'I feel many of my reflections are forced': a mixed methods qualitative study of international medical graduates' perspectives on reflection in UK general practice training.

BACKGROUND: UK general practice training requires trainees to evidence clinical competencies through reflective writing entries in online portfolios. Trainees who complete their medical degree in the UK experience reflection as an undergraduate, whereas 80% of international medical graduates (IMGs) have no previous experience of reflection. AIM: To explore international graduates' perspectives on the positive and negative aspects of reflection in the context of postgraduate GP training. DESIGN & SETTING: Qualitative 'free text' survey data obtained in 2021 was analysed with themes further explored by semi-structured interviews conducted 2022-2023. METHOD: Participants were IMGs with experience of the UK GP training scheme. Verbatim open question survey data underwent content analysis. Broad themes identified were used to develop the interview topic guide. A geographically dispersed, purposive sample of participants were recruited for semi structured interviews. Interview and survey data were then analysed thematically. RESULTS: 433 participants data sets are included: 422 of 485 responses to a UK wide survey including open questions and 11 interview transcripts. IMGs considered reflection to provide an effective approach for learning, an opportunity for self-assessment and professional development and a means of developing self-awareness. Concerns were expressed about how time-consuming recording reflection is, how its mandated aspect makes it forced, and fears regarding the medico-legal consequences of reflective writing. CONCLUSION: Despite a lack of previous experience in reflection, most international graduates showed an understanding of the benefits of reflection in GP training. However, the challenges of reflection must be addressed, to avoid devaluing reflection for clinical learning.

Cross-sectional survey of staff and family perspectives on the use of CCTV in Australian residential aged care.

OBJECTIVE: To describe staff and family members' opinions about closed-circuit television (CCTV) in communal and private areas of residential aged care facilities (RACF), and to investigate how this relates to perceptions of care quality. METHODS: A cross-sectional survey was developed to capture perceptions of CCTV's influence on care quality, and acceptable locations for CCTV placement. Data were recorded as ordinal-scale and open responses. Non-parametric tests of association were conducted. RESULTS: The survey was completed by 81 staff and 74 family members. Both staff and family were satisfied with care quality and safety, irrespective of CCTV use. More family members were in favour of CCTV in both public and private areas, compared to staff who favoured public areas. Staff and family assumed there was real-time monitoring, leading to a belief that CCTV monitoring would improve safety and prevent falls and abuse. Concerns were raised that CCTV could be used instead of improving staff-to-resident ratios and interaction. CONCLUSIONS: Overall, participants supported the use of CCTV more in public than in private areas and believed it reveals and prevents poor care. There was no association between CCTV use and satisfaction with care. Closed-circuit television can have positive impacts if all stakeholders are involved in implementation.

International graduates' experiences of reflection in postgraduate training: a cross-sectional survey.

BACKGROUND: Reflection is a key component of postgraduate training in general practice. International medical graduates (IMG) are thought to be less familiar with reflection, with international medical schools favouring more didactic methods of education. AIM: To explore IMGs' experiences of reflection prior to and during GP training and the support available for developing skills in reflection. DESIGN & SETTING: A cross sectional survey was sent to IMGs undertaking GP training in 12 of the 14 UK regions, from March to April 2021. METHOD: A pre-tested self-administered online questionnaire was used to collect data on experiences of reflection, both prior to and during GP training, and the support available for developing skills in reflection. RESULTS: In total, 485 of 3413 IMG trainees completed the questionnaire (14.2% response rate, representative of national demographics). Of these, 79.8% of participants reported no experience of reflection as an undergraduate and 36.9% reported no formal training in reflection during GP training. The majority (69.7%) of participants agreed that reflection was beneficial for their training and 58.3% reported that the best support in reflection came from their supervisors. Experience of reflection, opinions on the benefits, and best sources of support all varied by where the responders' primary medical qualification (PMQ) was obtained (all P values<0.01). CONCLUSION: Most IMGs have not experienced reflection prior to commencing UK GP training. There is diversity in experience and culture within this group that must be considered when tailoring educational interventions to support IMGs in their transition to UK GP training.

