data that are informative and likely actionable by clinicians in the delivery of person-centered care. Values can also facilitate discussions between patients and families and clarify patient preferences., (© 2022. The Author(s).)

Narrative medicine is a humanities-based discipline that posits that attention to the patient narrative and the collaborative formation of a narrative between the patient and provider is essential for the provision of health care. In this Special Article, we review the basic theoretical constructs of the narrative medicine discipline and apply them to the perioperative setting. We frame our discussion around the 4 primary goals of the current iteration of the perioperative surgical home: enhancing patient-centered care, embracing shared decision making, optimizing health literacy, and avoiding futile surgery. We then examine the importance of incorporating narrative medicine into medical education and residency training and evaluate the literature on such narrative medicine didactics. Finally, we discuss applying health services research, specifically qualitative and mixed methods, in the rigorous evaluation of the efficacy and impact of narrative medicine clinical programs and medical education curricula., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 International Anesthesia Research Society.)

Context: Depressive symptoms are prevalent and associated with greater healthcare utilization among hospitalized adults with cancer. Music therapy and massage therapy are available at many National Cancer Institute (NCI)-Designated Cancer Centers and recommended by the American Society of Clinical Oncology for depressive symptoms, but a paucity of studies have compared these two therapies., Objectives: We conducted a retrospective, multi-method program evaluation of single, first-time music therapy and massage therapy sessions delivered to hospitalized adults with cancer., Methods: The study was conducted at an NCI-Designated Comprehensive Cancer Center between February 2018 and October 2019. We assessed depressive symptoms with the Edmonton Symptom Assessment Scale (ESAS) depression item. We also invited patients to provide free-text comments describing their treatment experience., Results: Among 1764 patients (61.2% women, 72.7% white), 350 received music therapy and 1414 received massage therapy; music therapy was associated with a 0.4 point greater reduction (95% 0.3 to 0.6, P < 0.001) in the ESAS depression score relative to massage therapy. When analyses were restricted to the 452 (25.6%) patients with moderate-to-severe depressive symptoms (ESAS score ≥ 4), music therapy was associated with a 1.2 point greater reduction (95% CI 0.7 to 1.7, P < 0.001) relative to massage therapy, a clinically meaningful difference. In free-text comments, music therapy was described as energizing, uplifting, and evocative, whereas massage therapy was described as calming and relaxing., Conclusion: Among hospitalized adult cancer patients, both music therapy and massage therapy were associated with reduced depressive symptoms, but music therapy was associated with a greater reduction than massage therapy., (Copyright © 2021. Published by Elsevier Inc.)

Adolescents and young adults (AYAs) require a multidisciplinary approach to cancer care due to their complex biopsychosocial situations and varied developmental maturity. Currently, age and diagnosis determine referral to pediatric or adult oncology, with differing treatment paradigms and service utilization patterns, contributing to suboptimal improvements in outcomes. Understanding the unique perspectives of AYAs is essential to designing patient-centered AYA services. Thus, we conducted six focus groups with AYAs ( n = 25) treated by medical or pediatric oncologists to evaluate: (1) the unique experiences of cancer care as an AYA; (2) AYA-specific information needs and communication preferences; and (3) recommendations for service provision, delivery and accommodations for AYAs. Transcripts were analyzed using inductive thematic content analysis and identified six major themes to inform clinically-actionable recommendations and the development of a patient-reported outcome measure: (1) AYAs experience social isolation and loss of independence; (2) AYAs have an uncertain sense of the future and need conversations around survivorship and long-term and late effects; (3) AYAs desire greater control over discussions with their care team; (4) AYAs need additional navigational and social/caregiver supports; (5) AYAs prefer an inclusive AYA space in the hospital; and (6) LGBTQ+ patients experience distinct concerns as AYA cancer patients. These will form the basis for specific and tailored clinical recommendations to improve AYA cancer care delivery.

