Evaluation of a Daily Nine-Item "Handbook for Self-Care at Work" for Palliative Care Clinicians.

Context: A daily nine-item "Handbook for Self-Care at Work" was created to increase the well-being and satisfaction of the staff at the department of palliative care of a tertiary oncological center in the United States. Objectives: To evaluate the perceived usefulness of and adherence to the Handbook. Design, Setting and Participants: An anonymous survey was conducted among the palliative care staff asking for the frequency of utilization and the perception of usefulness of the Handbook. Additional data collected included demographics, satisfaction with professional life, frequency of burnout, and frequency of callousness toward people. We also compared the use and perception of the Handbook before and during the COVID-19 pandemic. Results: Of 52 palliative care clinicians, 39 (75%) completed the survey. Most participants were women and were <49 years. Most respondents (59%) found the Handbook useful or very useful. Offer help, ask for help, and hydration were perceived as the most useful items. The items most frequently achieved were movement, hydration, and eat light. The least useful perceived item was nap time, which was rarely achieved. During the COVID-19 pandemic, 32 (82%) respondents found the Handbook to be as/somewhat more/much more useful, and 29 (75%) were able to adhere to the items as/somewhat more/much more often than before. Conclusion: Most respondents found the Handbook useful and were able to accomplish the items most of the days. During the COVID-19 pandemic, the staff felt that the Handbook was more useful.

Accuracy of Highly Limited Echocardiographic Screening Images for Determining a Structurally Normal Heart: The Quick-Six Study.

INTRODUCTION: Experienced echocardiographers can quickly glean diagnostic information from limited echocardiographic views. The use of limited cardiac ultrasound, particularly as a screening tool, is increasing. During the COVID-19 pandemic, limited cardiac ultrasound has the major advantage of reducing exposure time between sonographer and patient. The sensitivity and negative predictive value of a "screening" echocardiogram with highly limited views is uncertain. AIM/METHOD: We examined the accuracy of limited echocardiography in 203 consecutive, de novo studies. We used six images: parasternal long axis, with colour Doppler over the mitral valve, and aortic valve, and apical four-chamber with colour Doppler over the mitral valve, and tricuspid valve. We compared the interpretation of 12 subjects with the final echocardiogram report, (gold standard). The subjects comprised four experienced echocardiography-specialised cardiologists, four experienced cardiologists with non-imaging subspecialty interests, and four senior cardiac sonographers. Studies were graded as: (1) normal or (2) needs full study (due to inadequate images or abnormality detected). Sensitivity, specificity, negative predictive value, positive predictive value and accuracy are reported. RESULTS: Forty-one per cent (41%) of studies were normal by the gold standard report. Overall, a screening echocardiogram had a sensitivity of 71.2%, specificity of 57.1% to detect an abnormal echocardiogram, negative predictive value 58.4%, positive predictive value of 70.2%, and accuracy of 65.4%. When inadequate images were excluded, overall accuracy was nearly identical at 64.6%. The overall accuracy between the three groups of interpreters was similar: 66.5% (95% CI 63.1-69.7) for echocardiography-specialised cardiologists, 65.3% (95% CI 61.9-68.5) for non-echocardiography specialised cardiologists, and 64.4% (95% CI 61.0-67.7) for sonographers. These groups are all highly experienced practitioners. There was no difference in sensitivity or specificity comparing echocardiography-specialised cardiologists with cardiologists of other subspecialty experience. Comparing cardiologists to sonographers, cardiologists had lower sensitivity (echocardiography specialists 67.6%, 95% CI 63.2-71.8, non-echocardiography specialists 62.0%, 95% CI 57.4-66.4) compared to sonographers (84.0% [95% CI 80.4-87.2, p<0.05]), but cardiologists had higher specificities (64.9% [95% CI 59.5-70.0] for the echocardiography specialists, and 69.9% [95% CI 64.7-74.8] for non echocardiography specialists), compared to 36.6% (95% CI 31.4-42.0, p<0.05) for the sonographer group. When looking at only the studies considered to be interpretable, cardiologists had higher positive predictive value (echocardiography specialists 73.7%, 95% CI 69.0-78.1, non echocardiography specialists 74.1%, 95% CI 68.8-79.9), as compared to sonographers (64.3%, 95% CI 59.8-68.5%). CONCLUSIONS: Limited cardiac ultrasound as a screening tool for a normal heart had a sensitivity of only 71%, when performed and interpreted by experienced personnel, raising questions regarding the safety of this practice. Caution is especially recommended in extrapolating its use to non-specialised settings.