My hip journey: A qualitative study of patients' experiences of an eHealth program for patient preparation and recovery from hip replacement surgery.

AIM AND OBJECTIVE: To explore patient experiences, perceived benefits and suggestions of an eHealth program for pre- and post-operative education for total hip arthroplasty. BACKGROUND: eHealth programs for surgical patients can facilitate the delivery of information, provide individualised rehabilitation plans and enable communication with health professionals to promote overall patient recovery. DESIGN: A qualitative descriptive study was conducted following the COREQ guidelines. A convenience sample of nine patients who had total hip arthroplasty and used the My Hip Journey eHealth program were recruited and participated in individual semi-structured telephone interviews. Interviews were audio recorded, transcribed verbatim and analysed using inductive thematic analysis. RESULTS: The participant group were aged between 53 and 70 years. The results are described in three overarching themes and sub-themes: (1) Supported surgical journey-how the My Hip Journey eHealth program supported them in their preparation and recovery from their surgery, and how the program provided information and encouraged engagement; (2) Motivated recovery-how patients found the program motivational, facilitated their self-management and enabled communication with the healthcare team if they had any concern; and (3) Functionality-how the program related to ease of use, its interactivity with the patient and suggestions for future use. CONCLUSIONS: The patients reported that using the eHealth program for pre- and post-operative education was helpful to their overall surgical experience and recovery. It was found to engage patients in their care, enabled self-management, encouraged communication with health professionals and motivated them with their recovery. These findings identify the potential for eHealth programs to support patients in the preparation and post-operative stages, and in their post-discharge self-care for other surgical and orthopaedic journeys. RELEVANCE TO CLINICAL PRACTICE: Patient experiences of eHealth education can inform nurses of the benefits of eHealth and the development of future eHealth education programs.

Reflecting on experiences of care: an exploratory qualitative descriptive study of the perspectives of stroke survivors, families and staff.

OBJECTIVE: The aim of this study was to identify barriers and enablers from the perspectives of stroke survivors, carers and staff to understand the experiences of care. DESIGN: The study used a qualitative descriptive methodology and employed semistructured interview technique. SETTING: A metropolitan stroke rehabilitation unit in Western Australia providing rehabilitation services for inpatients and outpatients. PARTICIPANTS: Overall, 10 participants (four staff, four stroke survivors and two primary carers) were interviewed. Transcripts were analysed using thematic analysis. RESULTS: Experiences of care focused on lack of time, urgency to regain mobility, postshock recovery, uncertainty about the future and the importance of accepting help once home. There was a degree of mismatch between staff experiences of the reality of what can be provided and the experiences and expectations of stroke survivors and families. However, the benefits of a specialised rehabilitation unit were found to contribute to a positive patient experience overall. The specialised unit demonstrated that services must optimise staff time with patients and carers in the poststroke rehabilitation journey to ensure benefits for the long-term well-being for both. CONCLUSION: Seeking patient, family and staff experiences of care can provide valuable insights into facilitating better patient, family and staff engagement for preparation for home-based rehabilitation for stroke survivors and their caregivers. Further research with a larger sample across diverse hospital settings would provide even greater insight into strategies to best address the reality of rehabilitation care and readiness of patients when returning home to the community.

Comparing an eHealth Program (My Hip Journey) With Standard Care for Total Hip Arthroplasty: Randomized Controlled Trial.

