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Background: Palliative medicine physicians may be at higher risk of burnout due to increased stressors and compromised resilience during the COVID-19 pandemic. Burnout prevalence and factors influencing this among UK and Irish palliative medicine physicians is unknown. Aim: To determine the prevalence of burnout and the degree of resilience among UK and Irish palliative medicine physicians during the COVID-19 pandemic, and associated factors. Design: Online survey using validated assessment scales assessed burnout and resilience: The Maslach Burnout Inventory Human Services Survey for Medical Personnel [MBI-HSS (MP)] and the Connor-Davidson Resilience Scale (CD-RISC). Additional tools assessed depressive symptoms, alcohol use, and quality of life. Setting/participants: Association of Palliative Medicine of UK and Ireland members actively practising in hospital, hospice or community settings. Results: There were 544 respondents from the 815 eligible participants (66.8%), 462 provided complete MBI-HSS (MP) data and were analysed. Of those 181/462 (39.2%) met burnout criteria, based on high emotional exhaustion or depersonalisation subscales of the MBI-HSS (MP). A reduced odds of burnout was observed among physicians who worked ⩽20 h/week (vs 31–40 h/week, adjusted odds ratio (aOR) 0.03, 95% confidence interval (CI) 0.002–0.56) and who had a greater perceived level of clinical support (aOR 0.70, 95% CI 0.62–0.80). Physicians with higher levels of depressive symptoms had higher odds of burnout (aOR 18.32, 95% CI 6.75–49.73). Resilience, mean (SD) CD-RISC score, was lower in physicians who met burnout criteria compared to those who did not (62.6 (11.1) vs 70.0 (11.3); p Conclusions: Over one-third of palliative medicine physicians meet burnout criteria. The provision of enhanced organisational and colleague support is paramount in both the current and future pandemics.

Opinion statementOpioids are an important treatment in managing cancer pain. Uncontrolled pain can be detrimental to function and quality of life. Common adverse effects of opioids such as sedation, constipation and nausea are well recognised, but opioid effects on the endocrine and immune systems are less apparent. The evidence for the immunomodulatory effects of opioids suggest that some opioids might be immunosuppressive and that their use might be associated with reduced survival and increased rates of infection in patients with cancer. However, the quality of this evidence is limited. Opioid-induced endocrinopathies, in particular opioid-induced hypogonadism, may also impact cancer survival and impair quality of life. But again, evidence in patients with cancer is limited, especially with regard to their management. There are some data that different opioids influence immune and endocrine function with varying outcomes. For example, some opioids, such as tramadol and buprenorphine, demonstrate immune-sparing qualities when compared to others. However, most of this data is preclinical and without adequate clinical correlation; thus, no opioid can currently be recommended over another in this context. Higher opioid doses might have more effect on immune and endocrine function. Ultimately, it is prudent to use the lowest effective dose to control the cancer pain. Clinical presentations of opioid-induced endocrinopathies should be considered in patients with cancer and assessed for, particularly in long-term opioid users. Hormone replacement therapies may be considered where appropriate with support from endocrinology specialists.

Rationale and Objectives Relatively little data exist on factors associated with radiologists’ burnout versus other medical specialties. We compared self-reported burnout among academic medical center radiologists versus nonradiologist peers to inform initiatives to increase wellbeing and professional satisfaction. Materials and Methods In 2017, our large urban academic medical center administered the Stanford Physician Wellness Survey to faculty in fifteen clinical departments (fourteen academic, one community-based). Faculty rated burnout via Likert scale (0—no burnout; 1—occasional stress/no burnout; 2—one or more burnout symptoms; 3—persistent burnout symptoms; 4—completely burned out); burnout defined as >=2. Responses in 11 domains (professional fulfillment, emotional exhaustion, interpersonal disengagement, sleep difficulties, self-compassion, negative work impact on personal relations, perceived appreciation, control over schedule, organizational/personal values alignment, electronic health record, perceived quality of supervisory leadership) compared radiologists versus nonradiologists for association with burnout, using Whitney-Mann U test to calculate Z scores. Results There was no significant difference in overall self-reported burnout between radiologists and nonradiologists, nor in self-rating for emotional exhaustion, interpersonal disengagement, self-compassion, control over schedule, organizational/personal values alignment, or electronic health record experience. Radiologists had significantly lower self-rating for work happiness (Z = -2.669, p = 0.0076), finding work meaningful (Z = -2.77351, p = 0.0055), perceiving physicians as highly valued (Z = -2.5486, p = 0.0108), and believing leadership treated them with respect and dignity (Z = -3.44149, p = 0.0006). Conclusion Compared to nonradiologist colleagues, radiologists were less likely to find work meaningful and more likely to feel unhappy and undervalued in the workplace and by leadership. Initiatives to increase perceived appreciation, leadership relationships, and meaningfulness of work for radiologists may reduce burnout.