Community-based organizations (CBOs) play a key role in assisting local communities, especially those in under-resourced areas, through their deep knowledge of the community's needs and available resources. We examined perceptions of COVID-19's impact on health-related services in CBOs located in Upper Manhattan, New York City (serving East Harlem, Central Harlem, Morningside Heights and Hamilton Heights, and Washington Heights and Inwood). Three focus groups were conducted on Zoom in November 2020; focus groups were composed of participants employed at CBOs in this catchment area. Deidentified interview transcripts were evaluated using an iterative process of thematic content analysis. We identified five major themes related to the impact of COVID-19 on community needs: 1) increased mistrust and decreased service utilization, 2) breakdowns in communication, 3) shift in need, 4) increased risk factors for negative health outcomes among staff and community, and 5) decreased funding and an uncertain future. Because of the pandemic, CBOs have pivoted to cater to the immediate and changing needs of the community and, in doing so, revised their menu of services as well as their service delivery model. In trying to maintain connectivity with and the trust of community members, participants had to construct novel strategies and develop new outreach strategies; participants also recognized the role strain of trying to balance community needs with home responsibilities. Given these findings, concern arises around the long-term health and well-being of community members and participants. The government must provide the necessary resources to ensure the viability of CBOs and create a stronger infrastructure for future emergencies., Competing Interests: Conflicts of Interest/Competing InterestsThe authors declare that there is no conflict of interests regarding the publication of this paper. On behalf of all authors, the corresponding author states that there is no conflict of interest., (© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2022.)

Purpose: High-quality cancer care must incorporate patients' personal values in decision making throughout illness. Unfortunately, patient values are neither consistently elicited nor easily accessible in the electronic health record (EHR). Memorial Sloan Kettering Cancer Center is deploying a major EHR innovation, called the Patient Values Tab, which provides ready access to patients' values and personhood. To inform the Tab's design, we interviewed a large, diverse group of institutional stakeholders to understand their user needs for this Tab., Methods: Qualitative data were collected through semistructured, audio-recorded, in-person, individual interviews. An interdisciplinary team of four coders conducted a process of thematic content analysis. Thematic saturation was achieved, and member checking was performed., Results: A total of 110 stakeholders were approached and interviewed. Participants comprised a wide range of disciplines or professions and others involved in hospital and/or clinic administration. Analysis revealed the following themes related to important Tab content: personhood, support system or resources, social history, communication preferences, future planning, end of life, and illness and treatment understanding. Participants also discussed implementation considerations, the Tab's potential to improve communication, and privacy implications., Conclusion: This study focused on a major EHR innovation to centralize information about values and personhood of patients with cancer. We elicited views of over 100 institutional stakeholders through in-depth interviews that were rigorously analyzed, yielding themes related to content and format that helped guide the Tab's design. The interviews generated a sense of ownership and enthusiasm for the Tab among future users. The Tab's introduction advances the use of the EHR as a driver of the delivery of patient-centered care., Competing Interests: Andrew S. EpsteinOther Relationship: UpToDate Jamie S. OstroffSpeakers' Bureau: Bristol-Myers SquibbResearch Funding: Pfizer, CVS FoundationPatents, Royalties, Other Intellectual Property: UptoDateTravel, Accommodations, Expenses: Bristol Myers Squibb Foundation Brittany KatzEmployment: Cota HealthcareStock and Other Ownership Interests: Bristol-Myers SquibbNo other potential conflicts of interest were reported.

Aim: To describe patient communication challenges encountered by oncology clinicians, which represent a fundamental barrier to implementing precision oncology. Materials & methods: We conducted three focus groups including breast, melanoma and thoracic oncology clinicians regarding their precision oncology communication experiences. Transcripts were reviewed and coded using inductive thematic text analysis. Results: We identified four themes: varied definitions of precision oncology exist, clinicians and patients face unique challenges to precision oncology implementation, patient communication challenges engendered or heightened by precision oncology implementation and clinician communication solutions and training needs. Conclusion: This study elucidated clinicians' perspectives on implementing precision oncology and related communication challenges. Understanding these challenges and developing strategies to help clinicians navigate these discussions are critical for ensuring that patients reap the full benefits of precision oncology.