BACKGROUND: The role of eHealth programs to support patients through surgical pathways, including total hip arthroplasty (THA), is rapidly growing and offers the potential to improve patient engagement, self-care, and outcomes. OBJECTIVE: The aim of this study is to compare the effects of an eHealth program (intervention) versus standard care for pre- and postoperative education on patient outcomes for primary THA. METHODS: A prospective parallel randomized controlled trial with two arms (standard care and standard care plus access to the eHealth education program) was conducted. Participants included those who underwent THA. Outcome measures were collected preadmission, at 6 weeks, and at 3 and 6 months after surgery. The primary outcome was the Hip Dysfunction and Osteoarthritis Outcome Score. Secondary outcomes were a 5-level 5-dimension quality of life measure and the self-efficacy for managing chronic disease scale. Demographic and clinical characteristics were also collected. A satisfaction survey was completed by all participants 6 weeks after surgery, and those in the intervention arm completed an additional survey specific to the eHealth program. RESULTS: A total of 99 patients were recruited: 50 in the eHealth program (intervention) and 49 in standard care (control). Clinical improvements were demonstrated in both groups across all time points. Per-protocol analysis demonstrated no differences between the groups for all outcome measures across all time points. Participants in the eHealth program reported that the program was accessible, that they felt comfortable using it, and that the information was helpful. CONCLUSIONS: This study demonstrated that the eHealth program, in addition to standard care, had no additional benefit to THA recovery compared with standard care alone. The study found that the eHealth program was highly valued by participants, and it supported the preoperative preparation, recovery, and postoperative rehabilitation of participants. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry ACTRN12617001433392; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373657.

Trainee engagement with reflection in online portfolios: A qualitative study highlighting the impact of the Bawa-Garba case on professional development.

BACKGROUND: Reflection is an essential tool for postgraduate medical training, yet fear of exposing incompetence is a known barrier for engagement with reflection. In the UK, this fear may have been amplified by the case of Dr Bawa-Garba, whose reflective e-portfolio entries informed a General Medical Council investigation resulting in the loss of her licence to practice. AIM: To identify themes GP trainees commonly explore in e-portfolio entries, and whether their reflective e-portfolio entries have changed following the Bawa-Garba case. METHOD: A phenomenological approach was applied. Semi-structured interviews continued to data saturation in a purposive sample of trainees (7) and trainers (4) recruited from a South Yorkshire GP training scheme. Transcript data were assigned to a coding framework with iterative thematic analysis. RESULTS: Dominant emergent themes were 'difficulty' and 'challenge'. All trainees described reluctance to submit significant event analyses (SEAs) on mistakes and near misses for fear of jeopardising their careers. International medical graduates were disproportionately affected by the challenges reflection posed. CONCLUSION: Following the Bawa-Garba case, trainees are disengaging with SEAs to reduce the risk of self-incrimination. Further guidance with which trainees can navigate their reflective e-portfolios is required to retain the value of reflection as a tool for professional development.

Evaluation of a Remote Symptom Assessment and Management (SAM) System for People Receiving Adjuvant Chemotherapy for Breast or Colorectal Cancer: Mixed Methods Study.

BACKGROUND: The Symptom Assessment and Management (SAM) program is a structured, online, nurse-supported intervention to support symptom self-management in people receiving adjuvant chemotherapy post surgery for breast or colorectal cancer. OBJECTIVE: The objective of this study was to describe the development, implementation strategy, and evaluation of the SAM system. METHODS: The development of the SAM program involved 3 phases. In phase 1, the web app was developed through consultation with consumers and clinicians and of the literature to ensure that the system was evidence-based and reflected the realities of receiving treatment and supporting patients through treatment. In phase 2, 7 participants recorded the severity of 6 symptoms daily over the course of 1 cycle of chemotherapy. In phase 3, 17 participants recorded their symptoms daily over the course of 3 cycles of chemotherapy. Once symptoms were recorded, participants received immediate feedback on the severity of their symptoms and self-management recommendations, which could include seeking immediate medical attention. Data on quality of life, symptom burden, anxiety and depression, distress, and self-efficacy were collected during treatment; participants' perceptions of the SAM program were evaluated following participation via interview. RESULTS: The outcomes of the SAM project include the development of a system that is reliable and easy to use and navigate. Participants reported benefits related to using the SAM program that included feeling more in control of managing their symptoms and feeling reassured. Engagement with the system on a daily basis was variable, with some participants completing the symptom tracker daily and others engaging some of the time. The feedback from all participants was that the system was easy to navigate and the information was relevant and supportive. CONCLUSIONS: The SAM program has the potential to enhance the management of symptoms for people receiving chemotherapy treatment. The system creates an accurate repository of symptoms that can be accessed easily and highlight patterns in symptom experience. These can be shared with clinicians, with patient permission, to inform and support treatment plans. The potential to predict the risk of developing severe symptoms can be developed to anticipate the need for care and support. Further considerations on how to increase engagement with the system, the value of the system for people diagnosed with other tumor types and treatment regimes, and the incorporation of the system into everyday clinical practice are needed.