Introduction Integrated care potentially improves health outcomes for older people with frailty. We aimed to assess the effectiveness of a new, proactive, multidisciplinary care service in improving the wellbeing and quality-of-life of older people with frailty. Methods A community-based non-randomised controlled trial. Participants (≥65 years, electronic Frailty Index ≥0.36) received either this new integrated care service plus usual care, or usual care alone. Data collection was at 3 time points: baseline, 2-4 weeks, and 10-14 weeks; the primary outcome was patient well-being at 2-4 weeks, measured using the Integrated Patient Outcome scale, IPOS. The secondary outcome was quality-of-life, measured using EQ-5D. Wellbeing and quality-of-life at 10-14 weeks were measured to test safety and duration of effect. Data was analysed with STATA v17. Results 199 intervention and 54 control participants were recruited. At baseline, participants were similar in age/gender/body mass index/ethnicity/living status. At 2-4 weeks, the intervention group had improved well-being (median IPOS reduction 5, versus control group increase 2, p Conclusion This new integrated care service improves the overall wellbeing and quality of life of older people with frailty at 2-4 weeks; improvement was sustained at 3 months. Ethics Approval: IRAS-250981 and NHS Research Ethics Committee 18/YH/0470.

To describe the imaging findings of intimate partner violence (IPV)–related injury and to evaluate the role of longitudinal imaging review in detecting IPV. Radiology studies were reviewed in chronological order and IPV-related injuries were recorded among 400 victims of any type of abuse (group 1) and 288 of physical abuse (group 2) from January 2013 to June 2018. The likelihood of IPV was assessed as low/moderate/high based on the review of (1) current and prior anatomically related studies only and (2) longitudinal imaging history consisting of all prior studies. The first radiological study date with moderate/high suspicion was compared to the self-reported date by the victim. A total of 135 victims (33.8%) in group 1 and 144 victims (50%) in group 2 demonstrated IPV-related injuries. Musculoskeletal injury was most common (58.2% and 44.5% in groups 1 and 2, respectively; most commonly lower/upper extremity fractures), followed by neurologic injury (20.9% and 32.9% in groups 1 and 2, respectively; most commonly facial injury). With longitudinal imaging history, radiologists were able to identify IPV in 31% of group 1 and 46.5% of group 2 patients. Amongst these patients, earlier identification by radiologists was provided compared to the self-reported date in 62.3% of group 1 (median, 64 months) and in 52.6% of group 2 (median, 69.3 months). Musculoskeletal and neurological injuries were the most common IPV-related injuries. Knowledge of common injuries and longitudinal imaging history may help IPV identification when victims are not forthcoming. • Musculoskeletal injuries were the most common type of IPV-related injury, followed by neurological injuries. • With longitudinal imaging history, radiologists were able to better raise the suspicion of IPV compared to the selective review of anatomically related studies only. • With longitudinal imaging history, radiologists were able to identify IPV earlier than the self-reported date by a median of 64 months in any type of abuse, and a median of 69.3 months in physical abuse.

Objective Determine whether differences exist in rates of follow-up recommendations made for pulmonary nodules after accounting for multiple patient and radiologist factors. Methods This Institutional Review Board–approved, retrospective study was performed at an urban academic quaternary care hospital. We analyzed 142,001 chest and abdominal CT reports from January 1, 2016, to December 31, 2018, from abdominal, thoracic, and emergency radiology subspecialty divisions. A previously validated natural language processing (NLP) tool identified 24,512 reports documenting pulmonary nodule(s), excluding reports NLP-positive for lung cancer. A second validated NLP tool identified reports with follow-up recommendations specifically for pulmonary nodules. Multivariable logistic regression was used to determine the likelihood of pulmonary nodule follow-up recommendation. Interradiologist variability was quantified within subspecialty divisions. Results NLP classified 4,939 of 24,512 (20.1%) reports as having a follow-up recommendation for pulmonary nodule. Male patients comprised 45.3% (11,097) of the patient cohort; average patient age was 61.4 years (±14.1 years). The majority of reports were from outpatient studies (62.7%, 15,376 of 24,512), were chest CTs (75.9%, 18,615 of 24,512), and were interpreted by thoracic radiologists (63.7%, 15,614 of 24,512). In multivariable analysis, studies for male patients (odds ratio [OR]: 0.9 [0.8-0.9]) and abdominal CTs (OR: 0.6 [0.6-0.7] compared with chest CT) were less likely to have a pulmonary nodule follow-up recommendation. Older patients had higher rates of follow-up recommendation (OR: 1.01 for each additional year). Division-level analysis showed up to 4.3-fold difference between radiologists in the probability of making a follow-up recommendation for a pulmonary nodule. Discussion Significant differences exist in the probability of making a follow-up recommendation for pulmonary nodules among radiologists within the same subspecialty division.

OBJECTIVE. The purpose of this article is to assess the effects of a pay-for-performance (PFP) initiative on clinical impact and usage of a radiology peer learning tool. MATERIALS AND METHODS. This retrospective study was performed at a large academic hospital. On May 1, 2017, a peer learning tool was implemented to facilitate radiologist peer feedback including clinical follow-up, positive feedback, and consultation. Subsequently, PFP target numbers for peer learning tool alerts by subspecialty divisions (October 1, 2017) and individual radiologists (October 1, 2018) were set. The primary outcome was report addendum rate (percent of clinical follow-up alerts with addenda), which was a proxy for peer learning tool clinical impact. Secondary outcomes were peer learning tool usage rate (number of peer learning tool alerts per 1000 radiology reports) and proportion of clinical follow-up alerts (percent of clinical follow-ups among all peer learning tool alerts). Outcomes were assessed biweekly using ANOVA and statistical process control analyses. RESULTS. Among 1,265,839 radiology reports from May 1, 2017, to September 29, 2019, a total of 20,902 peer learning tool alerts were generated. The clinical follow-up alert addendum rate was not significantly different between the period before the PFP initiative (9.9%) and the periods including division-wide (8.3%) and individual (7.9%) PFP initiatives (p = .55; ANOVA). Peer learning tool usage increased from 2.2 alerts per 1000 reports before the PFP initiative to 12.6 per 1000 during the division-wide PFP period (5.7-fold increase; 12.6/2.2), to 25.2 in the individual PFP period (11.5-fold increase vs before PFP; twofold increase vs division-wide) (p < .001). The clinical follow-up alert proportion decreased from 37.5% before the PFP initiative, to 34.4% in the division-wide period, to 31.3% in the individual PFP period. CONCLUSION. A PFP initiative improved radiologist engagement in peer learning by marked increase in peer learning tool usage rate without a change in report addendum rate as a proxy for clinical impact.