Acute pleiotropic effects of dapagliflozin in type 2 diabetic patients with heart failure with reduced ejection fraction: a crossover trial.

AIMS: This study aimed to explore the rapid effects of dapagliflozin in heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS: We studied the functional, echocardiographic, electrophysiological, lung ultrasound, ambulatory blood pressure (BP), microvascular and macrovascular function, and biochemical effects of 2 week treatment with dapagliflozin in 19 type 2 diabetic HFrEF patients in a double-blind, crossover, placebo-controlled trial. Dapagliflozin had no significant effect on clinical, functional, or quality of life parameters. Dapagliflozin reduced systolic BP [114 (105, 131) vs. 106 (98, 113) mmHg, P < 0.01] and diastolic BP [71 (61, 78) vs. 62 (55, 70) mmHg, P < 0.01]. There was no effect on cardiac chamber size, ventricular systolic function, lung ultrasound, or arterial wave reflection. Dapagliflozin increased creatinine [117 (92, 129) vs. 122 (107, 135) µmol/L, P < 0.05] and haemoglobin [135 (118, 138) vs. 136 (123, 144) g/L, P < 0.05]. There was a reduction in ventricular ectopy [1.4 (0.1, 2.9) vs. 0.2 (0.1, 1.4) %, P < 0.05] and an increase in standard deviation of normal heart beat intervals [70 (58, 90) vs. 74 (62, 103), P < 0.05]. Unexpectedly, dapagliflozin increased high-sensitivity troponin T [25 (19, 37) vs. 28 (20, 42) ng/L, P < 0.01] and reduced reactive hyperaemia index [1.29 (1.21, 1.56) vs. 1.40 (1.23, 1.84), P < 0.05]. CONCLUSIONS: After 2 weeks, while multiple parameters supported BP reduction and haemoconcentration with dapagliflozin, reduction in cardiac filling pressure, lung water, and functional improvement was not shown. Reduced ventricular ectopic burden suggests an early antiarrhythmic benefit. The small increase in troponin T and the reduction in the reactive hyperaemia index warrant further mechanistic exploration in this treatment of proven mortality benefit in HFrEF.

Empowering the Health and Well-Being of the Palliative Care Workforce: Evaluation of a Weekly Self-Care Checklist.

BACKGROUND: Workplace interventions are needed to prevent burnout and support the well-being of the palliative care workforce. MEASURES: We conducted a survey of all palliative care clinical staff to evaluate the usefulness and feasibility of checklist items and the checklist itself. We collected demographics, perceptions of professional satisfaction and burnout, and qualitative feedback aimed at improving the checklist. INTERVENTION: We implemented a 13-item self-care checklist, included in a handbook on palliative care carried in the laboratory coat of all clinical personnel, to remind them to care of their own well-being. OUTCOMES: Of 39 personnel contacted, 32 (82%) responded. Most (20; 62%) found the checklist useful. Exercise was the most highly ranked item, whereas watching visual arts was the lowest ranked item. CONCLUSIONS/LESSONS LEARNED: Numerous opportunities were identified to improve the checklist and facilitate achievement of checklist items. Survey data will be used in the next checklist version.

The Spectrum of Change in the Elite Athlete's Heart.