Survivors of head and neck cancer (HNC) can have multiple health concerns. To facilitate their care, we developed and pilot-tested a clinical informatics intervention, HN-STAR. HN-STAR elicits concerns online from HNC survivors prior to a routine oncology clinic visit. HN-STAR then presents tailored evidence-based clinical recommendations as a clinical decision support tool to be used during the visit where the oncology clinician and survivor select symptom management strategies and other actions. This generates a survivorship care plan (SCP). Online elicitation of health concerns occurs 3, 6, and 9 months after the clinic visit, generating an updated SCP each time. HN-STAR encompasses important methods of improving survivorship care (e.g., needs assessment, tailored interventions, dissemination of guidelines) and will be evaluated in a pragmatic trial to maximize external validity. This hybrid type 1 implementation-effectiveness trial tests HN-STAR effectiveness while studying barriers and facilitators to implementation in community oncology practices within the National Cancer Institute Community Oncology Research Program. Effectiveness will be measured as differences in key survivorship outcomes between HNC participants who do and do not use HN-STAR over one year after the clinic visit. The primary endpoint is HNC-specific quality of life; other outcomes include patient-centered measures and receipt of guideline-concordant care. Implementation outcomes will be assessed of survivors, providers, and clinic stakeholders. The hybrid design will provide insight into a dose-response relationship between the extent of implementation fidelity and effectiveness outcomes, as well as how to incorporate HN-STAR into standard practice outside the research setting., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Context: Music therapy (MT) is a nonpharmacologic therapy where licensed therapists provide active (e.g., singing, playing songs) or passive (e.g., listening) music-based interventions. Both active and passive MT are effective techniques for treating cancer-related symptoms. However, the influence of active vs. passive MT techniques on patient-reported perceptions and experiences of care have yet to be explored., Objectives: To understand how active and passive MT is perceived and experienced by patients with cancer., Methods: We conducted a retrospective analysis of semistructured interviews collected as part of a quality improvement study (n = 20) with patients in the inpatient setting who had received active or passive MT within the past 24 hours. Transcripts were analyzed using thematic content analysis., Results: Four themes emerged: 1) Different articulations of benefit for recipients of active vs. passive MT; 2) patient choice as a form of empowerment; 3) changed perception of hospital experience; and 4) differing recommendations for future MT. Recipients of active MT emphasized the session's interactive elements, finding the sessions stimulating by providing opportunities for joyous social interaction not centered on their diagnosis. Passive MT recipients focused on the calming therapeutic effect of the session, easing anxieties through focus and reflection on the music itself., Conclusion: This analysis builds on current MT literature by providing insights specifically from oncology patients treated in the inpatient setting. Patients experience active and passive MT in different ways and perceived unique benefits for coping with cancer from each technique. Our findings can inform development of specific MT for symptom control in hospital settings., (Copyright © 2020 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Patients with cancer are particularly vulnerable to stress and anxiety during the COVID-19 pandemic. Social distancing is critical for patients with cancer; however, it can also reduce their access to psychosocial coping resources., Objective: The aim of this study was to explore patient experiences to generate a model of how virtual mind-body programs can support the psychosocial well-being of patients with cancer., Methods: We conducted a qualitative study among patients (aged ≥18 years) who participated in a virtual mind-body program offered by a National Cancer Institute-designated Comprehensive Cancer Center during the COVID-19 pandemic. The program consisted of mind-body group therapy sessions of fitness, yoga, tai chi, dance therapy, music therapy, and meditation. Live integrative medicine clinicians held each session via Zoom videoconferencing for 30-45 minutes. In semistructured phone interviews (n=30), patients were asked about their overall impressions and perceptions of the benefits of the sessions, including impacts on stress and anxiety. Interviews were analyzed using grounded theory., Results: Among the 30 participants (average age 64.5 years, SD 9.36, range 40-80, 29 female), three major themes were identified relating to experiences in the virtual mind-body program: (1) the sessions helped the patients maintain structured routines and motivated them to adhere to healthy behaviors; (2) the sessions enhanced coping with COVID-19-related-stressors, allowing patients to "refocus" and "re-energize"; and (3) the sessions allowed patients to connect, fostering social relationships during a time of isolation. These themes informed the constructs of a novel behavioral-psychological-social coping model for patients with cancer., Conclusions: Virtual mind-body programming supported patients with cancer during the COVID-19 pandemic through a behavioral-psychological-social coping model by enhancing psychological coping for external stressors, supporting adherence to motivation and health behaviors, and increasing social connection and camaraderie. These programs have potential to address the behavioral, psychological, and social challenges faced by patients with cancer during and beyond the COVID-19 pandemic. The constructs of the conceptual model proposed in this study can inform future interventions to support isolated patients with cancer. Further clinical trials are needed to confirm the specific benefits of virtual mind-body programming for the psychosocial well-being and healthy behaviors of patients with cancer., (©Nicholas Emard, Kathleen A Lynch, Kevin T Liou, Thomas Atkinson, Angela K Green, Bobby Daly, Kelly Trevino, Jun J Mao. Originally published in JMIR Cancer (https://cancer.jmir.org), 08.06.2021.)

