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Abstract The emergence of SARS-CoV-2 into a highly susceptible global population was primarily driven by human mobility-induced introduction events. Especially in the early stages, understanding mobility was vital to mitigating the pandemic prior to widespread vaccine availability. We conducted a systematic review of studies published from January 1, 2020, to May 9, 2021, that used population-level human mobility data to understand SARS-CoV-2 transmission. Of the 5505 papers with abstracts screened, 232 were included in the analysis. These papers focused on a range of specific questions but were dominated by analyses focusing on the USA and China. The majority included mobile phone data, followed by Google Community Mobility Reports, and few included any adjustments to account for potential biases in population sampling processes. There was no clear relationship between methods used to integrate mobility and SARS-CoV-2 data and goals of analysis. When considering papers focused only on the estimation of the effective reproductive number within the US, there was no clear relationship identified between this measure and changes in mobility patterns. Our findings underscore the need for standardized, systematic ways to identify the source of mobility data, select an appropriate approach to using it in analysis, and reporting.

David James,1 Angela Jukkala,2 Andres Azuero,2 Pamela Autrey,3 Lynne Vining,4 Rebecca Miltner2 1Center for Nursing Excellence, University of Alabama at Birmingham Hospital, 2School of Nursing, University of Alabama at Birmingham, 3Nursing Administration, University of Alabama at Birmingham Hospital, 4Medical Intensive Care Unit, University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA Objective: Evidence documenting the negative impact of poor communication on patient safety during intra-hospital transfer is prevalent and attributed to 80% of serious medical errors. An event particularly vulnerable to communication error is the patient "handoff." One of the more common handoffs occurring in health care settings is the report provided between nurses at the change of shift. The objective of this article is to report the process used to develop and examine the reliability and validity of a Medical Intensive Care Unit (MICU) Shift Report Communication Scale to measure nurses' perception of the quality and quantity of communication during shift report. Design and participants: This was a scale development and descriptive study undertaken at the Medical Intensive Care Unit within an Academic Health Center. Forty-three medical intensive care nurses took part. Results: An exploratory factor analysis revealed three domains: communication openness, quality of information, and shift report. Medical Intensive Care Unit Shift Report Communication Scale scores ranged from 12 to 27 (mean = 18.78; standard deviation = 3.28). Perception of communication did not vary between nurses based on years of nursing experience or age. Scale reliability was good (Cronbach's alpha = 0.079). Nurses were likely to have had a positive perception of the openness of communication on the unit. However, they had a less favorable perception of peer ability to fully understand information shared during shift report and identified as a common problem the frequent need to review the chart to verify reported information. Conclusion: The MICU Shift Report Communication Scale may be used to provide useful information to support health care organizations and nurse leaders in the evaluation of nurse communication during shift report. Initial testing indicates that the MICU Shift Report Communication Scale is easy to use; however, additional testing with larger groups of nurses is needed. Keywords: medical error, patient handoff, patient safety

David E Vance,1 Michele Talley,1 Andres Azuero,1 Patricia F Pearce,2 Becky J Christian1 1School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA; 2Loyola University School of Nursing, New Orleans, LA, USA Abstract: The ability to critically evaluate the merits of a quantitative design research article is a necessary skill for practitioners and researchers of all disciplines, including nursing, in order to judge the integrity and usefulness of the evidence and conclusions made in an article. In general, this skill is automatic for many practitioners and researchers who already possess a good working knowledge of research methodology, including: hypothesis development, sampling techniques, study design, testing procedures and instrumentation, data collection and data management, statistics, and interpretation of findings. For graduate students and junior faculty who have yet to master these skills, completing a formally written article critique can be a useful process to hone such skills. However, a fundamental knowledge of research methods is still needed in order to be successful. Because there are few published examples of critique examples, this article provides the practical points of conducting a formally written quantitative research article critique while providing a brief example to demonstrate the principles and form. Keywords: quantitative article critique, statistics, methodology, graduate students