BackgroundBereaved people need a supportive response from those around them. Knowing children’s and surviving parents' needs following parental death is the first step to ensuring a supportive response. However, no systematic review has reported on this phenomenon.AimTo systematically identify and synthesise qualitative literature exploring support experiences of parentally bereaved children and surviving parents.MethodsSystematic review with thematic synthesis, following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. MEDLINE, Embase, PsycINFO, CINAHL and the British Nursing Database were searched for relevant papers to September 2021. Included studies were appraised for quality and thematically synthesised using Thomas and Harden’s thematic synthesis framework.ResultsFifteen qualitative studies from nine countries were included. There were four analytical themes from the children’s perspectives (1) Openness of communication with children about death and dying, (2) Children’s challenges of managing change, (3) Navigating emotions, and (4) Children’s acceptability, access and engagement with support. There were three analytical themes from the parents' perspectives: (1) Adjusting as a parent, (2) Supporting their children, and (3) Parent’s acceptability, access and engagement with support.ConclusionsFollowing a parental death, open and honest communication and involvement in what is happening within the family will help children cope. Both children and parents suppress emotions and avoid conversations to protect each other and those around them. A taboo around death exists and constrains the support some families receive. Childhood bereavement is a public health issue, with a need for professionals and communities to better understand and respond to the needs of bereaved families.CRD42020166179

Background: Malignant bowel obstruction occurs in up to 50% of people with advanced ovarian and 15% of people with gastrointestinal cancers. Evaluation and comparison of interventions to manage symptoms are hampered by inconsistent evaluations of efficacy and lack of agreed core outcomes. The patient perspective is rarely incorporated. Aim: To synthesise the qualitative data regarding patient, caregiver and healthcare professionals’ views and experience of malignant bowel obstruction to inform the development of a core outcome set for the evaluation of malignant bowel obstruction. Design: A qualitative systematic review was conducted, with narrative synthesis. The review protocol was registered prospectively ( https://www.crd.york.ac.uk/prospero , CRD42020176393). Data sources: MEDLINE, EMBASE, CINAHL, PsycINFO and Scopus databases were searched for studies published between 2010 and 2021. Reference lists were screened for further relevant publications, and citation tracking was performed. Results: Nine papers were included, reporting on seven studies which described the views and experiences of malignant bowel obstruction through the perspectives of 75 patients, 13 caregivers and 62 healthcare professionals. Themes across the papers included symptom burden, diverse experiences of interventions, impact on patient quality of life, implications and trajectory of malignant bowel obstruction, mixed experience of communication and the importance of realistic goals of care. Conclusion: Some of the most devastating sequelae of malignant bowel obstruction, such as pain and psychological distress, are not included routinely in its clinical or research evaluation. These data will contribute to a wider body of work to ensure the patient and caregiver perspective is recognised in the development of a core outcome set.

Purpose The aims of this study were to (1) describe the System for Coordinating Orders for Radiology Exams (SCORE), the objective of which is to manage unscheduled orders for outpatient diagnostic imaging in an electronic health record (EHR) with embedded computerized physician order entry; (2) assess the impact of SCORE and other related factors (eg, demographics) on the rate of unscheduled orders; and (3) assess the clinical necessity of orders canceled, expired, scheduled, and performed. Methods This institutional review board–approved retrospective study was conducted at a large academic institution between October 1, 2017, and July 1, 2019. The design and implementation of SCORE are described, including people (eg, competencies), processes (eg, standardized procedures), and tools (eg, EHR interfaces, dashboard). The rate of unscheduled imaging orders was compared before SCORE (October 1, 2017, to September 30, 2018) and after SCORE (October 1, 2018, to Jun 30, 2019) using χ2 analysis. For 447 randomly selected orders, mode of resolution was obtained from the EHR, and factors related to order resolution were assessed using multivariate analysis. Finally, clinical necessity was manually assessed by two physicians. Results Before SCORE, 52,204 of 607,020 examination orders (8.6%) were unscheduled, compared with 20,900 of 475,000 examination orders (4.4%) after SCORE (P Conclusions SCORE significantly reduced unscheduled diagnostic imaging orders. This patient safety initiative may help reduce errors resulting from diagnostic delays due to unscheduled examination orders.

