.
Objective Understanding the way therapy works is a complex undertaking. Historically, such enquiry has been dominated by “outcomes” leading to a lack of discourse about clinical processes. In the cancer setting, identifying clinical process can be even more complex because of the added challenges of an ongoing illness. This study investigated the therapeutic processes used in a meaning-based intervention developed for the advanced cancer setting: Meaning and Purpose therapy. Method Four sessions of therapy were delivered to 24 participants. Transcribed sessions ( n = 96) of the intervention were analyzed by two independent researchers to describe participant themes, therapeutic processes, and patterns of change related to common points in the intervention. Result Although both suffering and meaning were present in all sessions, when we tracked the focus of the content across sessions, there was a clear progressive shift toward meaning-centered content for all participants. This finding is in spite of the fact that all participants had progressive disease and were living with ongoing challenges. Significance of results Processes such as focusing on meaning, reflecting a sense of significance, joining with participants to explore their unique meaning, and directing them away from a preoccupation with suffering were identified as clear influences of a shift toward a meaning-based focus. These processes offer a fresh focus on meaning and a buffer to the distress of advanced cancer.
Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are widely used for the treatment of type 2 diabetes and/or obesity. The physiological actions of endogenous GLP-1, and synthetic GLP-1RAs include inhibition of gastric emptying. This has peri-procedural implications due to the potential increased risk of retained gastric contents which may result in pulmonary aspiration. There is a need for local evidence-based guidelines to best manage patients on GLP-1RAs and dual GLP-1 and glucose-dependent insulinotropic polypeptide receptor co-agonists (GLP-1/GIPRAs) presenting for surgical and medical procedures requiring sedation or anaesthesia. A panel of experts was formed to consider the peri-procedural implications of GLP-1RA and GLP-1/GIPRA use and establish best practice recommendations based on the current evidence.We recommend that all patients should be asked about glucagon-like peptide-1 receptor agonist (GLP-1RA) and dual GLP-1 and glucose-dependent insulinotropic polypeptide receptor co-agonist (GLP-1/GIPRA) use prior to anaesthesia or sedation for surgical and endoscopic procedures and be informed of the benefits and risks. We also recommend that GLP-1RAs and GLP-1/GIPRAs be continued in the peri-procedural period. Preprocedural diet modification with a 24-h clear fluid diet, followed by standard 6-h fasting, should be recommended for all patients receiving GLP-1RAs or GLP-1/GIPRAs. In patients who have not completed or are unable to have a 24-h liquid diet, risk stratification using gastric ultrasound or minimally sedated gastroscopy to assess gastric contents is recommended, as is the use of intravenous erythromycin. We cannot currently recommend using the absence of gastrointestinal symptoms for risk stratification, nor can we recommend an adequate cessation period for GLP-1RAs and GLP-1/GIPRAs to ensure gastric emptying has returned to baseline levels. This clinical guideline, developed by multiple professional bodies, outlines current best practice recommendations for patients taking GLP-1RAs and combined GLP-1/GIPRAs who require general anaesthesia, sedation and/or endoscopic procedures. The guide provides a structure for Australian and New Zealand primary health practitioners, gastroenterologists, surgeons, endocrinologists, anaesthetists and perioperative physicians to support clinical decisions in these patients.
BACKGROUND:People prescribed opioid agonist therapy (OAT) are a key population for hepatitis C virus (HCV) elimination. Health service engagement associated with OAT provision may facilitate hepatitis C testing and treatment. We aimed to quantify the HCV care cascade among people receiving OAT in Australia. METHODS:We extracted linked data from individuals attending any of 58 clinics participating in the ACCESS national sentinel surveillance network of primary care and sexual health clinics from 1 January 2016 to 31 December 2023. Outcomes included evidence of any HCV test (antibody or RNA) or direct-acting antiviral (DAA) prescription at an ACCESS clinic after their first OAT prescription. RNA positive individuals were inferred antibody positive; individuals with a DAA prescription were inferred RNA and antibody positive. We determined the number of individuals at each stage of the following cascade by the end of the study period: (1) positive antibody, (2) positive RNA, and (3) DAA prescription. RESULTS:Among 15 382 individuals prescribed OAT, 44% (6817) had an HCV antibody or RNA test after their first OAT prescription. Of these, 64% (4368/6817) were antibody positive by the end of the study period. Of these, 67% (2911/4368) were RNA positive, and of those, 69% (2007/2911) were prescribed DAAs. CONCLUSIONS:A high proportion of people prescribed OAT were not engaged in care by their OAT provider or across ACCESS network clinics, but when diagnosed, rates of treatment were high. Given high HCV antibody and RNA prevalence, integrating HCV care into regular OAT care should be a priority for HCV elimination in Australia.