Disrupted sleep and associated factors in Australian dementia caregivers: a cross-sectional study.

BACKGROUND: Sleep disturbance is an issue reported by caregivers. Waking at night is a feature of dementia and by proxy, sleep disturbance among caregivers is reported to be high. Little is known about the characteristics of dementia caregivers' sleep and the factors that may influence sleep disruption. The purpose of this study was to investigate the sleep characteristics and disturbances of Australian caregivers of a person living with dementia. In addition, it evaluated the psychological wellbeing of caregivers by evaluating associations between mood and sleep in this population. METHODS: This study used a cross-sectional, descriptive, correlation design. Participants were recruited with the assistance of Alzheimer's Australia, Dementia Australia and targeted social media advertising. In total, 104 adult, primary, informal caregivers of people with dementia participated, completing a questionnaire on demographic characteristics, the Depression, Anxiety and Stress Scale (DASS-21) and the Pittsburgh Sleep Quality Index (PSQI). RESULTS: In this study, 76% of caregivers were female who had been caring for someone living with dementia on average for 4.8 years. 44% of participants had two or more co-morbidities namely cardiovascular disease, osteoarthritis and diabetes. 94% of participants were poor sleepers with 84% with difficulty initiating sleep and 72% reporting having difficulty maintaining sleep. Overall, psychological distress was common with high levels of moderate to severe depression, anxiety and stress. Global PSQI scores were significantly positively associated with depression and anxiety, with the strongest correlation seen with stress scores. Depression scores were also moderately associated with daytime dysfunction. Stress was identified as a significant predictor of overall sleep quality. CONCLUSIONS: Sleep problems are common within the population of dementia caregivers. Due to the nature and duration of caregiving and the progression of dementia of the care recipient, there is the potential for a decline in the caregivers' mental and physical health. Caregivers of those living with dementia are more likely to have comorbidities, depression, anxiety and stress. Sleep quality is correlated with emotional distress in dementia caregivers although the direction of this association is unclear. Therefore, sleep and psychological wellbeing may be intertwined, with improvements in one aspect resulting in a positive impact in the other.

Bucindolol for the Maintenance of Sinus Rhythm in a Genotype-Defined HF Population: The GENETIC-AF Trial.

OBJECTIVES: The purpose of this study was to compare the effectiveness of bucindolol with that of metoprolol succinate for the maintenance of sinus rhythm in a genetically defined heart failure (HF) population with atrial fibrillation (AF). BACKGROUND: Bucindolol is a beta-blocker whose unique pharmacologic properties provide greater benefit in HF patients with reduced ejection fraction (HFrEF) who have the beta1-adrenergic receptor (ADRB1) Arg389Arg genotype. METHODS: A total of 267 HFrEF patients with a left ventricular ejection fraction (LVEF) <0.50, symptomatic AF, and the ADRB1 Arg389Arg genotype were randomized 1:1 to receive bucindolol or metoprolol therapy and were up-titrated to target doses. The primary endpoint of AF or atrial flutter (AFL) or all-cause mortality (ACM) was evaluated by electrocardiogram (ECG) during a 24-week period. RESULTS: The hazard ratio (HR) for the primary endpoint was 1.01 (95% confidence interval [CI]: 0.71 to 1.42), but trends for bucindolol benefit were observed in several subgroups. Precision therapeutic phenotyping revealed that a differential response to bucindolol was associated with the interval of time from the initial diagnoses of AF and HF to randomization and with the onset of AF relative to that of the initial HF diagnosis. In a cohort whose first AF and HF diagnoses were <12 years prior to randomization, in which AF onset did not precede HF by more than 2 years (n = 196), the HR was 0.54 (95% CI: 0.33 to 0.87; p = 0.011). CONCLUSIONS: Pharmacogenetically guided bucindolol therapy did not reduce the recurrence of AF/AFL or ACM compared to that of metoprolol therapy in HFrEF patients, but populations were identified who merited further investigation in future phase 3 trials.