To recognize most common patterns of upper extremity (UE) injuries in victims of Intimate Partner Violence (IPV). Radiological review of 308 patients who reported physical IPV at our institution from January 2013 to June 2018, identified 55 patients with 88 unique UE injuries. Demographic data and injury patterns and associations were collected from the electronic medical records. The cohort included 49 females and 6 males (age 19–63, mean 38). At the time of injury, IPV was reported in 15/88 (17%) and IPV screening was documented for 22/88 (25%) injuries. There were 46 fractures, 8 dislocations or subluxations, and 34 isolated soft tissue injuries, most commonly involving the hand (56/88). Fractures most commonly involved the fingers (21/46, 46%) and the 5th digit (8/27, 30%). Medial UE fractures (5th digit, 4th digit) constituted 44% of hand and finger fractures (12/27) and 26% of all fractures (12/46). Comminuted and displaced fractures were rare (8/46, 17%). Head and face injuries were the most common concomitant injuries (9/22, 41%) and subsequent injuries (21/61, 35%). Of 12 patients with recurrent UE injuries, 6 had recurrent injuries of the same hand. Five of 6 non-acute fractures (83%) were of the hand. Hand and finger injuries are the most common UE injuries in patients with IPV, with finger being the most common site and medial hand the most common region of fracture. Repeated injuries involving the same site and a combination of medial hand and head or face injuries could indicate IPV. • Upper extremity injuries in victims of intimate partner violence are most commonly seen in the hand and fingers. • Fingers are the most common site of fracture and the medial hand is the most common region of fracture in the upper extremity in victims of intimate partner violence. • In intimate partner violence victims with upper extremity injuries, concomitant injuries and subsequent injuries are most commonly seen in the head and neck region.

Background Intimate partner violence (IPV) is a global social and public health problem, but published literature regarding the exacerbation of physical IPV during the coronavirus disease 2019 (COVID-19) pandemic is lacking. Purpose To assess the incidence, patterns, and severity of injuries in IPV victims during the COVID-19 pandemic in 2020 compared with the prior 3 years. Materials and Methods The demographics, clinical presentation, injuries, and radiologic findings of patients reporting physical abuse arising from IPV during the statewide COVID-19 pandemic between March 11 and May 3, 2020, were compared with data from the same period for the past 3 years. Pearson χ2 and Fisher exact tests were used for analysis. Results A total of 26 victims of physical IPV from 2020 (mean age, 37 years ± 13 [standard deviation]; 25 women) were evaluated and compared with 42 victims of physical IPV (mean age, 41 years ± 15; 40 women) from 2017 to 2019. Although the overall number of patients who reported IPV decreased during the pandemic, the incidence of physical IPV was 1.8 times greater (95% CI: 1.1, 3.0; P = .01). The total number of deep injuries was 28 during 2020 versus 16 from 2017 to 2019; the number of deep injuries per victim was 1.1 during 2020 compared with 0.4 from 2017 to 2019 (P < .001). The incidence of high-risk abuse defined by mechanism was two times greater in 2020 (95% CI: 1.2, 4.7; P = .01). Patients who experienced IPV during the COVID-19 pandemic were more likely to be White; 17 (65%) victims in 2020 were White compared with 11 (26%) in the prior years (P = .007). Conclusion There was a higher incidence and severity of physical intimate partner violence (IPV) during the coronavirus disease 2019 (COVID-19) pandemic compared with the prior 3 years. These results suggest that victims of IPV delayed reaching out to health care services until the late stages of the abuse cycle during the COVID-19 pandemic. © RSNA, 2020.

Determine predictors of self-reported burnout among academic radiologists.In 2017, radiologists at an urban medical center completed the Stanford Wellness Survey, rating burnout via Likert scale (0: no burnout; 1: occasional stress, no burnout; 2: one or more burnout symptoms; 3: persistent burnout symptoms; 4: completely burned out). Univariate analyses assessed age, gender, family situation, clinical versus research focus, and academic rank for association with burnout (Likert scale ≥ 2). Responses in 11 domains querying definitions of burnout (professional fulfillment, emotional exhaustion, interpersonal disengagement), individual factors (sleep-related impairment, self-compassion, negative work impact on personal relationships), institutional factors (perceived appreciation, control over schedule, organizational or personal values alignment, electronic health record experience, supervisor's leadership quality) were evaluated for association with burnout, using χIn 159 of 204 (77.9%) completed radiologist surveys, 35.2% (56 of 159) reported burnout. Age40 years (P = .0068) and clinical focus (P = .0111) were significantly associated with burnout. In univariate analysis, all domains except electronic health record were statistically significant: emotional exhaustion (OR = 1.93, P.0001); professional fulfillment (OR = 0.78, P.0001); self-compassion (OR = 1.36, P.0001); perceived appreciation (OR = 0.78, P.0001); sleep-related impairment (OR = 1.20, P.0001); supervisor's leadership quality (OR = 0.91, P.0001); interpersonal disengagement (OR = 1.31, P.0001); organizational or personal values alignment (OR = 0.87, P = .0004); negative work impact on personal relationships (OR = 1.10, P = .0070); control over schedule (OR = 0.80, P = .0054); electronic health record experience (OR=1.03, P = .5392).Nearly all questions significantly predicted self-reported burnout, observed in over one-third of academic radiologists. Younger age and clinical focus were associated with burnout. Initiatives targeting individual factors (eg, sleep impairment, self-compassion) and institutional factors (eg, physician appreciation, leadership-faculty interactions) may reduce burnout.