BACKGROUND: Extreme levels of both strength and aerobic training result in increased left ventricular (LV) and right ventricular (RV) volumes and LV mass, a key component of athletes' heart. The aim of this study was to document temporal changes in the hearts of elite professional athletes (Australian Football League players) over a 2- to 6-year period. METHODS: Thirty-six Australian Football League players with 3.5 ± 2.7 years of professional training at enrollment prospectively underwent echocardiography in the preseasons of 2009, 2013, and 2015. At each time point, LV dimension and contractility and RV dimension, area, and contractility were measured using two-dimensional echocardiography. LV volumes, ejection fraction, and mass were measured using three-dimensional echocardiography. RESULTS: The mean age at baseline was 21.8 ± 2.6 years (range, 18-29 years). Most players (n = 20) had increases in fitness between studies (mean maximal oxygen uptake, 62.3 ± 3.6 vs 64.3 ± 2.1 mL/kg/min). In these players, there were increases in both LV and RV size and in LV mass. Players who were >25 years of age at their baseline scans demonstrated a trend toward increases in RV size and a decline in RV global longitudinal strain. Fitness level and playing position also affected the degree of physiological athletic cardiac remodeling. CONCLUSIONS: Australian football is a sport that involves both strength and aerobic training. This study, unique in its length and detail, demonstrates that remodeling in the athlete's heart is a continuous spectrum of change. This remodeling occurs over time in response to high levels of exercise, with proportional increase in LV mass and LV dimensions.

A Longitudinal Pilot Study for Examining Symptom Reduction in Patients With Cancer in a Palliative Care Program: A Primarily Rural Northeast Texas Population.

Many patients with cancer live in rural areas and research is lacking on the efficacy of palliative care programs in rural community settings. This pilot study was conducted in a primarily rural setting where healthcare professionals delivered palliative care to 52 mostly lower income patients with a variety of cancers. They were assessed for physical, financial, psychosocial and overall symptom intensity at baseline and at three consequent assessments. This pilot study demonstrated the potential efficacy of an outpatient palliative care program in a mostly rural setting in the reduction of physical, psychosocial, and overall symptom intensity in patients with cancer.

The 21st Century Echocardiography Laboratory in Australia and New Zealand: Rapid Evolution of Training and Workforce, Practice and Technology.

Echocardiography is a common and increasingly used noninvasive imaging tool in medicine. In this paper, we imagine the echocardiography laboratory of the future and consider the challenges we face currently, and may face in the future, and how these might be overcome; challenges such as training enough sonographers to meet the increasing demands of the ageing population living with chronic cardiovascular disease and the need for surveillance in other clinical scenarios. We consider the changing qualification framework and the requirements for accreditation and registration in Australia and New Zealand and the potential for migrant sonographers to meet some of the increasing demand. Advanced scopes of practice are likely to be a feature of the future workforce and we consider some of the ways these may evolve. Lastly, we consider how the evolving clinical landscape and technology may change the way echocardiography is delivered.

Delineating managed land for reporting national greenhouse gas emissions and removals to the United Nations framework convention on climate change.

Land use and management activities have a substantial impact on carbon stocks and associated greenhouse gas emissions and removals. However, it is challenging to discriminate between anthropogenic and non-anthropogenic sources and sinks from land. To address this problem, the Intergovernmental Panel on Climate Change developed a managed land proxy to determine which lands are contributing anthropogenic greenhouse gas emissions and removals. Governments report all emissions and removals from managed land to the United Nations Framework Convention on Climate Change based on this proxy, and policy interventions to reduce emissions from land use are expected to focus on managed lands. Our objective was to review the use of the managed land proxy, and summarize the criteria that governments have applied to classify land as managed and unmanaged. We found that the large majority of governments are not reporting on their application of the managed land proxy. Among the governments that do provide information, most have assigned all area in specific land uses as managed, while designating all remaining lands as unmanaged. This designation as managed land is intuitive for croplands and settlements, which would not exist without management interventions, but a portion of forest land, grassland, and wetlands may not be managed in a country. Consequently, Brazil, Canada and the United States have taken the concept further and delineated managed and unmanaged forest land, grassland and wetlands, using additional criteria such as functional use of the land and accessibility of the land to anthropogenic activity. The managed land proxy is imperfect because reported emissions from any area can include non-anthropogenic sources, such as natural disturbances. However, the managed land proxy does make reporting of GHG emissions and removals from land use more tractable and comparable by excluding fluxes from areas that are not directly influenced by anthropogenic activity. Moreover, application of the managed land proxy can be improved by incorporating additional criteria that allow for further discrimination between managed and unmanaged land.