Objective: Herbs and natural products are increasingly used by cancer patients for pain management, but few studies have examined their integration within conventional cancer care. This study describes the characteristics, experiences, and perspectives of cancer patients who were prescribed an herbal topical analgesic for pain management., Design and Setting: Program evaluation of a pilot herbal dispensary at a National Cancer Institute-designated comprehensive cancer center., Subjects: Cancer patients who were prescribed the Tibetree Pain-Relieving Plaster (PRP) by an integrative medicine physician., Methods: Sociodemographic and clinical characteristics of patients were abstracted from medical records. Semistructured phone interviews were conducted 1-2 weeks after PRP prescription to evaluate patient experiences with using PRP for pain. Interviews were analyzed through thematic content analysis., Results: From February 2019 to February 2020, 50 patients were prescribed PRP. Median age (range) was 63 years (21-86), 37 patients (74%) were female, 14 (28%) were non-White, and 38 (76%) were using oral analgesics. During interviews, the majority of patients reported that the PRP improved pain and health-related outcomes, was convenient to use, and addressed pain management needs that were not fulfilled by oral analgesics. However, a few patients described adverse experiences with PRP, including skin irritation., Conclusions: Understanding patient experiences and perspectives is a critical step toward evidence-based integration of herbs and natural products into cancer pain management. Findings from this program evaluation will inform the design of a randomized clinical trial on the efficacy and safety of PRP for pain in patients with cancer., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The risk for sexual victimization in college is high, and although there can be significant mental and physical consequences for the survivor, resource utilization for this issue is extremely low. The current study used the frameworks of both the ecological model and the theory of planned behavior to examine factors related to resource use in undergraduate survivors of unwanted sexual experiences. The sample consisted of 217 undergraduates who reported at least one unwanted sexual experience while in college (89% female, 76.5% Caucasian, M age 19.6). Data were collected in an online survey from a private liberal arts college, and were analyzed using decision tree modeling. Results suggested that resource use was less related to demographic or event characteristics, but rather related to victim response to the event as well as perceptions about control over potential resource use. In addition to key assault prevention efforts, it is thus important to also support survivor mental health and self-efficacy postassault.

Social scientists have advocated for the use of participatory research methods for Global Health project design and planning. However, community-engaged approaches can be time and resource-intensive. This article proposes a feasible framework for conducting a participatory needs assessment in time-limited settings using multiple, triangulated qualitative methods. This framework is outlined through a case study: a participatory needs assessment to inform the design of an ultrasound-guided biopsy training program in Nigeria. Breast cancer is the leading cause of death for Nigerian women and most cases in Nigeria are diagnosed at an advanced stage; timely diagnosis is impeded by fractious referral pathways, costly imaging equipment, and limited access outside urban centers. The project involved participant observation, surveys, and focus groups at the African Research Group for Oncology (ARGO) in Ile-Ife, Nigeria. Through this timely research and engagement, participants spoke about diagnostic challenges, institutional power dynamics, and infrastructure considerations for program implementation.