To evaluate the imaging findings of facial injuries in patients reporting intimate partner violence (IPV).A retrospective review of radiology studies performed for 668 patients reporting IPV to our institution's violence prevention support program identified 96 patients with 152 facial injuries. Demographics, imaging findings, and clinical data obtained from a review of the electronic medical records (EMR) were analyzed to categorize injury patterns.The study cohort consisted of 93 women and 3 men with a mean age of 35 years (range 19-76; median 32). At the time of presentation, 57 (59.3%) patients reported IPV as the mechanism of injury. The most frequent site of injury was the midface, seen in 65 (67.7%) patients. The most common fracture sites were the nasal bones (45/152, 29.6%), followed by the mandible (17/152, 11.1%), and orbits (16/152, 10.5%). Left-sided injuries were more common (90/152; 59.2%). A vast majority of fractures (94.5%) showed minimal or no displacement. Over one-third of injuries (60/152, 39.4%) demonstrated only soft tissue swelling or hematoma without fracture. Associated injuries were seen most frequently in the upper extremity, occurring synchronously in 11 (11.4%) patients, and preceding the index facial injury in 20 (21%) patients./advances in knowledge. The midface was the most frequent location of injury in victims of intimate partner violence, and the nasal bone was the most commonly fractured facial bone. Recognizing these injury patterns can help radiologists suspect IPV and prompt them to discuss the possibility of IPV with the clinical providers.

During the surge of Coronavirus Disease 2019 (COVID-19) infections in March and April 2020, many skilled-nursing facilities in the Boston area closed to COVID-19 post-acute admissions because of infection control concerns and staffing shortages. Local government and health care leaders collaborated to establish a 1000-bed field hospital for patients with COVID-19, with 500 respite beds for the undomiciled and 500 post-acute care (PAC) beds within 9 days. The PAC hospital provided care for 394 patients over 7 weeks, from April 10 to June 2, 2020. In this report, we describe our implementation strategy, including organization structure, admissions criteria, and clinical services. Partnership with government, military, and local health care organizations was essential for logistical and medical support. In addition, dynamic workflows necessitated clear communication pathways, clinical operations expertise, and highly adaptable staff.

Background: Despite evidence demonstrating the utility of using Person-Centred Outcome Measures within palliative care settings, implementing them into routine practice is challenging. Most research has described barriers to, without explaining the causal mechanisms underpinning, implementation. Implementation theories explain how, why, and in which contexts specific relationships between barriers/enablers might improve implementation effectiveness but have rarely been used in palliative care outcomes research. Aim: To use Normalisation Process Theory to understand and explain the causal mechanisms that underpin successful implementation of Person-Centred Outcome Measures within palliative care. Design: Exploratory qualitative study. Data collected through semi-structured interviews and analysed using a Framework approach. Setting/participants: 63 healthcare professionals, across 11 specialist palliative care services, were purposefully sampled by role, experience, seniority, and settings (inpatient, outpatient/day therapy, home-based/community). Results: Seven main themes were developed, representing the causal mechanisms and relationships underpinning successful implementation of outcome measures into routine practice. Themes were: Subjectivity of measures; Frequency and version of Integrated Palliative care Outcome Scale; Training, education, and peer support; Building and sustaining community engagement; Electronic system readiness; The art of communication; Reinforcing use through demonstrating value. Conclusions: Relationships influencing implementation resided at individual and organisational levels. Addressing these factors is key to driving the implementation of outcome measures into routine practice so that those using palliative care services can benefit from the systematic identification, management, and measurement of their symptoms and concerns. We provide key questions that are essential for those implementing and using outcome measures to consider in order to facilitate the integration of outcome measures into routine palliative care practice.

Assess the early voluntary adoption of a certainty scale to improve communicating diagnostic certainty in radiology reports.This institutional review board-approved study was part of a multifaceted initiative to improve radiology report quality at a tertiary academic hospital. A committee comprised of radiology subspecialty division representatives worked to develop recommendations for communicating varying degrees of diagnostic certainty in radiology reports in the form of a certainty scale, made publicly available online, which specified the terms recommended and the terms to be avoided in radiology reports. Twelve radiologists voluntarily piloted the scale; use was not mandatory. We assessed proportion of recommended terms among all diagnostic certainty terms in the Impression section (primary outcome) of all reports generated by the radiologists. Certainty terms were extracted via natural language processing over a 22-week postintervention period (31,399 reports) and compared with the same 22 calendar weeks 1 year pre-intervention (24,244 reports) using Fisher's exact test and statistical process control charts.Overall, the proportion of recommended terms significantly increased from 8,498 of 10,650 (80.0%) pre-intervention to 9,646 of 11,239 (85.8%) postintervention (P.0001 and by statistical process control). The proportion of recommended terms significantly increased for 8 of 12 radiologists (P.0005 each), increased insignificantly for 3 radiologists (P.05), and decreased without significance for 1 radiologist.Designing and implementing a certainty scale was associated with increased voluntary use of recommended certainty terms in a small radiologist cohort. Larger-scale interventions will be needed for adoption of the scale across a broad range of radiologists.

Assess the impact of a multifaceted intervention to improve the completeness of structured MRI reports for patients undergoing initial staging for rectal cancer. This Institutional Review Board-approved retrospective study was performed at a large academic hospital. MRI reports for initial staging of rectal cancer in 2017 and 2019 were analyzed pre- and post-implementation of multiple quality improvement interventions in 2018, including harmonizing MRI protocols across the institution, educational conferences and modules, and requiring second opinion consultation for all MRI rectal cancer examinations. The primary outcome measure was the completeness of rectal cancer staging MRI reports, classified as optimal, satisfactory, or unsatisfactory based on the inclusion of 15 quality measures pre-defined by a consensus of abdominal and cancer imaging subspecialists, colorectal surgeons, and radiation oncologists at our institution, based on published recommendations. Fisher’s exact test was used to evaluate changes in report quality and documentation of each quality measure. The study included 138 MRI reports, of which 72 (52%) were completed in 2017 pre-intervention. Post intervention, the proportion of optimal reports increased significantly from 52.8% (38/72) to 71.2% (47/66) (p = 0.035). Documentation of 1 quality measure (N stage) increased post intervention from 91.7% (66/72) to 100% (66/66) (p = 0.029). Documentation of 7 quality measures was 100% post intervention, with a documentation rate of > 95% for all quality measures except radial location of tumor. A combination of educational and system-wide interventions was associated with an improvement in the completeness of structured MRI reports for rectal cancer staging.

