Busy Clinical Settings Research Articles

Early improvement in HAMD-17 and HAMD-7 scores predict response and remission in depressed patients treated with fluoxetine or electroconvulsive therapy

BackgroundCompared to the 17-Item Hamilton Rating Scale for Depression (HAMD-17), the 7-Item Hamilton Rating Scale for Depression (HAMD-7) would be more practical for use in busy clinical settings. Herein, we aim to evaluate (1) whether the HAMD-7 is a reliable and valid measure that is sensitive to changes in depressive symptoms, and (2) whether early improvement of depressive symptoms, as measured by the HAMD-7, is capable of predicting response and remission in patients with major depressive disorder (MDD) during acute treatment with fluoxetine or electroconvulsive therapy (ECT). MethodsThis is a post-hoc analysis of two clinical trials in MDD. Internal consistency, validity, and sensitivity-to-change of the HAMD-17 and HAMD-7 were compared during acute treatment and at 3-month follow-up. Receiver operating characteristic analyses were used to evaluate the discriminative capacity of the HAMD-17 and HAMD-7. ResultsThe HAMD-7 is a reliable and valid measure that is sensitive to changes in depressive symptoms. Early improvement, as measured by either the HAMD-17 or HAMD-7, was capable of predicting response and remission to acute treatment with fluoxetine or ECT with good discriminative capacity. LimitationsThis is a post-hoc analysis of two open-label clinical trials with limited sample sizes. All patients were Taiwanese, which limits the generalizability of our results. ConclusionsHAMD-7 is a clinically useful measure that is capable of detecting early improvement of depressive symptoms. The HAMD-7 may have the potential to inform clinical assessment as part of measurement-based care.

Identification of Anxiety and Depression Symptoms in Patients With Cancer: Comparison Between Short and Long Web-Based Questionnaires.

BackgroundPhysicians and nurses in cancer care easily fail to detect symptoms of psychological distress because of barriers such as lack of time, training on screening methods, and knowledge about how to diagnose anxiety and depression. National guidelines in several countries recommend routine screening for emotional distress in patients with cancer, but in many clinics, this is not implemented. By inventing screening methods that are time-efficient, such as digitalized and automatized screenings with short instruments, we can alleviate the burden on patients and staff.ObjectiveThe aim of this study was to compare Web-based versions of the ultrashort electronic Visual Analogue Scale (eVAS) anxiety and eVAS depression and the short Hospital Anxiety and Depression Scale (HADS) with Web-based versions of the longer Montgomery Åsberg Depression Rating Scale-Self-report (MADRS-S) and the State Trait Anxiety Inventory- State (STAI-S) with regard to their ability to identify symptoms of anxiety and depression in patients with cancer.MethodsData were obtained from a consecutive sample of patients with newly diagnosed (<6 months) breast, prostate, or colorectal cancer or with recurrence of colorectal cancer (N=558). The patients were recruited at 4 hospitals in Sweden between April 2013 and September 2015, as part of an intervention study administered via the internet. All questionnaires were completed on the Web at the baseline assessment in the intervention study.ResultsThe ultrashort and short Web-based-delivered eVAS anxiety, eVAS depression and HADS were found to have an excellent ability to discriminate between persons with and without clinical levels of symptoms of anxiety and depression compared with recommended cutoffs of the longer instruments MADRS-S and STAI-S (area under the curve: 0.88-0.94). Cutoffs of >6 on HADS anxiety and >7 hundredths (hs) on eVAS anxiety identified patients with anxiety symptoms with high accuracy. For HADS depression, at a cutoff of >5 and eVAS depression at a cutoff of >7 hs, the accuracy was very high likewise.ConclusionsThe use of the short and ultrashort tools, eVAS and HADS, may be a suitable initial method of Web-based screening in busy clinical settings. However, there are still a proportion of patients who lack access to the internet or the ability to use it. There is a need to find solutions for this group to find all the patients with psychological distress.