Small-scale dynamic auroras have spatial scales of a few km or less, and temporal scales of a few seconds or less, which visualize the complex interplay among charged particles, Alfvén waves, and plasma instabilities working in the magnetosphere-ionosphere coupled regions. We summarize the observed properties of flickering auroras, vortex motions, and filamentary structures. We also summarize the development of fundamental theories, such as dispersive Alfvén waves (DAWs), plasma instabilities in the auroral acceleration region, ionospheric feedback instabilities (IFI), and the ionospheric Alfvén resonator (IAR)., Supplementary Information: The online version contains supplementary material available at 10.1007/s11214-021-00796-w., (© The Author(s) 2021, corrected publication 2021.)

Purpose: Cancer-related fatigue is a prevalent, debilitating symptom that contributes to increased health care utilization among hospitalized patients. Music therapy is a nonpharmacological intervention that uses active (eg, singing, selecting songs) and passive (eg, listening) techniques. Preliminary evidence from small trials suggests a potential benefit for cancer-related fatigue in the inpatient setting; however, it remains unclear which techniques are most effective., Methods: A cross-sectional mixed-methods study was performed to compare cancer-related fatigue before and after active or passive music therapy. Cancer-related fatigue was captured via the Edmonton Symptom Assessment Scale fatigue item. Patients were asked to provide postsession free-text comments., Results: A total of 436 patients (mean [standard deviation] age, 62.2 [13.4] years; n = 284 [65.1%] women; n = 294 [67.4%] white; active music therapy n = 360 [82.6%]; passive music therapy n = 76 [17.4%]) with a range of primary malignancies participated. Active music therapy was associated with a 0.88-point greater reduction in cancer-related fatigue (95% CI, 0.26 to 1.51; P = .006; Cohen's D, 0.52) at postsession as compared with passive music therapy when restricting the analysis to patients who rated their baseline cancer-related fatigue as moderate to severe (ie, ≥ 4; n = 236 [54.1%]). Free-text responses confirmed higher frequencies of words describing positive affect/emotion among active music therapy participants., Conclusions: In a large sample of inpatient adults with diverse cancer disease types, active music therapy was associated with greater reduction in cancer-related fatigue and increased reporting of positive affect/emotions compared with passive music therapy. Additional research is warranted to determine the specific efficacy and underlying mechanisms of music therapy on cancer-related fatigue.

Purpose: The incidence of breast cancer is rising in Nigeria, and one major barrier to care is the lack of affordable and appropriate breast cancer diagnosis by ultrasound (US)-guided biopsy. The prohibitive cost of US devices limits their availability in low- and middle-income countries. The emergence of mobile health (mHealth) imaging devices may offer an acceptable low-cost alternative. The purpose of this research was to perform a comprehensive needs assessment to understand knowledge, use, training needs, and attitudes as regards image-guided biopsy in Nigeria to inform the development of an mHealth-based US-guided biopsy training program., Methods: A multistakeholder needs assessment was conducted at the Sixth Annual African Research Group for Oncology Symposium. Voluntary anonymous surveys were administered to all attendees. A subset of attendees (ie, surgeons, radiologists, pathologists, and nurses) participated in six focus groups. Survey items and interview guides were developed collaboratively with local and international input., Results: Surveys focusing on use, training needs, and attitudes regarding US-guided biopsies were completed with a 55% response rate (n = 54 of 98) among participants from 22 hospitals across Nigeria. Respondents expressed dissatisfaction with the way breast biopsies were currently performed at their hospitals and high interest in having their institution participate in a US-guided biopsy training program. Focus group participants (n = 37) identified challenges to performing US-guided procedures, including equipment functionality and cost, staff training, and access to consumables. Groups brainstormed the design of an mHealth US-guided biopsy training program, preferring a train-the-trainer format combining in-person teaching with independent modules., Conclusion: A multidisciplinary needs assessment of local stakeholders identified a need for and acceptability of an mHealth-based US-guided biopsy training program in Nigeria.