Instantaneous Decrease in Left Ventricular Afterload during Transcatheter Aortic Valve Implantation Results in Immediate Changes in Left Ventricular Strain.

Severe aortic stenosis causes chronic increased afterload on the left ventricle (LV) resulting in myocardial hypertrophy and ultimately dysfunction if left untreated. Transcatheter aortic valve implantation (TAVI) immediately decreases the afterload on the LV by reducing the pressure gradient through the aortic valve. In our study, we aim to evaluate immediate changes in LV mechanics using intra-procedural transesophageal echocardiography (TEE) to assess circumferential and radial strain via speckle tracking. Intra-operative TEE was performed during TAVI for 53 patients (mean age 84 ± 8 years). Two-dimensional images in the transgastric view were acquired at the level of the papillary muscle. Circumferential and radial strain was calculated using speckle tracking with Philips Qlab software. Global LV afterload was measured by calculating valvulo-arterial impedance (Zva). Immediately post-TAVI, there was a change in both radial strain rate (Pre: 0.73 ± 0.04 vs. Post: 0.88 ± 0.04 per second, P < 0.001) and circumferential strain rate (-0.53 ± 0.04 (pre) vs. -0.74 ± 0.04 (post) per second, P < 0.001). There was also an immediate improvement in circumferential global strain parameters (-14.5 ± 5% (pre) vs. -16.0 ± 4.7% (post), P < 0.05), whereas there was no significant change seen in global radial strain (15.6 ± 0.8% (pre) vs. 15.2 ± 0.9% (post), P = 0.69). No significant change was seen in LV ejection fraction (51.5 ± 14.2% (pre) vs. 52.1 ± 14.0% (post), P = 0.77). Speckle tracking using TEE images is feasible and identifies significant improvements in LV strain and strain rate immediately following TAVI that is not detected by conventional measure of LV function.

Enhancing treatment access: evaluation of an Australian Web-based alcohol and drug counselling initiative.

INTRODUCTION AND AIMS: The provision of counselling and other health interventions over the Internet is an emerging treatment modality. In 2007, an evaluation of the first Australian pilot Web-based alcohol and other drug (AOD) counselling initiative, known as CounsellingOnline, was completed. This paper explores whether CounsellingOnline enhanced AOD service accessibility for clients. DESIGN AND METHODS: Service utilisation data (n = 2004) and client survey data (n = 277) were collected and analysed to evaluate service responses, service impact, client characteristics and client satisfaction. Comparative client data were obtained from a state-wide conventional counselling dataset (Alcohol and Drug Information System; n = 19,283) and a statewide telephone counselling database (DirectLine; n = 59,863). Results. Service responses, such as fast counsellor connection speed, low client attrition and anonymous login, contributed to good service accessibility. CounsellingOnline clients differed from conventional and telephone counselling clients, representing much higher proportions of young, employed and female clients. Notably, the majority of CounsellingOnline sessions occurred outside standard business hours. DISCUSSION AND CONCLUSIONS: CounsellingOnline has showed enhanced AOD service accessibility through its service responsiveness, high level of after-hours service utilisation, and appeal to a client group that differs from those seen in conventional and telephone AOD counselling services. The capacity of Web-based services such as CounsellingOnline to enhance service accessibility is significant, particularly for clients whose access to conventional treatment services is limited.

Give consideration to financial abuse among the older population.

This article, brought to you in association with Help the Aged, considers financial exclusion, low levels of financial capability, and cognitive impairment among older people, which can lead to them becoming reliant on significant others to manage their finances.

Improving engagement with older people.

This article seeks to explore how the older person can be involved and informed in making policy at a local level. Their experience and expertise is invaluable and older people are best placed to voice where services are falling down and their needs are not being met. Government needs to engage with the older person much more effectively.

Depression and older people: securing wellbeing in later life.

This article, brought to you in association with Help the Aged, looks at the factors that can contribute to depression in older people and highlights the information available from the Charity.