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Purpose While not always sufficient, surgery is a critical component of contemporary multidisciplinary cancer care and is generally necessary for the curative-intent treatment of most solid organ cancers. Patients who undergo aborted cancer surgery may experience many of the same surgical symptoms, need for recovery, and risk of complications as patients who undergo successful curative-intent surgery while simultaneously experiencing the psychosocial distress of a terminal change in their prognosis as well as the side effects of cancer left in situ . Methods A systematic review of the PubMed, Medline, CINAHL, and PsychInfo databases was performed of literature pertaining to the quality of life, experiences, care needs, coping strategies, and/or preferences of patients following aborted cancer surgery. Results Among 12,060 initially identified articles, none met the final inclusion criteria. Given this evidence gap, this commentary summarizes the lack of relevant literature on patient-centered outcomes following aborted cancer surgery and highlights opportunities for future patient-centered research. Conclusion There is a significant lack of patient-centered research pertaining to outcomes of aborted cancer surgery. Future research should focus on characterizing patients’ experiences, care needs, and preferences following aborted cancer surgery which might inform patient-centered interventions that can lead to improved quality and quantity of life.

The nurse practitioner (NP) role has emerged as a key role in primary care in the United States. NPs can help meet growing primary care needs, contribute to greater access to care for patients, and provide care that is of high quality, leads to high patient satisfaction, and is cost-effective. While many stakeholders in the fields of nursing and primary care have argued for further expanding NP scope of practice, others, predominantly medical organizations, have questioned this approach. NP practice is governed at the state level, but it is also influenced by organizational level factors, like institutional policies, which can influence the NP practice environment. Therefore, organized medicine's opposition, in combination with varying state laws and regulations, as well as organizational barriers have prevented NPs from practicing to the full extent of their education and training in many states. Thus, the overall goal of this dissertation is to provide further clarity around the integration of the NP role into the delivery of healthcare services in the United States via three specific aims. Aim 1 provides an evidence-based overview of the terms used in the existing literature to describe NP integration into primary care and determines characteristics of distinct models of care. This first aim will help reduce confusion around the labeling and operationalization of terms, it will further allow health professionals to work towards common goals, and it will provide a foundation for future outcomes research around NP-physician models of care. Aim 2 examines why some states have achieved full NP scope of practice authority while others have not. This second aim can help guide state policy makers and NP professional organizations in their lobbying efforts and decision making around future NP policy efforts. Further, understanding why some states have achieved full scope of practice authority while others have not is critical as NPs working in full scope of practice states have reported more favorable work environments and, if utilized effectively, NPs can be considered part of the solution to the primary care physician shortage. Aim 3 provides specific recommendations for administrators that will improve the NP-administrator relationship in primary care practices. This third aim can help create more favorable NP practice environments, which are essential for NPs to succeed in their work.

Background Surgical resection is a necessary component of curative-intent treatment for most solid-organ cancers but is occasionally aborted, most often due to occult metastatic disease or unanticipated unresectability. Despite its frequency, little research has been performed on the experiences, care needs, and treatment preferences of patients who experience an aborted cancer surgery. Methods Semistructured interviews of patients who had previously experienced an aborted cancer surgery were conducted, focusing on their recalled experiences and stated preferences. All interviews were audio recorded, transcribed, and coded by two independent researchers by using NVivo 12. An integrative approach to qualitative analysis was used—both inductive and deductive methods—and iteratively identifying themes until saturation was reached. Results Fifteen patients with an aborted cancer surgery participated in the interviews. Cancer types included pancreatic ( n = 9), cholangiocarcinoma ( n = 3), hepatocellular carcinoma ( n = 1), gallbladder ( n = 1), and neuroendocrine ( n = 1). The most common reasons for aborting surgery included local tumor unresectability ( n = 8) and occult metastatic disease ( n = 7). Five subthemes that characterized the patient experience following an aborted cancer surgery emerged, including physical symptoms, emotional responses, impact on social and life factors, coping mechanisms, and support received. Conclusions This qualitative study characterizes the impact of aborted cancer surgery on multiple domains of quality of life: physical, emotional, social, and existential. These results highlight the importance of developing patient-centered interventions that focus on enhancing quality of life after aborted cancer surgery.