Karen Heaton1, Andres Azuero1, Jennan Phillips1, Herretta Pickens1, Deborah Reed21School of Nursing Birmingham, University of Alabama at Birmingham, AL, USA; 2College of Nursing, Lexington, KY, University of Kentucky, USAAbstract: The current study was conducted by performing secondary analysis of data drawn from a study of sustained work indicators of older farmers. The primary outcome variable was the reported occurrence or non-occurrence of injuries because of farm work in the past year. There were three explanatory variables of interest: (1) whether respondents reported ever having been diagnosed with arthritis/rheumatism by a medical doctor; (2) whether participants reported having mobility problems; and (3) a farm task injury risk index. Additional explanatory variables included the estimated number of days spent on farming activities in the past year, as well as demographic characteristics such as age, sex, and race. Institutional review board approvals were obtained for the original study prior to data collection, and for the current study prior to secondary analysis of data. Descriptive statistics were calculated for the outcome and explanatory variables. Initial multivariable longitudinal models for the occurrence of injuries were fitted with the explanatory variables. Odds ratios for the effects of interest were calculated using the final models. A longitudinal model was fitted using data in waves 1, 3, and 5, with a farm task injury risk index as outcome variable and wave, sex, age, race, and estimated number of days spent on farming activities in the past year as explanatory variables for exploration of the relationship between the farm task injury risk index and these variables. In this group of older farmers, aging was protective for injury, and was associated with decreased farm task injury risk index. Arthritis/rheumatism was associated in our study with occurrence of injury because of farm work across all four waves. Our results indicated that farmers with mobility problems were twice as likely to experience injuries because of farm work compared to farmers with no mobility problems. Increased farm task injury risk index was associated with a 40% increase in odds for the occurrence of injury due to farm work. In this study of older farmers, the type of work, and not the amount of work was significantly associated with injury risk. Implications for future studies of farm injury include the need for nurse researchers and others to incorporate objective validated measures of mobility and health care provider diagnoses of arthritis, and arthritis type. Nurse researchers should proceed with ongoing evaluation of the farm task injury risk index to determine its validity, reliability, and usefulness as a predictor of farm injuries. In the practice setting, nurses may apply findings from this study to provide injury prevention teaching to older farmers and their families. For example, discussions of the more risky farm tasks, injury prevention strategies, and treatment modalities including those that promote improved mobility should be targeted to older farmers with arthritis and actual or potential mobility issues. Ultimately, these nursing research and practice efforts may lead to preservation of function, and decreased injury risk and severity among older farmers.Keywords: aging, arthritis, mobility, farm injury

Angela Jukkala1, Karen Meneses1, Andres Azuero1, June Cho1, Patrick McNees1,21School of Nursing, 2School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, USAObjective: Infertility is a severe and often underestimated consequence of successful treatment for breast cancer. Ensuring young breast cancer survivors receive patient-centered health information on the impact of treatment on fertility and fertility preservation options in a timely manner is a critical component of high quality nursing care. The objective of this manuscript is to report the process used to develop and examine the reliability and validity of an instrument to measure a breast cancer survivor’s self-assessed knowledge of fertility and fertility preservation.Design: A scale development and descriptive study.Setting: Online and global.Participants: Ninety-two young breast cancer survivors (ages 25–45 years).Methods: Participants completed the Knowledge of Fertility and Fertility Preservation (KF) Scale as part of their participation in a larger study, the Fertility Cancer Project (FCP).Results: An exploratory factor analysis revealed five domains: normal reproductive function; general information about fertility; cancer treatment factors affecting fertility; infertility information; and alternative parenting options. A confirmatory factor analysis confirmed the validity of the construct with a demonstrated good fit between the factor structure of the new scale and the observed data. Many participants self-assessed their overall knowledge of fertility and fertility preservation as “a little” and the majority rated their knowledge of infertility information as “a little”.Conclusion: The KF Scale can be used to provide useful information to support health care professionals in the development of patient-centered education that is responsive to the unique needs of each young breast cancer survivor. The initial testing of the KF Scale indicates that it is reliable and easy to use; however, additional testing with larger and more diverse groups of breast cancer survivors is needed to further determine reliability and validity. The KF Scale could also be examined as a possible measure of self-assessed knowledge of fertility and fertility preservation across diverse groups of young cancer survivors, such as survivors of Hodgkin’s disease or childhood leukemia.Keywords: knowledge of fertility, knowledge of fertility and fertility preservation scale, Fertility Cancer Project