A genotype-directed comparative effectiveness trial of Bucindolol and metoprolol succinate for prevention of symptomatic atrial fibrillation/atrial flutter in patients with heart failure: Rationale and design of the GENETIC-AF trial.

BACKGROUND: Few therapies are available for the safe and effective treatment of atrial fibrillation (AF) in patients with heart failure. Bucindolol is a non-selective beta-blocker with mild vasodilator activity previously found to have accentuated antiarrhythmic effects and increased efficacy for preventing heart failure events in patients homozygous for the major allele of the ADRB1 Arg389Gly polymorphism (ADRB1 Arg389Arg genotype). The safety and efficacy of bucindolol for the prevention of AF or atrial flutter (AFL) in these patients has not been proven in randomized trials. METHODS/DESIGN: The Genotype-Directed Comparative Effectiveness Trial of Bucindolol and Metoprolol Succinate for Prevention of Symptomatic Atrial Fibrillation/Atrial Flutter in Patients with Heart Failure (GENETIC-AF) trial is a multicenter, randomized, double-blinded "seamless" phase 2B/3 trial of bucindolol hydrochloride versus metoprolol succinate, for the prevention of symptomatic AF/AFL in patients with reduced ejection fraction heart failure (HFrEF). Patients with pre-existing HFrEF and recent history of symptomatic AF are eligible for enrollment and genotype screening, and if they are ADRB1 Arg389Arg, eligible for randomization. A total of approximately 200 patients will comprise the phase 2B component and if pre-trial assumptions are met, 620 patients will be randomized at approximately 135 sites to form the Phase 3 population. The primary endpoint is the time to recurrence of symptomatic AF/AFL or mortality over a 24-week follow-up period, and the trial will continue until 330 primary endpoints have occurred. CONCLUSIONS: GENETIC-AF is the first randomized trial of pharmacogenetic guided rhythm control, and will test the safety and efficacy of bucindolol compared with metoprolol succinate for the prevention of recurrent symptomatic AF/AFL in patients with HFrEF and an ADRB1 Arg389Arg genotype. (ClinicalTrials.govNCT01970501).

How does adjuvant chemotherapy affect menopausal symptoms, sexual function, and quality of life after breast cancer?

OBJECTIVE: The aim of the study was to determine the association between adjuvant chemotherapy for breast cancer and menopausal symptoms, sexual function, and quality of life. METHODS: Participants attended a menopause clinic with a dedicated service for cancer survivors at a large tertiary women's hospital. Information about breast cancer treatments including adjuvant chemotherapy was collected from medical records. Menopausal symptoms were recorded with the Greene Climacteric Scale and Functional Assessment of Cancer Therapy, Breast Cancer, and Endocrine Symptom Subscales. Sexual symptoms were recorded using Fallowfield's Sexual Activity Questionnaire. Quality of life was measured with Functional Assessment of Cancer Therapy scales. RESULTS: The severity of vasomotor, psychological, or sexual symptoms (apart from pain) did not differ between those who had received adjuvant chemotherapy (n = 339) and other breast cancer survivors (n = 465). After adjustment for current age, time since menopause, and current use of antiestrogen endocrine therapy, the risk of "severe pain" with sexual intercourse was twice as common after chemotherapy (31.6% vs 20.0%, odds ratio [OR] 2.18, 95% CI 1.25-3.79). Those treated with chemotherapy were more likely to report "severe problems" with physical well-being (OR 1.92, 95% CI 1.12-3.28) and lower breast cancer-specific quality of life (OR 1.89 95% CI 1.13-3.18), but did not differ in other quality of life measures. CONCLUSIONS: In this large study of breast cancer patients presenting to a specialty menopause clinic, previous chemotherapy was not associated with current vasomotor or psychological symptoms. Severe pain with intercourse was significantly more common in those treated with adjuvant chemotherapy.