Purpose Effective cancer care coordination (CCC) is an integral component of health care delivery and critical to achieving optimal oncologic outcomes. Neoadjuvant therapy (NT), the delivery of multimodality therapy prior to surgery, is inherently complex and multidisciplinary, but CCC during NT is poorly understood. The objective of this study was to characterize patient perceptions of CCC during NT using a mixed methods approach. Methods This study is a cross-sectional analysis of patients with gastrointestinal cancers receiving NT who participated in a prospective longitudinal cohort study evaluating their real-time experience using a customized smartphone application. Patients completed the Cancer Care Coordination Questionnaire for Patients (CCCQ-P), a 20-item validated measure of care coordination quality, six weeks after initiating NT. Items were scored on a 5-point Likert scale, and subsections on communication (13 questions) and navigation (7 questions) were calculated with higher scores signifying better CCC. Univariate linear regression was used to calculate the impact of fragmented care and other factors on perceived CCC. Semi-structured interviews were conducted among a convenience sample of patients ( n  = 5); transcribed interviews were then coded using an inductive approach. Results Among 82 participants, mean age was 61 years old, 68% were male, and mean number of comorbidities was 1.68. Overall (mean 76.6 out of 100), communication subsection (48.6 out of 65), and navigation subsection (28.0 out of 35) CCCQ-P scores suggested overall positive perceptions of care coordination. Qualitative analysis of patient interviews highlighted the need for coordination among physicians before communicating the plan to patients as well as the importance of providers communicating plans in verbal and written form. Conclusions Successful completion of NT requires significant care coordination between patients and healthcare professionals. Yet, in this cross-sectional analysis of patients on a prospective cohort study, patient perceptions of CCC during NT were overall positive. Future research should focus on optimizing other aspects of care delivery in order to improve outcomes of NT.

Purpose Neoadjuvant therapy (NT) is increasingly utilized for patients with localized pancreatic ductal adenocarcinoma (PDAC). Patients with cancer have high information needs and the Internet has materialized as a leading source of information for many patients. Nevertheless, little is known about the availability, accessibility, quality, and readability of online information regarding NT for PDAC. Methods A search of online patient informational materials (PIMs) pertaining to NT for PDAC was conducted using a combination of common search engines and browsers. Two independent researchers evaluated the readability, quality, and availability of unique PIMs from the top 25 websites from each search using validated measures. Results Among the 130 websites retrieved, 46 (35.4%) unique PIMs focused on treatment of PDAC. Only 30 (23%) mentioned NT as a possible treatment option. Downstaging was the rationale for NT mentioned in the majority (90%) of websites. The mean quality and reliability of the 30 PIMs, assessed using the DISCERN instrument, was 3.3 ± 0.7, suggesting moderate quality/reliability. The mean readability score, assessed using the SMOG Grade tool, was 10.96 ± 1.49, which is equivalent to an 11th grade reading level. Conclusion The low availability, poor readability, and moderate quality of online informational materials regarding NT for PDAC highlight the need for new patient-centered resources to educate patients and caregivers on an increasingly utilized treatment strategy for localized PDAC.

Cardiovascular risk models remain incomplete. Small-molecule metabolites may reflect underlying disease and, as such, serve as novel biomarkers of cardiovascular risk. We studied 2,023 consecutive patients undergoing cardiac catheterization. Mass spectrometry profiling of 69 metabolites and lipid assessments were performed in fasting plasma. Principal component analysis reduced metabolites to a smaller number of uncorrelated factors. Independent relationships between factors and time-to-clinical events were assessed using Cox modeling. Clinical and metabolomic models were compared using log-likelihood and reclassification analyses. At median follow-up of 3.1 years, there were 232 deaths and 294 death/myocardial infarction (MI) events. Five of 13 metabolite factors were independently associated with mortality: factor 1 (medium-chain acylcarnitines: hazard ratio [HR] 1.12 [95% CI, 1.04-1.21], P = .005), factor 2 (short-chain dicarboxylacylcarnitines: HR 1.17 [1.05-1.31], P = .005), factor 3 (long-chain dicarboxylacylcarnitines: HR 1.14 [1.05-1.25], P = .002); factor 6 (branched-chain amino acids: HR 0.86 [0.75-0.99], P = .03), and factor 12 (fatty acids: HR 1.19 [1.06-1.35], P = .004). Three factors independently predicted death/MI: factor 2 (HR 1.11 [1.01-1.23], P = .04), factor 3 (HR 1.13 [1.04-1.22], P = .005), and factor 12 (HR 1.18 [1.05-1.32], P = .004). For mortality, 27% of intermediate-risk patients were correctly reclassified (net reclassification improvement 8.8%, integrated discrimination index 0.017); for death/MI model, 11% were correctly reclassified (net reclassification improvement 3.9%, integrated discrimination index 0.012). Metabolic profiles predict cardiovascular events independently of standard predictors.