OBJECTIVES:To determine how many people who die of cancer in Victoria receive palliative care and early palliative care (more than 3 months before death); to assess the impact of early palliative care on the quality of end-of-life care. STUDY DESIGN:Retrospective, population-based cohort study; analysis of linked Victorian Cancer Registry data and routinely collected data for inpatient, non-admitted health service and emergency department care during the 12 months prior to death. SETTING, PARTICIPANTS:Victorian adults who died of cancer during 1 January 2018-31 January 2023. MAIN OUTCOME MEASURES:Proportions of people who received palliative care (any time) or early palliative care (more than 3 months prior to death); likelihood of quality of end-of-life care measures: dying outside an acute hospital; chemotherapy, two or more emergency department visits, two or more hospital admissions during final 30 days of life; advance care plan at death. RESULTS:Of 53,305 people who died of cancer (mean age, 74.8 years [standard deviation, 13.0 years]; 29,527 men [55.4%]), palliative care was provided for 38,697 (72.6%); 17,409 people (32.7%) received early palliative care. The most frequent palliative care type was palliative approach to care (Z51.5 code; 33,974 people, 63.7%). The overall proportion of people who received palliative care did not change markedly during 2018-2022; the proportion who received early palliative care declined slightly, from 34.8% (95% confidence interval [CI], 33.6-35.9) to 33.0% (95% CI, 31.7-33.8). People who received early palliative care were more likely than people who received late palliative care to have an advance care plan (adjusted odds ratio [aOR], 1.46; 95% CI, 1.38-1.55) and to die outside hospital (aOR, 2.50; 95% CI, 2.37-2.64); they were less likely to have two or more of emergency department presentations (aOR, 0.75; 95% CI, 0.70-0.81), two or more hospital admissions (aOR, 0.58; 95% CI, 0.55-0.61) or chemotherapy (aOR, 0.51; 95% CI, 0.47-0.55) during their final 30 days of life. CONCLUSION:72.6% of people who died of cancer in Victoria during 2018-2023 had received palliative care, but only 33% had received it early. End-of-life care may be improved by providing palliative care early. The low early palliative care rate, despite the potential for improved outcomes for people who receive it, indicates that action is needed.
Introduction and aim Optimisation of underlying chronic respiratory disease (CRD) is a necessary first step to addressing breathlessness. We aimed to develop and evaluate a disease-agnostic education package and mnemonic to support primary care providers to recognise breathlessness and facilitate optimisation of underlying CRD. Methods A blended education package comprising one live webinar, three self-paced online courses, two podcasts and five case studies was developed by a working group of general practitioners (GPs), respiratory clinicians and researchers and adapted into a practical mnemonic (the BREATHE clinical approach). Content was validated against a systematic state-of-the-art review of international and national guidelines. Semi-structured interviews with GPs, general practice nurses and a practice manager were conducted to evaluate the educational content and design. Interviews were transcribed and analysed thematically with inductive coding. Results Seven disease-agnostic recommendations were developed and validated against 33 clinical practice documents: Breathlessness (measure severity); Respiratory illness (confirm diagnosis); Extra illnesses (consider other causes of breathlessness); Adherence (check medication use and technique); Tobacco (discuss smoking cessation); Help (consider referral to specialist services); Exercise (consider pulmonary rehabilitation). 13 interviews were conducted (eight GPs; four nurses; one practice manager); this showed the BREATHE educational package and clinical approach to be acceptable. Time constraints were frequently cited as a barrier to education engagement, with flexible education preferred. Respondents described the BREATHE clinical approach as a comprehensive tool that would enable clinicians to “remember the specifics”, while highlighting the need for multiple consultations to address all elements of care. Conclusion The BREATHE clinical approach and education package were favourably received as useful tools to support primary care providers to optimise treatment for people with CRD.