Tools and data services registry: a community effort to document bioinformatics resources.

Life sciences are yielding huge data sets that underpin scientific discoveries fundamental to improvement in human health, agriculture and the environment. In support of these discoveries, a plethora of databases and tools are deployed, in technically complex and diverse implementations, across a spectrum of scientific disciplines. The corpus of documentation of these resources is fragmented across the Web, with much redundancy, and has lacked a common standard of information. The outcome is that scientists must often struggle to find, understand, compare and use the best resources for the task at hand.Here we present a community-driven curation effort, supported by ELIXIR-the European infrastructure for biological information-that aspires to a comprehensive and consistent registry of information about bioinformatics resources. The sustainable upkeep of this Tools and Data Services Registry is assured by a curation effort driven by and tailored to local needs, and shared amongst a network of engaged partners.As of November 2015, the registry includes 1785 resources, with depositions from 126 individual registrations including 52 institutional providers and 74 individuals. With community support, the registry can become a standard for dissemination of information about bioinformatics resources: we welcome everyone to join us in this common endeavour. The registry is freely available at https://bio.tools.

Nature and severity of menopausal symptoms and their impact on quality of life and sexual function in cancer survivors compared with women without a cancer history.

OBJECTIVE: After cancer treatment, troublesome menopausal symptoms are common but poorly understood. Using standardized instruments, we measured differences in symptom nature, severity, impact on quality of life, and sexual function between cancer survivors and noncancer participants. METHODS: The Menopause Symptoms After Cancer Clinic operates within the general menopause service in a large women's hospital, providing menopause advice and management to women with menopausal symptoms and a cancer history. Menopausal symptoms were recorded using the Greene Climacteric Scale, past-week symptoms were recorded using the Functional Assessment of Cancer Therapy breast cancer subscale and endocrine symptom subscale, and sexual symptoms were recorded using Fallowfield's Sexual Activity Questionnaire. RESULTS: Cancer survivors (n = 934) and noncancer participants (n = 155) did not significantly differ by age at menopause (46 y) or age at first clinic visit (51 y). Cancer survivors were more likely than noncancer participants to be severely troubled by vasomotor symptoms (hot flushes and night sweats; odds ratio, 1.71; 95% CI, 1.06-2.74) and reported more frequent (6.0 vs 3.1 in 24 h; P < 0.001) and more severe (P = 0.008) hot flushes. In contrast, cancer survivors were significantly less troubled by psychological and somatic symptoms and reported better quality of life than noncancer participants. Groups did not differ significantly in physical or functional well-being, gynecologic symptom severity, or sexual function. CONCLUSIONS: Cancer survivors are more troubled by vasomotor symptoms than noncancer participants, but noncancer participants report greater psychological symptoms. Sexual function does not differ. An improved understanding of the nature and impact of menopause on cancer survivors can be used to direct management protocols.

Protein Phylogenetic Analysis of Ca(2+)/cation Antiporters and Insights into their Evolution in Plants.