Background: Chronic breathlessness is a disabling syndrome that profoundly impacts patients’ and caregivers’ lives. Driving is important for most people, including those with advanced disease. Regular, low-dose, sustained-release morphine safely reduces breathlessness, but little is known about its impact on driving. Aim: To understand patients’ and caregivers’ (1) perspectives and experiences of driving with chronic breathlessness; and (2) perceived impact of regular, low-dose, sustained-release morphine on driving. Design: A qualitative study embedded in a pragmatic, phase III, randomised, placebo-controlled trial of low-dose, sustained-release morphine (⩽32 mg/24 h) for chronic breathlessness. Semi-structured interviews were conducted immediately after participants withdrew or completed the randomised, placebo-controlled trial. Informed by grounded theory, a constant comparative approach to analysis was adopted. Setting/participants: Participants were recruited from an outpatients palliative care service in Adelaide, Australia. Participants included patients ( n = 13) with severe breathlessness associated with chronic obstructive pulmonary disease and their caregivers ( n = 9). Results: Participants were interviewed at home. Eleven received morphine 8–32 mg. Three themes emerged: (1) independence; (2) breathlessness’ impact on driving; and (3) driving while taking regular, low-dose, sustained-release morphine. Conclusion: Driving contributed to a sense of identity and independence. Being able to drive increased the physical and social space available to patients and caregivers, their social engagement and well-being. Patients reported breathlessness at rest may impair driving skills, while the introduction of sustained-release morphine seemed to have no self-reported impact on driving. Investigating this last perception objectively, especially in terms of safety, is the subject of ongoing work.

OBJECTIVE. The objective of this study was to assess impact of a report template quality improvement (QI) initiative on use of preferred phrases for communicating normal findings in structured abdominal CT and MRI reports. SUBJECTS AND METHODS. This prospective QI initiative, designed to decrease use of equivocal phrases and increase use of preferred and acceptable phrases (defined by multidisciplinary experts including patient advocates) in radiology reports, was performed in an academic medical center with over 800,000 annual radiologic examinations and was exempt from institutional review board approval. The intervention populated the preferred term "normal" (default) and acceptable specified pertinent negative phrases (pick-list option) when describing abdominal organ subheadings (liver, pancreas, spleen, adrenal glands, kidneys) within the "Findings" heading of abdominal CT and MRI report templates. We tabulated frequencies of the term "normal", specified pertinent negatives, and equivocal phrases in 21,629 reports before (June 1, 2017, to February 28, 2018) and 23,051 reports after (April 1, 2018, to December 31, 2018) the intervention using natural language processing and recorded trainee participation in report generation. We assessed intervention impact using statistical process control (SPC) charts and the Fisher exact test. RESULTS. Equivocal phrases were used less frequently in abdominal CT and MRI reports for both attending radiologists and trainees after the intervention (p < 0.05, SPC). Use of the term "normal" increased for reports generated by attending radiologists alone but decreased for reports created with trainee participation (p < 0.05, SPC). Frequency of pertinent negatives increased for reports with trainee participation (p < 0.05, SPC). CONCLUSION. A QI intervention decreased use of equivocal terms and increased use of preferred and acceptable phrases when communicating normal findings in abdominal CT and MRI reports.

Constipation affects about half of patients with advanced illness and nearly all terminally ill patients receiving opioids. Constipation can be very distressing, leading to abdominal pain/distension, anorexia, nausea/vomiting, faecal impaction, intestinal obstruction, urinary retention and incontinence; reducing quality of life. A thorough assessment is critical to diagnose it, assess its severity, impact and associated symptoms, and find the cause. Management includes explanations to the patient/family, treating reversible causes (where appropriate) and optimizing non-pharmacological treatments and drugs. In constipation this is principally laxatives. For opioid-induced constipation, peripherally acting μ-opioid receptor antagonists are recommended if laxatives are ineffective. Malignant bowel obstruction can occur in abdominal and pelvic cancers. It can cause nausea, vomiting, abdominal distension and pain. A range of potential surgical and non-surgical treatment options exist for malignant bowel obstruction, aiming to reduce symptom burden and improve quality of life. Pharmacological treatments are delivered parentally and include a prokinetic in patients who have partial or functional obstruction and no colic. Otherwise antiemetics, antispasmodics and antisecretory agents are primarily used. Somatostatin analogues (e.g. octreotide) are often used in malignant bowel obstruction, although data do not support routine use.

