Frequency and duration of suffering of cervical cancer patients and caregivers: Results from an international Delphi study.

This paper describes a Delphi process executed between August and September, 2020, to identify types of physical, psychological, social and spiritual suffering and their severity, prevalence and duration associated with cervical cancer to enable estimation of the global and regional palliative care needs of these cervical cancer patients and their family caregivers. Patients were dichotomized into decedents (those who died of cervical cancer in any given year) and non-decedents (those who had cervical cancer in any given year but did not die in that year). A two-round web-based Delphi study was conducted using a panel of 12 experts with first-hand experience taking care of cervical cancer patients and their family caregivers, two from each World Health Organization (WHO) region. We identified thirteen types of physical suffering, six psychological types, three social types and three spiritual types. Frequencies and durations were given for each of the suffering types for a decedent, a non-decedent and a primary family caregiver. Our findings of the types, severity, frequency and duration of suffering associated with cervical cancer should inform global, regional, national and local health care strategic planning so that the health investments can be better aligned with the needs.

Analyzing the Unique Needs of International Palliative Care Learners Attending a United States-Based Palliative Care Education and Practice Course.

Background: Many seriously ill patients in need of palliative care (PC) globally never receive it, partly due to a lack of well-trained providers. Objectives: We analyzed feedback from international participants in a U.S.-based PC training course: "Palliative Care Education and Practice" to identify elements of the course that would meet the needs of international learners. Design: This was a qualitative analysis of international course participants' written survey responses. Survey questions were related to anticipated PC practice change, barriers to PC practice change, and course strengths/weaknesses. Results: Key barriers to PC practice change included lack of awareness of PC among local providers, challenges navigating institutional leaders, and a lack of trained providers. Participants requested an increased focus on topics such as resiliency, leadership, and pediatric PC. Conclusions: To address the needs of international learners, PC courses should consider offering a specific track for international participants, as well as an increased focus on topics such as resiliency, leadership development, and pediatric PC.

Cervical Cancer-Associated Suffering: Estimating the Palliative Care Needs of a Highly Vulnerable Population.

PURPOSE: To enable design of optimum palliative care for women with cervical cancer, we studied the most common types of suffering and their severity, prevalence, and duration. METHODS: We first reviewed the literature on the major types, severity, prevalence, and duration of suffering associated with cervical cancer. We then conducted a modified Delphi process with experts in cervical cancer care to supplement the literature. For each type of suffering, we distinguished between decedents (those who die from cervical cancer in a given year) and nondecedents (those who have cervical cancer in a given year but do not die). By applying the suffering prevalence and duration estimates to the number of decedents, nondecedents, and family caregivers in 2017, we were able to estimate their palliative care needs and the intensity of palliative care needed to respond adequately to this suffering. RESULTS: There is a high prevalence among decedents of moderate or severe pain (84%), vaginal discharge (66%), vaginal bleeding (61%), and loss of faith (31%). Among both decedents and nondecedents, there is a high prevalence of clinically significant anxiety (63% and 50%, respectively), depressed mood (52% and 38%, respectively), and sexual dysfunction (87% and 83%, respectively). Moderate or severe financial distress is prevalent among decedents, nondecedents, and family caregivers (84%, 74%, and 66%, respectively). More than 40% of decedents and nondecedents are abandoned by their intimate partners. Most patients experience some combination of moderate or severe physical, psychological, social, and spiritual suffering. In total, 258,649 decedents and 2,558,857 nondecedents needed palliative care in 2017, approximately 85% of whom were in low- and middle-income countries where palliative care is rarely accessible. CONCLUSION: Among women with advanced cervical cancer, suffering is highly prevalent and often severe and multifaceted.

Essential Package of Palliative Care for Women With Cervical Cancer: Responding to the Suffering of a Highly Vulnerable Population.