Roland Matthews1, Andres Azuero2, Senait Asmellash3, Earl Brewster1, Edward E Partridge4, Chandrika J Piyathilake51Department of Obstetrics and Gynecology, The Morehouse School of Medicine, Atlanta, Georgia, USA; 2School of Nursing, 3Departments of Surgery, 4Obstetrics and Gynecology, 5Nutrition Sciences, University of Alabama at Birmingham, Birmingham, Alabama, USABackground: An early detection of precursor lesions of cervical cancer will help to eliminate the worldwide burden of cervical cancer.Methods: This exploratory study aimed to identify, by matrix-assisted laser desorption/ionization (MALDI) time-of-flight (TOF) mass spectrometry (MS), serum protein profiles that distinguish cervical intraepithelial neoplasia grades CIN 1 or lower (≤CIN 1) from CIN 2+ among 127 women infected with human papillomavirus (HPV) 16. Of these 127 women, 25 and 23 were diagnosed with CIN 2 or CIN 3, respectively (cases), and 79 were diagnosed with ≤CIN 1 (non-cases). Serum protein profiles were generated by MALDI-TOF-MS. A total of 95 m/z peaks were tested for association with case status by two racial groups, African American (AAs) and Caucasian American (CAs).Results: Overall, 2 protein peaks identified by our study demonstrated higher specificity for identifying CIN 2+ than previously published studies. An increasing intensity of [m/z 4459] was associated with a higher risk of being a case, regardless of race with a specificity of 58% for CIN 2 and a specificity of 75% for CIN 3. An increasing intensity of [m/z 4154] was not only associated with a higher risk of being a case only among CAs, but also had an opposite effect among AAs.Conclusion: Identification of specific proteins associated with the peaks detected in serum and development of antibody-based tests such as ELISA should lead to the development of race-specific, non-invasive and cost effective screening tests with higher specificity for identifying HPV 16 associated CIN 2+.Keywords: serum mass spectrometry, cervical intraepithelial neoplasia, race

Abstract Background Ventricular shunts are one of the most frequent techniques used for the management of hydrocephalus. The ventriculoperitoneal shunt (VPS) is the most commonly performed procedure, and the ventriculoatrial shunt (VAS) is the second option in most medical centers. The main objective of this study is to introduce and describe a surgical approach for VAS outlining our experience and comparing it with traditional shunting techniques. Methods In this retrospective cohort comparison study, we included patients with hydrocephalus treated with a surgical procedure between January 2010 and February 2021 at a single academic institution. We categorized the procedures into two groups: patients with VPS and conventional VAS grouped together into the conventional technique (CT) group, and the second group was patients with whom we performed VAS with complete internal jugular vein occlusion (IJVOT). We compared the surgical time, postoperative complications, and occurrence of shunt failure among the groups by performing univariate analysis using the Fisher exact test. Results Out of the 106 patients included in the analysis, IJVOT was performed in 66 patients, and CT in 40 patients. The median surgical time was 60 min (IQR 60–90) for IJVOT versus 100 min (IQR 60–120) for CT (p

Objective: Cognitive intra-individual variability (IIV), dispersion of cognitive performance across cognitive domains, indicates diminished cognitive control resulting from brain pathology or aging. For people with HIV-Associated Neurocognitive Disorder (HAND), cognitive IIV may interfere with and/or be improved by cognitive training. In this current secondary data analysis, we explored whether cognitive IIV functions as an outcome or moderator variable in speed of processing (SOP) training in middle-aged and older people living with HIV (PLWH). Method: In this randomized clinical trial, 216 PLWH with HAND or borderline HAND were randomized to either: 1) 10 h of SOP training; 2) 20 h of SOP training, or 3) 10 h of Internet Navigation Control Training. Participants completed a seven-domain cognitive battery at baseline, posttest after training, and years 1 and 2 follow up; from this, the coefficient of variation (CoV) served as the cognitive IIV dispersion score. Participants also completed a gold-standard measure of SOP (i.e., Useful Field of View Test (UFOV®), a targeted cognitive outcomes of the SOP training paradigm) at each time point. Results: Using linear mixed-effect models, no strong pattern of SOP training effects were detected on cognitive IIV. However, a three-way interaction tests between time, group, and baseline cognitive IIV CoV suggested potential moderation effects. Stratified analyses showed differential treatment effects between the lower cognitive IIV and higher cognitive IIV group. Conclusions: Although SOP training did not improve cognitive IIV, cognitive IIV may be a modifier of SOP training. Implications for future research and other types of training are provided.