Global assessment of migraine severity measure: preliminary evidence of construct validity

BackgroundIn persons with migraine, severity of migraine is an important determinant of several health outcomes (e.g., patient quality of life and health care resource utilization). This study investigated how migraine patients rate the severity of their disease and how these ratings correlate with their socio-demographic, clinical, and psycho-social characteristics.MethodsThis is a cohort of 263 adult migraine patients consecutively enrolled in the Neurological Disease and Depression Study (NEEDs). We obtained a broad range of clinical and patient-reported measures (e.g., patients’ ratings of migraine severity using the Global Assessment of Migraine Severity (GAMS), and migraine-related disability, as measured by the Migraine Disability Scale (MIDAS)). Depression was measured using the 9-item Patient Health Questionnaire (PHQ-9) and the 14-item Hospital Anxiety and Depression Scale (HADS). Median regression analysis was used to examine the predictors of patient ratings of migraine severity.ResultsThe mean age for the patients was 42.5 years (SD = 13.2). While 209 (79.4%) patients were females, 177 (67.4%) participants reported “moderately severe” to “extremely severe” migraine on the GAMS, and 100 (31.6%) patients had chronic migraine. Patients’ report of severity on the GAMS was strongly correlated with patients’ ratings of MIDAS global severity question, overall MIDAS score, migraine type, PHQ-9 score, and frequency of migraine attacks. Mediation analyses revealed that MIDAS mediated the effect of depression on patient ratings of migraine severity, accounting for about 32% of the total effect of depression. Overall, migraine subtype, frequency of migraine, employment status, depression, and migraine-related disability were statistically significant predictors of patient-ratings of migraine severity.ConclusionsThis study highlights the impact of clinical and psychosocial determinants of patient-ratings of migraine severity. GAMS is a brief and valid tool that can be used to assess migraine severity in busy clinical settings.

Correlation Between Neurologic Impairment Grade and Ambulation Status in the Adult Spina Bifida Population.

The aim of the study was to identify which neurologic impairment scales correlate with ambulation status in adults with spina bifida. A retrospective chart review was performed on patients seen at the University of Pittsburgh Medical Center Adult Spina Bifida Clinic. Findings were graded using several neurologic impairment scales: two versions of the National Spina Bifida Patient Registry classification, the International Standards for Neurological Classification of Spinal Cord Injury motor level, and the Broughton Neurologic Impairment Scale. Ambulation ability was ranked using the Hoffer classification system. Data collected from 409 patient records showed significant correlations between Hoffer ambulation status and all neurologic impairment scales evaluated. The strongest correlation was noted with the Broughton classification (rs = -0.771, P < 0.001). High correlations were also noted with both versions of the National Spina Bifida Patient Registry: strength 3/5 or greater (rs = -0.763, P < 0.001), and strength 1/5 or greater (rs = -0.716, P < 0.001). For the International Standards for Neurological Classification of Spinal Cord Injury motor level, only a moderate correlation was observed (rs = -0.565, P < 0.001). Multiple grading scales can be used to measure motor function in adult spina bifida patients. Although the Broughton classification seems to be the most highly correlated with ambulation status, the less complex National Spina Bifida Patient Registry scale is also highly correlated and may be easier to administer in busy clinic settings. Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Explain the clinical significance of identifying ambulation status and maximizing ambulation potential in adults with spina bifida; (2) Describe each of the neurologic grading scales examined in this study, identifying potential shortcomings in applying them to the adult spina bifida population; and (3) Administer the National Spina Bifida Patient Registry (NSBPR) impairment scale motor assessment in a standard adult spina bifida outpatient clinic visit. Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