Women with cervical cancer, especially those with advanced disease, appear to experience suffering that is more prevalent, complex, and severe than that caused by other cancers and serious illnesses, and approximately 85% live in low- and middle-income countries where palliative care is rarely accessible. To respond to the highly prevalent and extreme suffering in this vulnerable population, we convened a group of experienced experts in all aspects of care for women with cervical cancer, and from countries of all income levels, to create an essential package of palliative care for cervical cancer (EPPCCC). The EPPCCC consists of a set of interventions, medicines, simple equipment, social supports, and human resources, and is designed to be safe and effective for preventing and relieving all types of suffering associated with cervical cancer. It includes only inexpensive and readily available medicines and equipment, and its use requires only basic training. Thus, the EPPCCC can and should be made accessible everywhere, including for the rural poor. We provide guidance for integrating the EPPCCC into gynecologic and oncologic care at all levels of health care systems, and into primary care, in countries of all income levels.

Augmented Package of Palliative Care for Women With Cervical Cancer: Responding to Refractory Suffering.

The essential package of palliative care for cervical cancer (EPPCCC), described elsewhere, is designed to be safe and effective for preventing and relieving most suffering associated with cervical cancer and universally accessible. However, it appears that women with cervical cancer, more frequently than patients with other cancers, experience various types of suffering that are refractory to basic palliative care such as what can be provided with the EPPCCC. In particular, relief of refractory pain, vomiting because of bowel obstruction, bleeding, and psychosocial suffering may require additional expertise, medicines, or equipment. Therefore, we convened a group of experienced experts in all aspects of care for women with cervical cancer, and from countries of all income levels, to create an augmented package of palliative care for cervical cancer with which even suffering refractory to the EPPCCC often can be relieved. The package consists of medicines, radiotherapy, surgical procedures, and psycho-oncologic therapies that require advanced or specialized training. Each item in this package should be made accessible whenever the necessary resources and expertise are available.

Inadequate postgraduate training of skin and soft tissue infections in an era of community-associated methicillin-resistant Staphylococcus aureus.

BACKGROUND: Since 2002, the incidence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) skin and soft tissue infections (SSTIs) has been steadily increasing and CA-MRSA may now account for most community-based SSTIs. Although consensus remains vague, using antibiotics with MRSA coverage has shown improved rates of clinical resolution. The goal of this pilot study was to assess resident physicians' awareness and management of CA-MRSA SSTIs in the acute/ambulatory care setting. METHODS: This is a prospective cross-sectional survey-design study based on clinical case scenarios approved by the university's institutional review board. The survey was distributed to residents in internal medicine, general surgery, and emergency medicine. The survey was designed to assess (1) their knowledge of MRSA prevalence in community SSTIs and (2) their choice of empiric antibiotic for community-based SSTIs. RESULTS: Across all residency programs, only 15.7% of residents correctly estimated prevalence of CA-MRSA in SSTIs in the acute care/ambulatory setting to be 50% or higher. In practice, 28.6% of general surgery residents, 50.0% of internal medicine residents, and 69.7% of emergency medicine residents would use an antibiotic with appropriate MRSA coverage. CONCLUSION: This pilot study reveals that a substantial number of resident physicians are unaware of the increasing prevalence of CA-MRSA SSTIs and continue to use ß-lactam antibiotics for empiric pharmacotherapy of community-based SSTIs. More education is desperately needed on this crucial topic across various residency training programs.

Multiple brain abscesses due to Actinomyces species.

We report a case of multiple brain abscesses due to Actinomyces species in a 35-year-old immunocompetent man who presented with a 2-month history of headache, diplopia, fever, and weight loss. Despite receipt of broad-spectrum antibiotics for over a month, he continued to have headaches and diplopia. He subsequently underwent right anterior temporal lobectomy and evacuation of abscesses. The diagnosis was aided by identification of sulfur granule on histopathological examination of cerebral cavitary lesion and Gram-positive filamentous rods seen on tissue-Gram stain.