BackgroundThe Hispanic and Latinx community is disproportionately affected by Alzheimer disease and related dementias (ADRDs). In the United States, approximately 8.5 million caregivers of individuals with ADRDs identify as Hispanic and Latinx people, and caregiving-related stress and burden place caregivers at elevated risk for poor mental health outcomes, as well as loneliness and social isolation. To date, there is limited knowledge about the daily stress experiences of Hispanic and Latinx caregivers. Given this knowledge gap, it is critical to examine how personal, cultural, and contextual factors influence daily stress, mental health, and resilience over time among Hispanic and Latinx ADRD caregivers. ObjectiveThe goal of this protocol report is to present the rationale, methodology, planned analytical strategy, progress completed to date, and implications of future findings for “Nuestros Días” (Spanish for “our days”), a fully remote daily diary (DD), observational cohort study examining the day-to-day experiences of Hispanic and Latinx ADRD caregivers. MethodsThe study will recruit a cohort of up to 500 Hispanic and Latinx caregivers of individuals living with ADRD. Participants will complete measures assessing contextual, individual-level, and cultural factors at 3 intervals (enrollment, 6 months, and 12 months). Each of the timepoints will be followed by 21 days of DD surveys to report on daily stress, stress moderators, and mental health variables. ResultsData collection began in March 2023 and is projected to end in December 2026. As of March 2024, we have enrolled 60 caregivers in the Nuestros Días study, 78.9% (n=15) of whom are Spanish speakers. The current completion rate for DD surveys is 79.4%, averaging approximately 18 surveys out of 21 completed. We expect to enroll 10 to 15 participants per month moving forward to achieve our enrollment goal. ConclusionsResults from this study will identify which Hispanic and Latinx ADRD caregivers, and under what circumstances, appear to be at the greatest risk of experiencing poor mental health outcomes over time. This study represents a critical step forward in providing key guidance to develop effective, culturally sensitive interventions to support the health and well-being of Hispanic and Latinx ADRD caregivers, a historically underrepresented and underserved population in aging and caregiving research. International Registered Report Identifier (IRRID)DERR1-10.2196/55216

Introduction: The preparation of the pedicle and the insertion of a transpedicular screw is a high-risk procedure during spine surgeries. To avoid pedicle screw misplacement in posterior spinal deformity surgery, patient specific 3D‐printed guides can be used but technical issues reported in 17% of screw fixations. To address this concern, our team has developed single-level guide templates and a locking screw mechanism. We share our experience using a surgical planning and support system with 3D printed patient-specific guides that utilize a locking screw, highlighting the advantages of incorporating it into complex spine surgeries. Materials and Methods: The surgical planning and support system is composed of six phases: (1) spine digitization, (2) segmental analysis and vertebral characterization, (3) planning of angulation, depth, and diameter of transpedicular screws, (4) 3D printing of the spine model, and the locking single level drill guides, (5) selection of surgical instruments, and (6) surgery. Illustrative cases: High resolution tomographic images of two 15-year-old females and one 16-year-old male were processed through software analysis for segmental analysis and vertebral characterization. This process aimed to propose the most suitable plan in a multidisciplinary meeting. Sterilized 3D-printed patient-specific locking spine drill guide models were utilized for the spinal instrumentation. Conclusions: Multiple countries are now developing 3D printed drill guides for screw fixation in severe scoliosis. Our guide represents the first one using a transitory locking mechanism to improve accuracy of fixation. The 3D printed locking drill guides enabled accurate insertion and direction of the transpedicular screw, resulting in improvements in sagittal and coronal balance, and all screws classified as accurately placed and with minimal difference with the planned trajectory. Additional outcomes such as surgical time, intraoperative bleeding, radiation exposure, hospital stay, and postoperative complications should also be considered for further studies in this area.