Cation transport is a critical process in all organisms and is essential for mineral nutrition, ion stress tolerance, and signal transduction. Transporters that are members of the Ca(2+)/cation antiporter (CaCA) superfamily are involved in the transport of Ca(2+) and/or other cations using the counter exchange of another ion such as H(+) or Na(+). The CaCA superfamily has been previously divided into five transporter families: the YRBG, Na(+)/Ca(2+) exchanger (NCX), Na(+)/Ca(2+), K(+) exchanger (NCKX), H(+)/cation exchanger (CAX), and cation/Ca(2+) exchanger (CCX) families, which include the well-characterized NCX and CAX transporters. To examine the evolution of CaCA transporters within higher plants and the green plant lineage, CaCA genes were identified from the genomes of sequenced flowering plants, a bryophyte, lycophyte, and freshwater and marine algae, and compared with those from non-plant species. We found evidence of the expansion and increased diversity of flowering plant genes within the CAX and CCX families. Genes related to the NCX family are present in land plant though they encode distinct MHX homologs which probably have an altered transport function. In contrast, the NCX and NCKX genes which are absent in land plants have been retained in many species of algae, especially the marine algae, indicating that these organisms may share "animal-like" characteristics of Ca(2+) homeostasis and signaling. A group of genes encoding novel CAX-like proteins containing an EF-hand domain were identified from plants and selected algae but appeared to be lacking in any other species. Lack of functional data for most of the CaCA proteins make it impossible to reliably predict substrate specificity and function for many of the groups or individual proteins. The abundance and diversity of CaCA genes throughout all branches of life indicates the importance of this class of cation transporter, and that many transporters with novel functions are waiting to be discovered.

Unmet psychological and practical needs of patients with cancer in rural and remote areas of Western Australia.

INTRODUCTION: The financial and psychological impacts of cancer treatment on patients can be severe. Practical issues, such as childcare, medical supplies and obtaining 'home help' can impose financial strain on patients and their families, and this is often exacerbated by a simultaneous loss of income if a patient is unable to continue employment during treatment, or if family members become full-time carers. These financial difficulties are often more severe for patients from rural regions because cancer services tend to be concentrated in metropolitan areas, requiring rural patients to relocate or undertake lengthy, frequent commutes to access treatment. The needs of rural cancer patients may differ from and exceed those of metropolitan cancer patients. Because of this, it is important to assess the needs of rural and metropolitan populations to develop appropriate, tailored supportive-care interventions. This article compares the unmet supportive-care needs of rural/remote with metropolitan cancer patients in Western Australia (WA), a large and sparsely populated Australian state with a substantial rural and remote population. This article is part of a larger program of research assessing the supportive-care needs of WA cancer patients. METHODS: Participants were identified through the Western Australian Cancer Registry (WACR) and considered eligible if diagnosed with any type of cancer between 6 months and 2 years previously. A random sample of 2079 potential participants was generated, structured to include all cancer types and geographical areas, and with both sexes randomised within these groups. Following confirmation and exclusion of deceased patients and those patients excluded at the treating doctor's request, 1770 patients were contacted. Participants were asked to complete a demographic questionnaire and the Supportive Care Needs Survey Long Form (SCNS-59). Data from participants who completed and returned both questionnaires were analysed using descriptive statistics and χ(2) tests; and any missing data were addressed through imputation. RESULTS: Eight hundred and twenty-nine participants (47% response) completed the SCNS-LF59 and 786 (94.8%) completed both questionnaires. Of the 786 respondents, 234 (30%) were from rural areas and 169 (22%) were from remote areas. Among the 15 items with the highest frequency for 'some needs' on the survey, participant needs did not vary by geographical location, with no significant differences found for any of the 15 items. The item for which the greatest, albeit non-significant (p = 0.12) difference was seen, was 'concern about financial situation'. The differences among all other items were not significant (p-values from 0.28 to 0.96). Furthermore, the proportion of participants reporting 'moderate to high need' on these items also did not differ significantly across geographical populations (p-values from 0.13 to 0.91). CONCLUSIONS: The lack of discrepancy between rural, remote and metropolitan cancer patients' unmet needs provides a positive message regarding the state of WA cancer services and the level of support provided to rural and remote WA residents. Future research should also assess the unmet needs of rural and remote carers and families in comparison with metropolitan carers and families, to ensure that services are well-equipped to meet the needs of all individuals involved in a patient's cancer journey.