The aims of the study were to assess a system-based approach to event investigation and analysis-collaborative case reviews (CCRs)-and to measure impact of clinical specialty on strength of action items prescribed.A fully integrated CCR process, co-led by radiology and an institutional patient safety program, was implemented on November 1, 2017, at our large academic medical center for evaluating adverse events involving radiology. Quality and safety teams performed reviews for events identified with other departments who maintained their existing processes. This institutional review board-approved study describes the program, including percentage of CCR from an institutional Electronic Safety Reporting System, percentage of CCR per specialty, and action item completion rates and strength (e.g., stronger) based on a Veterans Administration-designed hierarchy. χ2 analysis assessed impact of clinical specialty on strength of action prescribed.Seventy-three CCR in 2018 generated 260 action items from 10 specialties. Seventy percent (51/73) were adverse events identified through Electronic Safety Reporting System. The specialty most frequently associated with CCR was radiology (16/73, 22%). Most action items (204/260, 78%) were completed in 1 year; stronger action items were completed in 71 (27%) of 260. Radiology was responsible for 61 action items; 25 (41%) of 61 were strong versus all other specialties with strong action items in 46 (23%) of 199 (P0.01).An integrated multispecialty CCR co-led by the radiology department and an institutional patient safety program was associated with a higher proportion of CCR, stronger action items, and higher action item completion rate versus other hospital departments. Active engagement in CCR can provide insights into addressing adverse events and promote patient safety.

Background: Delirium is common and distressing for patients receiving palliative care. Interventions targetting modifiable risk factors in other settings have been shown to prevent delirium. Research on delirium risk factors in palliative care can inform context-specific risk-reduction interventions. Aim: To investigate risk factors for the development of delirium in adult patients receiving specialist palliative care. Design: Systematic review and meta-analysis (PROSPERO CRD42019157168). Data sources: CINAHL, Cochrane Database of Systematic Reviews, Embase, MEDLINE and PsycINFO (1980-2021) were searched for studies reporting the association of risk factors with delirium incidence/prevalence for patients receiving specialist palliative care. Study risk of bias and certainty of evidence for each risk factor were assessed. Results: Of 28 included studies, 16 conducted only univariate analysis, 12 conducted multivariate analysis. The evidence for delirium risk factors was limited with low to very low certainty. Potentially modifiable risk factors: Opioids and lower performance status were positively associated with delirium, with some evidence also for dehydration, hypoxaemia, sleep disturbance, liver dysfunction and infection. Mixed, or very limited, evidence was found for some factors targetted in multicomponent prevention interventions: sensory impairments, mobility, catheter use, polypharmacy (single study), pain, constipation, nutrition (mixed evidence). Non-modifiable risk factors: Older age, male sex, primary brain cancer or brain metastases and lung cancer were positively associated with delirium. Conclusions: Findings may usefully inform interventions to reduce delirium risk but more high quality prospective cohort studies are required to enable greater certainty about associations of different risk factors with delirium during specialist palliative care.

Background: Real-world effectiveness of interventions in palliative care need to be systematically quantified to inform patient/clinical decisions. Neuropathic pain is prevalent and difficult to palliate. Tricyclic antidepressants have an established role for some neuropathic pain aetiologies, but this is less clear in palliative care. Aim: To describe the real-world use and outcomes from amitriptyline or nortriptyline for neuropathic pain in palliative care. Design: An international, prospective, consecutive cohort post-marketing/phase IV/pharmacovigilance/quality improvement study of palliative care patients with neuropathic pain where the treating clinician had already made the decision to use a tricyclic antidepressant. Data were entered at set times: baseline, and days 7 and 14. Likert scales graded benefits and harms. Setting/participants: Twenty-one sites (inpatient, outpatient, community) participated in six countries between June 2016 and March 2019. Patients had clinician-diagnosed neuropathic pain. Results: One hundred and fifty patients were prescribed amitriptyline (110) or nortriptyline (40) of whom: 85% had cancer; mean age 73.2 years (SD 12.3); mean 0–4 scores for neuropathic pain at baseline were 1.8 (SD 1.0). By day 14, doses of amitriptyline were 57 mg (SD 21) and nortriptyline (48 mg (SD 21). Fifty-two (34.7%) patients had pain improvement by day 14 (amitriptyline (45/110 (43.3%); nortriptyline (7/40 (18.9%)). Thirty-nine (27.7%) had new harms; (amitriptyline 29/104 (27.9%); nortriptyline 10/37 (27.0%); dizziness ( n = 23), dry mouth ( n = 20), constipation ( n = 14), urinary retention ( n = 10)). Benefits without harms occurred (amitriptyline (26/104 (25.0%); nortriptyline (4/37 (10.8%)). Conclusions: Benefits favoured amitriptyline while harms were similar for both medications.

ObjectivesTo describe the current, real-world use of non-steroidal anti-inflammatory drugs for pain and the associated benefits and harms.MethodsA prospective, multicentre, consecutive cohort pharmacovigilance study conducted at 14 sites across Australia, Aotearoa/New Zealand and the UK including hospital, hospice inpatient and outpatient services. Pain scores and harms were graded using the National Cancer Institute Common Terminology Criteria for Adverse Events at baseline, 2 days and 14 days. Ad-hoc safety reporting continued until day 28.ResultsData were collected from 92 patients between March 2018 and October 2021. Most patients had cancer (91%) and were coprescribed opioids (90%). At 14 days, 83% of patients had benefit from non-steroidal anti-inflammatory drugs and 22% had harm. The most common harms were nausea (8%), vomiting (3%), acute kidney injury (3%) and non-gastrointestinal bleeding (3%); only 2% were severe and no patients ceased their non-steroidal anti-inflammatory drugs due to toxicity. Overall, 65% had benefit without harm and 3% had harm without benefit.ConclusionsMost patients benefited from non-steroidal anti-inflammatory drugs with only one in five patients experiencing tolerable harm. This suggests that short-term use of non-steroidal anti-inflammatory drugs in patients receiving palliative care is safer than previously thought and may be underused.