Objetivo: describir las características de los pacientes con infarto agudo de miocardio sin lesiones coronarias obstructivas (MINOCA), así como sus desenlaces cardiovasculares a dieciocho meses. Materiales y método: estudio de cohortes, ambispectivo, de los pacientes que fueron llevados a angiografía coronaria por diagnóstico de infarto agudo de miocardio (IAM), entre los años 2015 y 2019. Se seleccionó el grupo de MINOCA y obtuvieron datos de desenlaces como reconsultas y eventos cardiovasculares mayores a dieciocho meses. Resultados: de los 433 pacientes incluidos, 141 (33%) cumplían definición de MINOCA; el dolor torácico y los equivalentes anginosos fueron las manifestaciones clínicas más prevalentes (62 y 62.4% respectivamente). La mayoría se presentaron con IAM sin elevación del ST (92.1%), con FEVI ≥ 50% (42.6%). En el seguimiento a dieciocho meses, se obtuvieron datos de 102 pacientes, de los que el 22% reconsultó y 18% presentó reinfarto. La mortalidad durante el seguimiento fue del 12% por causa cardiovascular y del 36% por todas las causas. Conclusiones: se encontró una mayor proporción de MINOCA respecto a lo descrito en la literatura y con predominio de manifestaciones clínicas atípicas. Es llamativo, igualmente, el alto porcentaje importante de preinfartos y muerte de origen cardiovascular durante el seguimiento de esta cohorte.

Abstract Background Though financial hardship is a well‐documented adverse effect of standard‐of‐care cancer treatment, little is known about out‐of‐pocket costs and their impact on patients participating in cancer clinical trials. This study explored the financial effects of cancer clinical trial participation. Methods This cross‐sectional analysis used survey data collected in December 2022 and May 2023 from individuals with cancer previously served by Patient Advocate Foundation, a nonprofit organization providing social needs navigation and financial assistance to US adults with a chronic illness. Surveys included questions on cancer clinical trial participation, trial‐related financial hardship, and sociodemographic data. Descriptive and bivariate analyses were conducted using Cramer's V to estimate the in‐sample magnitude of association. Associations between trial‐related financial hardship and sociodemographics were estimated using adjusted relative risks (aRR) and corresponding 95% confidence intervals (CI) from modified Poisson regression models with robust standard errors. Results Of 650 survey respondents, 18% (N = 118) reported ever participating in a cancer clinical trial. Of those, 47% (n = 55) reported financial hardship as a result of their trial participation. Respondents reporting trial‐related financial hardship were more often unemployed or disabled (58% vs. 43%; V = 0.15), Medicare enrolled (53% vs. 40%; V = 0.15), and traveled >1 h to their cancer provider (45% vs. 17%; V = 0.33) compared to respondents reporting no hardship. Respondents who experienced trial‐related financial hardship most often reported expenses from travel (reported by 71% of respondents), medical bills (58%), dining out (40%), or housing needs (40%). Modeling results indicated that respondents traveling >1 h vs. ≤30 min to their cancer provider had a 2.2× higher risk of financial hardship, even after adjusting for respondent race, income, employment, and insurance status (aRR = 2.2, 95% CI 1.3–3.8). Most respondents (53%) reported needing $200–$1000 per month to compensate for trial‐related expenses. Over half (51%) of respondents reported less willingness to participate in future clinical trials due to incurred financial hardship. Notably, of patients who did not participate in a cancer clinical trial (n = 532), 13% declined participation due to cost. Conclusion Cancer clinical trial‐related financial hardship, most often stemming from travel expenses, affected almost half of trial‐enrolled patients. Interventions are needed to reduce adverse financial participation effects and potentially improve cancer clinical trial participation.

Introducción: El Hospital Militar Central cuenta con un grupo especial para la atención de pacientes con trauma de guerra que incluye una evaluación inicial y manejo urgente de las lesiones que amenacen la vida, mediante un enfoque de control de daños que busca preservar la vida del paciente, salvar la extremidad y conservar su función. Materiales y Métodos: Estudio observacional, descriptivo, transversal de pacientes de las fuerzas militares de Colombia, que sufrieron fracturas de fémur o tibia por trauma de guerra entre 2012 y 2020; y tratados mediante fijación externa en este Hospital. Objetivos: Describir las complicaciones del trauma de guerra tras un año de manejo de pacientes con fracturas de fémur o tibia utilizando un protocolo de control de daños en el Hospital Militar Central, centro de referencia para este tipo de trauma en el país. Resultados: Se realizó una revisión retrospectiva de pacientes con fracturas femorales o tibiales por traumas de guerra entre 2012 y 2020, manejados con un protocolo de control de daños. Se seleccionaron 72 soldados, el 96% de las fracturas eran abiertas, el 91% (66 casos) sufrió alguna complicación, como lesión nerviosa, lesión vascular, defecto de cobertura, infección, falta de consolidación. Conclusiones: El trauma de guerra continúa representando una de las etiologías de politraumatismo en pacientes jóvenes de nuestro país que, a su vez, sigue teniendo grandes implicaciones clínicas y económicas. Las lesiones óseas de las extremidades requieren un manejo por etapas basado en la fijación externa según los principios de control de daños.