DIAGNOSTIC ACCURACY OF THE SLU AMSAD SCALE FOR DEPRESSION IN NON-DEMENTED ELDERLY

Introduction Despite its significant impact, geriatric depression remains both underdiagnosed and undertreated ( 1 ). In the absence of specific diagnostic criteria, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria currently represent the gold standard diagnostic tool for late-life depression. Given the fact that most elderly patients receive mental health care in primary care settings ( 2 ), there is an increasing need to develop practical diagnostic tools to be used by primary care practitioners. The Saint Louis University (SLU) AMSAD tool is a brief (5-item) questionnaire that was recently developed to screen for late-life depression. The 5 items reference appetite, mood, sleep, activity and death ideation using simple language and scaling. Previous research has supported its validity and reliability in cognitively intact older adults, in relation to the Geriatric Depression Scale (GDS)-15 and the Montgomery-Asberg Depression Rating Scale (MADRS) ( 3 ). However, few studies have examined the diagnostic accuracy of depression screening instruments in older adults. The objective of this study was to evaluate the accuracy and reliability of the SLU AMSAD regarding diagnosis of major depressive disorder (MDD) per DSM-5 criteria in a sample of older adults without major neurocognitive disorder. Methods A convenience sample of 50 patients, ≥ 65 years of age was enrolled through our specialized geriatric psychiatry outpatient clinic. Patients with a clinical suspicion/diagnosis of major neurocognitive disorder as reflected by a Saint Louis University Mental Status (SLUMS) score of Results Descriptive Analysis The sample had a mean (SD) age of 73.5 (7.1) years; 58% (n = 28) were women, 88% (n = 44) were Caucasian, and 86% (n = 43) had at least a high school level of education. The mean SLUMS score was 25.9 (2.9). For the depression measures, mean scores were 6.5 (4.5) for the GDS-15; 15.6 (11.4) for the MADRS; and 4.9 (3.2) for the SLU AMSAD. The SLU AMSAD evidenced adequate internal consistency reliability (alpha = .77). 30% (n = 15) of patients met DSM-5 criteria for MDD diagnosis. Diagnostic Accuracy and Correlations In the initial ROC analysis, total scores (continuous variables) for the GDS-15, MADRS, and SLU AMSAD were evaluated in relation to the DSM-5 designation of No MDD vs. MDD. AUC values were uniformly high (≥ .93), with correspondingly high levels of sensitivity (.93) and specificity (≥ .80). Optimal cut-offs were 9+ for GDS-15, 18+ for MADRS, and 7+ for SLU AMSAD. The SLU AMSAD was equivalent to GDS-15 and superior to MADRS in these analyses. ROC analyses using established categories for the depression measures were then executed. When score results were categorized as No vs. Any (Mild, Moderate, or Severe) Depression, AUC values ranged from .69-.79, with perfect sensitivity (1.0) but modest specificity (range = .37-.57). When score results were categorized as No-Mild vs. Moderate-Severe Depression, AUC values were again high (range = .82-.89), with adequate levels of sensitivity (.87-.93) and specificity (.71-.86). Moreover, total score correlations were nearly uniform across the depression measures (.69-.70). Scores categorized as No vs. Any (Mild, Moderate, or Severe) Depression yielded correlations with DSM-5 MDD that ranged from .39-.53; scores categorized as No-Mild vs. Moderate-Severe Depression yielded correlations ranging from .59-.75. When scores were categorized according to the optimal cut-off value, SLU AMSAD and GDS-15 had correlations of .75 with DSM-5 MDD, while the MADRS correlation was .68. Conclusions The results indicated strong diagnostic accuracy for all three depression scales in relation to the DSM-5, by ROC and correlational analyses. The SLU AMSAD performed at least as well as the GDS-15 (three times the length of the AMSAD) and slightly better than the much longer and complex MADRS. However, the clinical superiority of the SLU AMSAD for depression screening in the elderly, in relation to the other measures, is supported by the fact that it encompasses only 5 simply-worded, simply-scaled items. Thus, the SLU AMSAD emerges as a potentially strong candidate for depression screening in busy clinical settings, including primary care but also in the emergency department. This research was funded by No funding was received for this research.

Developing the Geriatric Injury Documentation Tool (Geri-IDT) to Improve Documentation of Physical Findings in Injured Older Adults

Standardization in tools and documentation of child abuse and intimate partner violence have proven helpful in completely documenting injuries and suspected abuse among these populations. Similar tools do not yet exist for older adults and elder abuse. To (1) use insights from experts to develop a tool to assist clinicians in appropriately and completely documenting physical findings in injured older adults for potential future forensic investigation of abuse or neglect and (2) to assess the feasibility of incorporating this tool into clinical practice. Two-phase, exploratory qualitative study. Phase 1: individual interviews with elder abuse experts from various specialties in medicine and criminal justice. Phase 2: focus groups with anticipated end users of the tool. Phase 1 telephone-based key informant interviews were conducted with 11 elder abuse experts (2 detectives, 3 prosecutors, 1 forensic pathologist, 2 geriatricians, and 3 emergency medicine physicians). Phase 2 focus groups were conducted among emergency medicine (n = 10) and primary care (n = 8) providers. Key informant interviews were conducted telephonically while the two focus groups were held in-person at an emergency medicine site in New York, NY, and a primary care site in Los Angeles, CA. Experts agreed that medical providers' documentation of geriatric injuries is usually inadequate for investigating alleged elder abuse/neglect. They highlighted elements needed for forensic investigation: initial appearance before treatment is initiated, complete head-to-toe evaluation, documentation of all injuries (even minor ones), and documentation of pertinent negatives. Several noted the value of photographs to supplement written documentation. End users identified practical challenges to utilizing a tool, including the burden of additional or parallel documentation in a busy clinical setting, and how to integrate it into existing electronic medical records. A practical tool to improve medical documentation of geriatric injuries for potential forensic use would be valuable. Practical challenges to utilization must be overcome.