Prior studies used submission numbers or report addendum rates to measure peer learning programs' (PLP) impact. We assessed the educational value of a PLP by manually reviewing cases submitted to identify factors correlating with meaningful learning opportunities (MLOs).This institutional review board-exempted, retrospective study was performed in a large academic radiology department generating800,000 reports annually. A PLP facilitating radiologist-to-radiologist feedback was implemented May 1, 2017, with subsequent pay-for-performance initiatives encouraging increasing submissions,18,000 by 2019. Two radiologists blinded to submitter and receiver identity categorized 336 randomly selected submissions as a MLO, not meaningful, or equivocal, resolving disagreements in consensus review. Primary outcome was proportion of MLOs. Secondary outcomes included percent engagement by subspecialty clinical division and comparing MLO and report addendum rates via Fisher's exact tests. We assessed association between peer learning category, pay-for-performance interventions, and subspecialty division with MLOs using logistic regression.Of 336 PLP submissions, 65.2% (219 of 336) were categorized as meaningful, 27.4% (92 of 336) not meaningful, and 7.4% (25 of 336) equivocal, with substantial reviewer agreement (86.0% [289 of 336], κ = 0.71, 95% confidence interval 0.64-0.78). MLO rate (65.2% [219 of 336]) was five times higher than addendum rate (12.9% [43 of 333]) for the cohort. MLO proportion (adjusted odds ratios 0.05-1.09) and percent engagement (0.5%-3.6%) varied between subspecialty divisions, some submitting significantly fewer MLOs (P.01). MLO proportion did not vary between peer learning categories.Educational value of a large-scale PLP, estimated through manual review of case submissions, is likely a more accurate measure of program impact. Incentives to enhance PLP use did not diminish the program's educational value.

Assess use of a diagnostic certainty scale (CS) for abdominal imaging reports and identify factors associated with greater adoption.This retrospective, Institutional Review Board-exempt study was conducted at an academic health system. Abdominal radiology reports containing diagnostic certainty phrases (DCPs) generated 4/1/2019-3/31/2021 were identified by a natural language processing tool. Reports containing DCPs were subdivided into those with/without a CS inserted at the end. Primary outcome was monthly CS use rate in reports containing DCPs. Secondary outcomes were assessment of factors associated with CS use, and usage of recommended DCPs over time. Chi-square test was used to compare proportions; univariable and multivariable regression assessed impact of other variables.DCPs were used in 81,281/124,501 reports (65.3%). One-month post-implementation, 82/2310 (3.6%) of reports with DCPs contained the CS, increasing to 1862/4644 (40.1%) by study completion (p 0.001). Multivariable analysis demonstrated reports containing recommended DCPs were more likely to have the CS (Odds Ratio [OR] 4.5; p 0.001). Using CT as a reference, CS use was lower for ultrasound (OR 0.73; p 0.001) and X-ray (OR 0.38; p 0.001). There was substantial inter-radiologist variation in CS use (OR 0.01-26.3, multiple p values).DCPs are very common in abdominal imaging reports and can be further clarified with CS use. Although voluntary CS adoption increased 13-fold over 2 years, 50% of reports with DCPs lacked the CS at study's end. More stringent interventions, including embedding the scale in report templates, are likely needed to reduce inter-radiologist variation and decrease ambiguity in conveying diagnostic certainty to referring providers and patients.

E3-SCF (Skp1/cullin-1/F-box protein) polyubiquitin ligases activate the proteasomal degradation of over a thousand proteins, but the evolutionary diversification of the F-box protein (FBP) family of substrate receptor subunits has challenged their elucidation in protists. Here, we expand the FBP candidate list in the social amoeba Dictyostelium and show that the Skp1 interactome is highly remodeled as cells transition from growth to multicellular development. Importantly, a subset of candidate FBPs was less represented when the posttranslational hydroxylation and glycosylation of Skp1 was abrogated by deletion of the O

Background: Trials of interventions for delirium in various patient populations report disparate outcomes and measures but little is known about those used in palliative care trials. A core outcome set promotes consistency of outcome selection and measurement. Aim: To inform core outcome set development by examining outcomes, their definitions, measures and time-points in published palliative care studies of delirium prevention or treatment delirium interventions. Design: Prospectively registered systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Data sources: We searched six electronic databases (1980–November 2020) for original studies, three for relevant reviews and the International Clinical Trials Registry Platform for unpublished studies and ongoing trials. We included randomised, quasi-randomised and non-randomised intervention studies of pharmacological and non-pharmacological delirium prevention and/or treatment interventions. Results: From 13/3244 studies (2863 adult participants), we identified 9 delirium-specific and 13 non-delirium specific outcome domains within eight Core Outcome Measures in Effectiveness Trials (COMET) taxonomy categories. There were multiple and varied outcomes and time points in each domain. The commonest delirium specific outcome was delirium severity ( n = 7), commonly using the Memorial Delirium Assessment Scale (6/8 studies, 75%). Four studies reported delirium incidence. Non-delirium specific outcomes included mortality, agitation, adverse events, other symptoms and quality of life. Conclusion: The review identified few delirium interventions with heterogeneity in outcomes, their definition and measurement, highlighting the need for a uniform approach. Findings will inform the next stage to develop consensus for a core outcome set to inform delirium interventional palliative care research.