Esta investigación busca identificar la influencia de la gestión humana sobre la competitividad de las pequeñas y medianas empresas colombianas (Pymes). Para ello se aplica una investigación cuantitativa donde se encuesta a 174 gerentes. Se reconocen como variables independientes las prácticas de gestión humana dadas por el modelo AMO (Ability, Motivatión, Oportunity) y como variable dependiente los índices de competitividad. Como resultado se obtiene que la gestión humana influencia la competitividad principalmente con aquellas prácticas que promueven habilidades como la selección y formación. Estos resultados aportan a la gestión de las Pymes desde la perspectiva de la gestión humana y contribuyen al mejoramiento de las políticas públicas nacionales y gubernamentales para el mejoramiento de la competitividad.

Abstract Background We aimed to describe the roles and challenges of family caregivers involved in patients' cancer treatment decision‐making. Methods Family caregiver‐reported data were analyzed from a national survey conducted in the United States by CancerCare® (2/2021–7/2021). Four select‐all‐that‐apply caregiver roles were explored: (1) observer (patient as primary decision‐maker); (2) primary decision‐maker; (3) shared decision‐maker with patient and (4) decision delegated to healthcare team. Roles were compared across five treatment decisions: where to get treatment, the treatment plan, second opinions, beginning treatment and stopping treatment. Ten challenges faced by caregivers (e.g., information, cost, treatment understanding) were then examined. χ2 and regression analyses were used to assess associations between roles, decision areas, challenges and caregiver sociodemographics. Results Of 2703 caregiver respondents, 87.6% reported involvement in patient decisions about cancer treatment, including 1661 who responded to a subsection further detailing their roles and challenges with specific treatment decisions. Amongst these 1661 caregivers, 22.2% reported an observing role, 21.3% a primary decision‐making role, 53.9% a shared decision‐making role and 18.1% a role delegating decisions to the healthcare team. Most caregivers (60.4%) faced ≥1 challenge, the most frequent being not knowing how treatments would affect the patient's physical condition (24.8%) and quality of life (23.2%). In multivariable models, being Hispanic/Latino/a was the strongest predictor of facing at least one challenge (b = −0.581, Wald = 10.69, p

ContextPatients with advanced cancer often involve family caregivers in health-related decision-making from diagnosis to end-of-life; however, few interventions have been developed to enhance caregiver decision support skills.ObjectivesAssess the feasibility, acceptability, and potential efficacy of individual intervention components of CASCADE (CAre Supporters Coached to be Adept DEcision Partners), an early telehealth, palliative care coach-led decision support training intervention for caregivers.MethodsPilot factorial trial using the multiphase optimization strategy (October 2019-October 2020). Family caregivers and their care recipients with newly-diagnosed advanced cancer (n = 46 dyads) were randomized to1 of 8 experimental conditions that included a combination of one of the following three CASCADE components: 1) effective decision support psychoeducation; 2) decision support communication training; and 3) Ottawa Decision Guide training. Feasibility was assessed by completion of sessions and questionnaires (predefined as ≥80%). Acceptability was determined through postintervention interviews and participants' ratings of their likelihood to recommend. Measures of effective decision support and caregiver and patient distress were collected at Twelve and Twenty four weeks.ResultsCaregiver participants completed 78% of intervention sessions and 81% of questionnaires; patients completed 80% of questionnaires. Across conditions, average caregiver ratings for recommending the program to others was 9.9 on a scale from 1-Not at all likely to 10-Extremely likely. Individual CASCADE components were observed to have potential benefit for effective decision support and caregiver distress.ConclusionWe successfully piloted a factorial trial design to examine components of a novel intervention to enhance the decision support skills of advanced cancer family caregivers. A fully-powered factorial trial is warranted.Key messageWe pilot tested components of CASCADE, an early palliative care decision support training intervention for family caregivers of patients with advanced cancer. CASCADE components were acceptable and the trial design feasible, providing promising future directions for palliative care intervention development and testing. Pilot results will inform a fully-powered trial.