Shared patient and provider values in end-stage renal disease decision making: Identifying the tensions

ObjectiveTo examine concordance and tensions in values among stakeholder groups across the shared decision making process for end-stage renal disease patients treated with hemodialysis. MethodsA thematic analysis of transcripts from three stakeholder groups: hemodialysis patients (2 groups, n = 17), nephrologists (1 group, n = 9), and non-physician providers (dietitians, social workers, and registered nurses) (1 group, n = 8). A framework of decision-making components (communication, information, decision, behavior, and outcome) guided analysis of values within and across groups. ResultsShared values included communication that informed patients and involved family; information about function, trajectory, life context, and patient experience; behavior to manage diet; and outcomes of function, safety, and survival. Identified thematic tensions in patient-provider values were: personalized vs. routinized communication; shared vs. separate information; managed vs. adherent behavior; and participating vs. protected outcome. Patient behavior emerged as a contested area of control. ConclusionEmphasizing shared values and bridging values conflicts may ease tensions surrounding self-care behavior by facilitating discussions about diet, medications, and consistent dialyzing. Practice implicationsMore individualized information needs to be delivered to patients in a personalized communication approach that can still be achieved within a busy dialysis clinic setting.

Prospective Comparison of Semi-Automated 2-Dimensional Global Longitudinal Strain Measurements using three Different Software Programs in a Busy Clinical Setting

Introduction: Global longitudinal strain (GLS) is a measure of myocardial function which can provide incremental information in certain clinical conditions. Previously, measurement of GLS was time-consuming and subject to variability. Recent revisions of algorithms for assessment of GLS based on the 2015 EACVI/ASE/Industry Task Force consensus recommendations for standardisation of deformation imaging are aimed at improving its application in the clinical setting. Our aim was to compare peak GLS measurements obtained using three different commercially available software systems in a busy clinical setting. Methods: Twenty patients in sinus rhythm (45% female) were scanned systematically with head-to-head acquisition and no modification of patient's position using equipment from two different vendors (Philips and GE). GLS was measured off-line using Philips QLAB 10.5 and GE EchoPAC BT13). Inter- and intra-observer variability and agreement between the measurements using the two software products were evaluated. Comparisons were also made with measurements made using vendor independent software (TomTec, Germany). Results: Mean heart rate was 72 ± 14 bpm and mean LVEF 61 ± 10%. Inter-observer CVs for GLS were 4.50% (Philips) and 2.69% (GE); and intra-observer CV were 5.60% (Philips) and 3.98% (GE), indicating good reproducibility. The Pearson's correlation coefficients (CC) between GLS values were high (A, C, E) indicating good agreement between the three algorithms with minimal bias (see Bland-Altman plots; B, D, F). Conclusion: There was a high level of agreement and reproducibility for GLS measurements using Philips, GE and TomTec software, with all giving comparable GLS values, suggesting feasibility of routine GLS assessment in a busy clinical setting.

Experiential Teaching Paradigms: Adapting the Medical Education Literature to Academic Pathology Practice

The medical education literature has presented many experiential teaching paradigms to help faculty teach more effectively in busy clinical settings. Three prominent teaching models are The Aunt Minnie model, the SNAPPS model, and the One-Minute Preceptor. Teaching paradigms can help faculty to develop into effective teachers. Each of these models can be adapted to a busy academic pathology practice. The Aunt Minnie model is effective in cases with high pattern recognition, such as repetitive trays of biopsies. The SNAPPS model is learner directed and is easily adapted for an advanced learner with complex cases requiring ancillary testing. The One-Minute Preceptor method is effective for teachers with groups of learners, such as multiheaded scope sessions.