Abstract Rationale Opioid abuse is increasing, but its impact on critical care resources in the United States is unknown. Objectives We hypothesized that there would be a rising need for critical care among opioid-associated overdoses in the United States. Methods We analyzed all adult admissions, using a retrospective cohort study from 162 hospitals in 44 states, discharged between January 1, 2009, and September 31, 2015 to describe the incidence of intensive care unit (ICU) admissions for opioid overdose during this time. Admissions were identified using the Clinical Database/Resource Manager of Vizient, the successor to the University Health System Consortium. Results Our primary outcome was opioid-associated overdose admissions to the ICU. The outcome was defined on the basis of previously validated ICD-9 codes. Our secondary outcomes were in-hospital death and markers of ICU resources. The final cohort included 22,783,628 admissions; 4,145,068 required ICU care. There were 52.4 ICU admissions for overdose per 10,000 ICU admissions over the entire study (95% confidence interval [CI], 51.8–53.0 per 10,000 ICU admissions). During this time period, opioid overdose admissions requiring intensive care increased 34%, from 44 per 10,000 (95% CI, 43–46 per 10,000) to 59 per 10,000 ICU admissions (95% CI, 57–61 per 10,000; P < 0.0001). The mortality rate of patients with ICU admissions with overdoses averaged 7% (95% CI, 7.0–7.6%) but increased to 10% in 2015 (95% CI, 8.8–10.8%). Conclusions The number of deaths of ICU patients with opioid overdoses increased substantially in the 7 years of our study, reflecting increases in both the incidence and mortality of this condition. Our findings raise the need for a national approach to developing safe strategies to care for patients with overdose in the ICU, to providing coordinated resources in the hospital for patients and families, and to helping survivors maintain sobriety on discharge.

The Max Planck Institute Grand Ensemble (MPI‐GE) is the largest ensemble of a single comprehensive climate model currently available, with 100 members for the historical simulations (1850–2005) and four forcing scenarios. It is currently the only large ensemble available that includes scenario representative concentration pathway (RCP) 2.6 and a 1% CO2 scenario. These advantages make MPI‐GE a powerful tool. We present an overview of MPI‐GE, its components, and detail the experiments completed. We demonstrate how to separate the forced response from internal variability in a large ensemble. This separation allows the quantification of both the forced signal under climate change and the internal variability to unprecedented precision. We then demonstrate multiple ways to evaluate MPI‐GE and put observations in the context of a large ensemble, including a novel approach for comparing model internal variability with estimated observed variability. Finally, we present four novel analyses, which can only be completed using a large ensemble. First, we address whether temperature and precipitation have a pathway dependence using the forcing scenarios. Second, the forced signal of the highly noisy atmospheric circulation is computed, and different drivers are identified to be important for the North Pacific and North Atlantic regions. Third, we use the ensemble dimension to investigate the time dependency of Atlantic Meridional Overturning Circulation variability changes under global warming. Last, sea level pressure is used as an example to demonstrate how MPI‐GE can be utilized to estimate the ensemble size needed for a given scientific problem and provide insights for future ensemble projects. Key Points The 100‐member MPI‐GE is currently the largest publicly available ensemble of a comprehensive climate model MPI‐GE currently has the most forcing scenarios of all large ensemble projects: RCP2.6, RCP4.5, RCP8.5, and 1% CO2 The power of MPI‐GE is to estimate the forced response and internal variability, including changing variability, to unprecedented precision