Recent systematic reviews and meta-analyses have reported positive benefit of multicomponent "bundled" palliative care interventions for patients and family caregivers while highlighting limitations in determining key elements and mechanisms of improvement. Traditional research approaches, such as the randomized controlled trial (RCT), typically treat interventions as "bundled" treatment packages, making it difficult to assess definitively which aspects of an intervention can be reduced or replaced or whether there are synergistic or antagonistic interactions between intervention components. Progressing toward palliative care interventions that are effective, efficient, and scalable will require new strategies and novel approaches. One such approach is the Multiphase Optimization Strategy (MOST), a framework informed by engineering principles, that uses a systematic process to empirically identify an intervention comprised of components that positively contribute to desired outcomes under real-life constraints. This article provides a brief overview and application of MOST and factorial trial design in palliative care research, including our insights from conducting a pilot factorial trial of an early palliative care intervention to enhance the decision support skills of advanced cancer family caregivers (Project CASCADE).

Abstract Background Family caregivers play an increasing role in cancer treatment decision‐making. We examined bias reported by family caregivers in the support they and their patient received from their healthcare team when making these decisions, including associations with distress. Methods Analysis of 2021 national survey data of family caregivers of patients with cancer (N = 2703). Bias experienced in decision support was assessed with the item: “Have you felt that the support you and the person with cancer have received for making cancer‐related decisions by your doctor or healthcare team has been negatively affected by any of the following?” Check‐all‐that‐apply response options included: age, race, language, education, political affiliation, body weight, insurance type or lack of insurance, income, religion, sexual orientation, and gender/sex. Chi‐square and regression analyses assessed associations between bias and caregiver distress (GAD‐2, PHQ‐2). Results Of 2703 caregiver respondents, 47.4% (n = 1281) reported experiencing ≥1 bias(es) when receiving decision support for making cancer‐related decisions. Bias was more prevalent among younger caregivers, males, transwomen/men or gender non‐conforming caregivers, racial/ethnic minorities, and those providing care over a longer time period. The odds of having high anxiety (GAD‐2 scores ≥ 3) were 2.1 times higher for caregivers experiencing one type of bias (adjusted OR, 2.1; 95% CI, 1.6–2.8) and 4.2 times higher for caregivers experiencing ≥2 biases (adjusted OR, 4.2; 95% CI, 3.4–5.3) compared to none. Similar results were found for high depression scores (PHQ‐2 scores ≥ 3). Conclusions Nearly half of caregivers involved in their care recipients' cancer‐related decisions report bias in decision support received from the healthcare team. Experiencing bias was strongly associated with high psychological distress.

Vehicle routing problem (VRP) is a classic problem studied in logistic. One of the most important variations within this problem is called Green Vehicle Routing Problem (GVRP), in which environmental aspects are considered when designing product delivery routes. This variant arises due to the high levels of pollution produced by transport vehicles, so it is a variation whose study represents a vital impact nowadays. This project will consider a GVRP and will be developed considering the characteristics of multi-depot (MDVRP) and multi-product (MPVRP) to minimize the costs of assignation of vehicles and CO2 emissions. To solve the problem, this project proposes a hybridization between the classic tabu search (TS) metaheuristic and the PAES algorithm (TS+PAES) to generate the Pareto frontier of both objectives. An integer mixed linear programming model is formulated and developed for each objective function separately to have an optimal point of comparison for the efficiency of the proposed algorithm. Also, the TS+PAES algorithm is compared to the nearest neighbor algorithm for large instances. Two computational experiments were carried out, one for small and the other one for large instances. The experiment for small instances showed that the GAP of each extreme of the frontier compared to the MILP model is on average 0.73%. For large instances, the metaheuristic improves in 0.1% the results presented by the MILP model showing that the metaheuristic provides closer near-optimal solutions in less computational time. Besides, the metaheuristic, in comparison with the nearest neighborhood heuristic, improves in 44.21% the results of emissions and in 3.88% the costs. All these results demonstrate the effectiveness of the metaheuristic.