A primary care programme to improve identification and stepped-care support of Asians with mental health and lifestyle issues.

INTRODUCTION Asians living in Western countries have a higher incidence of mental health and lifestyle issues, but are less likely to disclose these to health-care professionals due to stigma. Instead, they tend to present to primary care with somatic concerns. AIM To assess the feasibility and acceptability of a well-validated electronic screening and stepped-care support tool (eCHAT) to identify mental health and lifestyle issues among Asian patients. METHODS A mixed-methods (interviews and survey) co-design approach explored patient and clinic staff perspectives on a translated version of eCHAT (AsiaCHAT). Recruitment was through a large primary care organisation with a high proportion of Asian patients. Of the 307 approached, 277 participated (92% acceptance rate). RESULTS Problems of depression (n = 12) and anxiety (n = 69) were identified among patients, as were sexual health concerns (n = 22) among younger participants. Overall, participants and clinic staff rated AsiaCHAT as a useful and acceptable tool for disclosing and discussing patient concerns. Problems of finances, time constraints and competing demands made long-term implementation challenging. DISCUSSION AsiaCHAT is a promising tool for identifying mental health and lifestyle concerns among Asians presenting to primary care. The electronic screener supports patient and provider discussion of sensitive topics and the stepped-care support function helps direct care. Its flexible functionality means that there is potential to integrate it into busy clinic settings as well as online patient portals, and the programme aligns with current policy to improve Asian health in New Zealand.

Early Symptom Measurement of Post-Stroke Depression: Development and validation of a new short version.

The aim of this study was to develop and test the psychometric properties of the Early Symptom Measurement of Post-Stroke Depression-Short Form (ESMPSD-SF). The ESMPSD is a specific measurement tool designed to detect early depressive symptoms in acute stroke patients, but it is too long for use in busy clinical settings. A psychometric study was conducted. Five hundred and twenty-one post-stroke patients completed two questionnaires, the demographic and the ESMPSD questionnaire, over a period of 10months, from July 2016-April 2017. The item reduction process was used to reduce the number of items in the ESMPSD questionnaire and consisted of item analysis, exploratory, and confirmatory factor analysis. The item reduction process resulted in a 12-item short version questionnaire with evidence of acceptable construct validity and internal reliability. Four factors explaining high total variance were extracted: "low," "guilt," "emotional," and "wakefulness". Estimates of all confirmatory model fit indices met the standard criteria. All standardized factor loading estimates of the 12 items met the standard criteria and the variances explained by the items were acceptable. Moreover, internal reliability estimates of the 12-item questionnaire were acceptable, and the corrected item-total correlation and item-subscale correlation also demonstrated evidence of acceptable reliability of the short form questionnaire. The ESMPSD-SF demonstrates evidence of acceptable reliability and validity to screen early depressive symptoms in acute stroke patients in busy clinical settings.

Comparison of agreement and efficiency of a swept source-optical coherence tomography device and an optical low-coherence reflectometry device for biometry measurements during cataract evaluation.

PurposeTo compare the agreement and efficiency of a swept source-optical coherence tomography biometer, IOLMaster 700 (IOLM700), and a low-coherence optical reflectometry biometer, LENSTAR LS 900 (LS900), when acquiring biometry measurements during cataract evaluation.MethodsA retrospective chart review of biometry measurements that were performed in 64 eyes of 32 patients on the same day using the LS900 and the IOLM700. The total image acquisition time per subject was compared between the two machines using a Wilcoxon rank-sum test. Bland–Altman plots showing the mean difference and 95% limits of agreement were graphed. Intraclass correlation coefficients (ICCs) were calculated for the mean axial length (AL), anterior chamber depth (ACD), lens thickness (LT), and two keratometry mean values (K1 and K2) that were output from each device.ResultsThe average time to complete biometry measurements in both eyes was significantly shorter for the IOLM700 compared with the LS900 (44.5±12.4 vs 168.8±67.2 seconds, P<0.001). The Bland–Altman analysis and ICCs showed high degrees of agreement for the mean biometry values (ICC: AL 0.9999, ACD 0.9993, LT 0.9571, K1 0.9922, K2 0.9926) generated by the two devices.ConclusionThere was a high level of agreement between the mean biometry output measures for IOLM700 and LS900. However, it took ~73% less time on average to acquire the images when using the IOLM700 compared with the LS900. In a busy clinic setting, use of the IOLM700 for biometry measures may save time and prove more efficient.