Background: Distal radius fractures in the pediatric population are common injuries with a remarkable capability to remodel. The degree of angulation that can reasonably be expected to remodel is controversial though, particularly when it comes to angulation in the coronal plane. The purpose of this study was to quantify the rate of coronal remodeling, via the distal radius physis, present in a retrospective cohort of skeletally immature patients with coronally angulated distal radius fractures., Methods: A retrospective chart review was performed to identify skeletally immature patients treated for an angulated distal radius fracture with over 10 degrees of angulation in the coronal plane during the healing process at a single institution by either a pediatric orthopaedic surgeon or an orthopaedic trauma surgeon from 2009 to 2018. Coronal angulation was measured at every visit where radiographs were available from time of injury to the final follow-up visit to determine the rate of remodeling., Results: In total, 36 patients with distal radius fractures with a mean age of 7.93 years (range, 4 to 12 y) at the time of injury were identified. The median peak angulation during the healing process in the coronal plane was 17 degrees (range, 12.4 to 30.4 degrees). The mean follow-up period was 6.4 months from the time of maximum angulation to the final visit. The median time from cast removal to final follow-up was 6.59 months (range, 2.5 to 8.72 mo). At final follow-up, the median coronal angulation was 3.35 degrees (range, 0.24 to 14.0 degrees). At the 95% confidence level, remodeling rates ranged from 2.00 to 2.59 degrees per month. The mean rate of coronal angulation remodeling from maximum angulation to final follow-up was 2.30 degrees per month., Conclusions: Distal radius fractures have a large capacity to remodel in the pediatric population. This remodeling occurs in a predictable and reliable manner, even in the coronal plane. On the basis of this study, coronal angulation was shown to remodel at a rate of at least 2 degrees per month for the first 6 months following the injury, which should likely continue at a similar rate for the first year after the injury. Repeat manipulation is not indicated in skeletally immature patients where the maximum coronal angulation is <24 degrees, which provides a conservative estimate of the amount of remodeling that can be expected to occur in the first year after fracture., Level of Evidence: Level III-retrospective comparative study.

Objective: Perioperative communication is critical for procedural learning. In order to develop a periprocedural faculty development tool, we aimed to characterize the current status of preoperative communication in US General Surgery residency programs., Design: After Association of Program Directors in Surgery approval, a survey was distributed to general surgery programs. Participants were asked about perioperative communication, including the frequency of preoperative briefings, defined as dedicated educational discussions prior to a procedure. Data were analyzed using descriptive statistics., Setting: An anonymous electronic survey was distributed to interested programs in early 2019., Participants: US General Surgery trainees and attending surgeons., Results: A total of 348 responses were recorded from 27 programs: 199 (57%) attending surgeons and 149 (43%) surgical trainees. Most respondents (83%) were from a university-affiliated program. Attending surgeons indicated a higher frequency of performing preoperative briefings compared to trainees (p < 0.001). Both trainees and attending surgeons were more likely to select their own group when asked who initiates a preoperative briefing. The majority of respondents (58%) agreed that discussing autonomy preoperatively improves resident autonomy for the case. In regards to the timing of preoperative briefings, most took place in/adjacent to the operating room, with only 60 participants (17%) participating in preoperative briefings the day/night prior to the operation. The most frequent topic discussed during preoperative briefings was "procedural content." Most participants selected "time constraints" as the greatest barrier to preoperative briefings and indicated that attending surgeon engagement was necessary to facilitate their use. Trainees were less likely to report engaging in immediate postoperative feedback, but more likely to report postoperative self-reflection., Conclusions: Preoperative briefings are not necessarily routine and attendings and trainees differ on their perceptions related to their content and frequency. Efforts to address timing and scheduling and encourage dual-party engagement in perioperative communication are key to the development of tools to enhance this important aspect of procedural learning., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)