Impact of translational selection on codon usage bias in the archaeon Methanococcus maripaludis.

Patterns of codon usage have been extensively studied among Bacteria and Eukaryotes, but there has been little investigation of species from the third domain of life, the Archaea. Here, we examine the nature of codon usage bias in a methanogenic archaeon, Methanococcus maripaludis. Genome-wide patterns of codon usage are dominated by a strong A + T bias, presumably largely reflecting mutation patterns. Nevertheless, there is variation among genes in the use of a subset of putatively translationally optimal codons, which is strongly correlated with gene expression level. In comparison with Bacteria such as Escherichia coli, the strength of selected codon usage bias in highly expressed genes in M. maripaludis seems surprisingly high given its moderate growth rate. However, the pattern of selected codon usage differs between M. maripaludis and E. coli: in the archaeon, strongly selected codon usage bias is largely restricted to twofold degenerate amino acids (AAs). Weaker bias among the codons for fourfold degenerate AAs is consistent with the small number of tRNA genes in the M. maripaludis genome.

The multidisciplinary management of menopausal symptoms after breast cancer: a unique model of care.

OBJECTIVE: The aim of this study was to describe a unique model of multidisciplinary care for women with menopausal symptoms after breast cancer and present preliminary data for 653 women. METHODS: The nature and severity of menopausal symptoms in women with breast cancer were measured using a standardized scale. RESULTS: A total of 578 women with breast cancer were managed at the Menopausal Symptoms After Cancer Clinic between January 2003 and December 2008. The most common reasons for these women to seek treatment were hot flushes (41%), night sweats (36%), loss of interest in sex (30%), difficulty sleeping (25%), and fatigue (22%). Extreme vaginal dryness was also reported in 19% of these women. Chemotherapy-induced ovarian failure was reported by 29% of the breast cancer patients seen. A range of management approaches were offered, with 55% of the women prescribed nonhormonal pharmacological therapies for vasomotor symptoms, including vitamin E 400 IU twice daily (21%), venlafaxine 75 mg CR once daily (13%), clonidine 50 microg twice daily (11%), or gabapentin 300 mg three times daily (4%). CONCLUSIONS: Vasomotor symptoms, sexual dysfunction, and sleep disturbance are the most distressing menopausal symptoms requiring management after breast cancer. Menopausal symptom management after breast cancer may be complex, and we present a novel model of care using a multidisciplinary approach. Additional benefits of this multidisciplinary approach include education opportunities, improved communication and networking opportunities, and decision making in line with evidence-based guidelines.

Forces that influence the evolution of codon bias.

The frequencies of alternative synonymous codons vary both among species and among genes from the same genome. These patterns have been inferred to reflect the action of natural selection. Here we evaluate this in bacteria. While intragenomic variation in many species is consistent with selection favouring translationally optimal codons, much of the variation among species appears to be due to biased patterns of mutation. The strength of selection on codon usage can be estimated by two different approaches. First, the extent of bias in favour of translationally optimal codons in highly expressed genes, compared to that in genes where selection is weak, reveals the long-term effectiveness of selection. Here we show that the strength of selected codon usage bias is highly correlated with bacterial growth rate, suggesting that selection has favoured translational efficiency. Second, the pattern of bias towards optimal codons at polymorphic sites reveals the ongoing action of selection. Using this approach we obtained results that were completely consistent with the first method; importantly, the frequency spectra of optimal codons at polymorphic sites were similar to those predicted under an equilibrium model. Highly expressed genes in Escherichia coli appear to be under continuing strong selection, whereas selection is very weak in genes expressed at low levels.