WHY HEARING STATUS MATTERS IN DELIVERY OF VALUE BASED HEALTH CARE

Hearing loss (HL) is a major public health issue with two-thirds of adults age 70+ years in the US having clinically-significant HL. As society ages, the number of persons with HL is increasing. HL is independently associated with accelerated cognitive decline, poorer physical functioning and is a risk factor for falls. It results in higher healthcare costs, poor physician-patient communication, and may contribute to suboptimal medical outcome due to communication errors and associated poor adherence to treatment recommendations. As healthcare provision shifts to value-based care, effective communication assumes greater import. We propose that systematic screening in healthcare settings can identify individuals whose HL may threaten delivery of care. We will discuss options for screening individuals with multi-morbidity and offer cost effective solutions for optimizing hearing status in persons with HL. Case studies will highlight how optimizing hearing status can reduce listening effort, fatigue and expedite throughput in busy clinic settings.

Detecting Non-cognitive Features of Prodromal Neurodegenerative Diseases.

: Background: Prodromal Neurodegenerative Disease (ND) due to tauopathies such as Alzheimer’s Disease (AD) and Synucleinopathies (SN) such as Parkinson's Disease (PD) and Dementia with Lewy Bodies (DLB) present subtly. Although ND are considered cognitive disorders, in fact ND present with behavioral and even medical symptomatology years to decades prior to the onset of cognitive changes. Recognizing prodromal ND syndromes is a public health priority because ND is common, disabling and expensive. Diagnosing prodromal ND in real world clinical settings is challenging because ND of the same pathology can present with different symptoms in different people. Individual variability in nature and variability in nurture across the life course influence how ND pathology manifests clinically. The objective of this study was to describe how non-cognitive symptoms from behavioral, medical, neurological and psychiatric domains cluster in prodromal and early stages of ND.Methods: This was an observational study of patients receiving routine clinical care for memory disorders. All patients receiving a standardized evaluation including complete neurological history and examination and standardized brief neuropsychological testing. A Principal Component Analysis (PCA) considering emotion, motor, sensory and sleep factors was performed on the entire sample of patients in order to identify co-occurring symptom clusters. All patients received a consensus diagnosis adjudicated by at least two dementia experts. Patients were grouped into Cognitively Normal, Detectable Cognitive Impairment, and Mild Cognitive Impairment categories due to AD and/or PD/LBD or NOS pathology. Symptom cluster scores were compared between clinical diagnostic groups.Results: In this study 165 patients completed baseline neuropsychological testing and reported subjective measures of non-cognitive symptoms. Four syndrome specific symptom factors emerged and eight non-specific symptom factors. Symptoms of personality changes, paranoia, hallucinations, cravings, agitation, and changes in appetite grouped together into a cluster consistent with an “SN Non-motor Phenotype”. Appetite, walking, balance, hearing, increased falls, and dandruff grouped together into a cluster consistent with an “SN Motor Phenotype”. The Prodromal AD phenotype included symptoms of anxiety, irritability, apathy, sleep disturbance and social isolation. The fourth factor included symptoms of increased sweating, twitching, and tremor grouped into a cluster consistent with an Autonomic phenotype.Conclusions: Non-cognitive features can be reliably measured by self-report in busy clinical settings. Such measurement can be useful in distinguishing patients with different etiologies of ND. Better characterization of unique, prodromal, non-cognitive ND trajectories could improve public health efforts to modify the course of ND for all patients at risk.

Referral rates and supportive care metrics for a first-year community oncology AYA program.

63 Background: Adolescent and young adult (AYA) oncology patients have a unique set of needs compared to younger and older patients that are often not addressed by primary providers in a busy clinical setting. Genetic counseling, fertility preservation, clinical trial enrollment and psychosocial support are a few of the key needs to address in this group. The AYA Cancer Program was created to specifically address these issues and mitigate the disparity in care and outcomes often seen in the AYA cohort. This study examines the number of patients referred to the AYA Cancer Program in its first year and evaluates the role of the program in addressing the supportive care needs of AYA patients. Methods: The study assessed patients actively under treatment between ages 15-39 from September 1, 2016 to September 1, 2017. The number of referrals to the AYA program, participation in the AYA program, and met supportive care needs (fertility, genetics, clinical trial participation) were examined. Results: During the first year of the clinic, 63 (22%) of the 288 AYA patients seen throughout the whole institution were seen in the AYA clinic. An additional 34 (12%) patients were referred but did not come to the appointment. 192 (69%) patients were not referred. Compared to non-referred patients, AYA clinic patients were more likely to be enrolled on a clinical trial (54% vs. 18%), have a documented fertility counseling discussion (94% vs. 16%) and receive a genetics referral (69% vs. 43%). Patients that were referred to the clinic but did not come were slightly more likely than non-referred patients to be offered the above services as well but still trailed the group of patients seen in the AYA clinic. Conclusions: Patients that were seen in the AYA program were more likely to receive fertility referrals, genetic referrals and had increased clinical trial participation compared to patients that were not referred. This highlights the essential role of the AYA clinic in meeting these under addressed needs in the AYA population. [Table: see text]

Perspectives of Nurses in Africa and Canada Regarding Having Conversations About Sexuality With Cancer Patients

Background: Cancer treatment can have a significant impact on an individual's quality of life. In particular, body image and sexuality can be compromised. There is increasing evidence that conversations about these specific consequences are not happening often between cancer patients and health care providers, especially in busy clinical settings. Aim: This work will contrast the perspectives of nurses caring for cancer patients in Canada and in Africa regarding having conversations about the topic of sexuality with patients and family members after a cancer diagnosis. Methods: Data were collected through interviews with nurses (n=34) in Canada and through small group discussions with nurses (n=25) in Africa. Data were reviewed using a descriptive qualitative approach, identifying significant themes. Results: Overall, participants acknowledged treatment can have an impact on a patient's sexuality. If conversations occurred, it was during consent processes before treatment began or when a patient raised a question about a specific side effect. These conversations rarely covered more than the physical changes and did not focus on the impact of changes on emotional and personal relationships or intimacy. Most providers waited for patients to raise any concerns or questions. Most participants expressed their own personal discomfort and lack of training for holding these types of conversations. They perceived the conversations as difficult for themselves as well as for patients. The topic of sexuality was often described as a taboo topic, especially in Africa, and one that was influenced strongly by cultural perspectives. Having time and privacy to hold the discussions were also seen as barriers. Conclusion: The findings support the need to clarify role responsibilities for cancer nurses, as well as other members of the cancer care team, about patient care regarding the area of sexuality, and the provision of education.

Modified Criteria for Diagnosing “Cognitive Frailty”

The concept of cognitive frailty has recently been proposed by an International Consensus Group as the presence of physical frailty and cognitive impairment [defined using the Clinical Dementia Ratings (CDR)=0.5], without concurrent dementia. However, CDR is difficult to implement and not often available in epidemiologic studies or busy clinical settings, and an alternative to CDR is required. We suggest an alternative definition of cognitive frailty as: 1) physical frailty, 2) more than 1.5 standard deviation below the mean for age-, gender-, and education-adjusted norms on any cognitive function test (e.g., the Montreal Cognitive assessment test, the Alzheimer’s disease assessment scale-cognitive subscale, verbal learning test, Digit Span, Boston Naming Test, Trail Making Test, and Frontal Assessment Battery), and 3) no dependency in instrumental activities of daily living. The redefined criteria for cognitive frailty would be more feasible to implement and thus more applicable in epidemiologic studies and busy clinical settings.

Testing of a Tool for Prostate Cancer Screening Discussions in Primary Care.

As prostate cancer (PCa) screening decisions often occur in outpatient primary care, a brief tool to help the PCa screening conversation in busy clinic settings is needed. A previously created 9-item tool to aid PCa screening discussions was tested in five diverse primary care clinics. Fifteen providers were recruited to use the tool for 4 weeks, and the tool was revised based upon feedback. The providers then used the tool with a convenience sample of patients during routine clinic visits. Pre- and post-visit surveys were administered to assess patients' knowledge of the option to be screened for PCa and of specific factors to consider in the decision. McNemar's and Stuart-Maxwell tests were used to compare pre-and post-survey responses. 14 of 15 providers completed feedback surveys and had positive responses to the tool. All 15 providers then tested the tool on 95 men aged 40-69 at the five clinics with 2-10 patients each. The proportion of patients who strongly agreed that they had the option to choose to screen for PCa increased from 57 to 72% (p = 0.018) from the pre- to post-survey, that there are factors in the personal or family history that may affect PCa risk from 34 to 47% (p = 0.012), and that their opinions about possible side effects of treatment for PCa should be considered in the decision from 47 to 61% (p = 0.009). A brief conversation tool for the PCa screening discussion was well received in busy primary-care settings and improved patients' knowledge about the screening decision.

Saliva as a diagnostic specimen for testing respiratory virus by a point-of-care molecular assay: a diagnostic validity study

ObjectivesAutomated point-of-care molecular assays have greatly shortened the turnaround time of respiratory virus testing. One of the major bottlenecks now lies at the specimen collection step, especially in a busy clinical setting. Saliva is a convenient specimen type that can be provided easily by adult patients. This study assessed the diagnostic validity, specimen collection time and cost associated with the use of saliva. MethodsThis was a prospective diagnostic validity study comparing the detection rate of respiratory viruses between saliva and nasopharyngeal aspirate (NPA) among adult hospitalized patients using Xpert® Xpress Flu/RSV. The cost and time associated with the collection of saliva and nasopharyngeal specimens were also estimated. ResultsBetween July and October 2017, 214 patients were recruited. The overall agreement between saliva and NPA was 93.3% (196/210, κ 0.851, 95% CI 0.776–0.926). There was no significant difference in the detection rate of respiratory viruses between saliva and NPA (32.9% (69/210) versus 35.7% (75/210); p 0.146). The overall sensitivity and specificity were 90.8% (81.9%–96.2%) and 100% (97.3%–100%), respectively, for saliva, and were 96.1% (88.9%–99.2%) and 98.5% (94.7%–99.8%), respectively, for NPA. The time and cost associated with the collection of saliva were 2.26-fold and 2.59-fold lower, respectively, than those of NPA. ConclusionsSaliva specimens have high sensitivity and specificity in the detection of respiratory viruses by an automated multiplex Clinical Laboratory Improvement Amendments-waived point-of-care molecular assay when compared with those of NPA. The use of saliva also reduces the time and cost associated with specimen collection.

Assessing pressure injury risk using a single mobility scale in hospitalised patients: a comparative study using case-control design.

Pressure injury is known to cause not only debilitating physical effects, but also substantial psychological and financial burdens. A variety of pressure injury risk assessment tools are in use worldwide, which include a number of factors. Evidence now suggests that assessment of a single factor, mobility, may be a viable alternative for assessing pressure injury risk. The aim of this study was to ascertain whether using the Braden mobility subscale alone is comparable to the full Braden scale for predicting the development of pressure injury. This study, a retrospective case-control design, was conducted in a large tertiary acute care hospital in Singapore. Medical records of 100 patients with hospital-acquired pressure injury were matched with 100 medical records of patients who had no pressure injury at a 1:1 ratio. Patients who were assessed using the Braden mobility subscale as having 'very limited mobility' or worse were 5.23 (95% confidence interval (CI) 2.66-10.20) times more likely to develop pressure injury compared with those assessed as having 'slightly limited' mobility or 'no limitation'. Conversely, patients assessed using the Braden scale as having 'low risk' or higher were 3.35 (95% CI 1.77-6.33) times more likely to develop pressure injury compared with those assessed as 'no risk'. Using full model logistic regression analysis, the Braden mobility subscale was the only factor that was a significant predictor of pressure injury and it remained significant when analysed for the most parsimonious model using backward logistic regression. These findings provide the empirical evidence that using the Braden mobility subscale alone as an assessment tool for predicting pressure injury development is comparable to using the full Braden scale. Use of this single factor would simplify pressure injury risk assessment and support its use within busy clinical settings.