Catherine L. Granger

Introduction: Gastrointestinal cancer surgery commonly leads to postoperative complications and other adverse outcomes. While prehabilitation shows promise in reducing adverse postoperative outcomes, most hospitals have resource limitations that preclude its use as standard of care. Additionally, the need to expedite surgery from diagnosis often creates a narrow window for prehabilitation initiatives. Online, self-reported screening tools may address these challenges by facilitating early identification of high-risk patients and enabling targeted preoperative interventions, thereby allowing equitable allocation of limited resources. Therefore, the primary aim of this study is to evaluate the predictive utility of a tri-modal (physical, nutritional, psychological) screening tool for patients undergoing gastrointestinal cancer surgery. Methods: This prospective international cohort study will recruit 1214 adults undergoing elective gastrointestinal cancer surgery across 35 sites from 19 countries. Participants will complete an online screening tool developed through a comprehensive, multistep, predefined process. The screening tool comprises the Duke Activity Status Index, Patient-Generated Subjective Global Assessment Short Form and the Patient Health Questionnaire-4, in English, Spanish, French or Portuguese. These tools were selected based on a scoping review, followed by an international Delphi consensus process. The primary outcomes include rate of postoperative complications, major complications (Clavien-Dindo Classification grade III–V) and overall complication severity assessed by the Comprehensive Complications Index; all assessed 30 days postoperatively. Secondary outcomes include hospital length of stay, readmission rate within 30 days, discharge destination (home vs other), days at home and alive in 30 days postsurgery, 30-day all-cause mortality and 12-month survival. Primary analyses will establish optimal screening tool cut-points to stratify patients into clinically actionable risk categories for postoperative complications and examine the independent predictive value of these screening scores after adjusting for established clinical risk factors. Ethics and dissemination: This study has received ethical approval from the Sydney Local Health District Human Research and Ethics Committee (X25-0333 and 2025/ETH02465) and has been registered on the Open Science Framework (10.17605/OSF.IO/HVCGD). The results of Preoperative Risk Evaluation for Cancer Treatment will be submitted to reputable journals and presented at national and international conferences.

Background: Immunotherapy has rapidly become part of lung cancer care, however the ability of people to participate in rehabilitation in conjunction with immunotherapy remains largely unknown. The aims of this study were to (a) understand stakeholder perspectives of lung cancer immunotherapy treatment and (b) co‐design a rehabilitation programme for people with lung cancer during and following immunotherapy. Methods: Experience‐based co‐design, involving three distinct online phases: (1) patient, carer and healthcare professional interviews to understand immunotherapy and rehabilitation experiences; (2) separate workshops for healthcare professionals and patients/carers, to identify priority areas for future rehabilitation programme design; and (3) combined workshops to refine the draft programme. Transcripts were analysed by two researchers, guided by the Consolidated Framework for Implementation Research. Results: Seventeen stakeholders were involved in the interviews and/or workshops: seven patients, one carer and nine exercise healthcare professionals. Key themes included: immunotherapy side effects varied but were generally more tolerable than chemotherapy; rehabilitation information was lacking, and access varied; healthcare professional training in immunotherapy was limited. Rehabilitation enablers included supervision and monitoring from healthcare professionals with expertise in cancer; routine rehabilitation discussion with oncologists and nurses; dedicated funding. Lack of education about symptom control when exercising was a barrier for patients. Essential rehabilitation elements included individualised programmes, group‐based, flexibility for centre‐ or home‐based programmes. Programme components included education, aerobic and strength exercise and screening for nutrition and psychology needs. Conclusions: This research has furthered understanding of the lung cancer immunotherapy treatment journey and identified key design requirements of a rehabilitation programme. Patient or Public Contribution: Two patient advocates contributed to this study as members of the project steering committee. Their contributions for this study included reviewing and providing feedback on the proposed study design and the interview and workshop topic and question guides. Patient, carer and healthcare professionals co‐designed the rehabilitation programme through individual interviews and a series of small‐group workshops.

Purpose We conducted a multi-site randomised controlled trial (RCT) of home-based exercise and self-management for patients after lung cancer surgery, which improved the intervention group’s exercise capacity and self-efficacy and objectively measured physical function. We conducted this qualitative evaluation of the RCT to explore participants’ experiences of the program and understand factors influencing participation, behaviour change, and acceptability. Methods A qualitative study nested within an RCT (ACTRN12617001283369), informed by the Theoretical Domains Framework (TDF) and Theoretical Framework of Acceptability (TFA). The intervention group participated in a 12-week postoperative remotely delivered exercise and self-management program. Following intervention maturation, consecutive intervention participants participated in individual, semi-structured telephone interviews at program discharge. Interviews were audio recorded, transcribed verbatim, cross-checked, and analysed using directed content analysis. Results Twenty-one participants took part in interviews (88% of those approached). Thirty-three themes were developed from the qualitative data and mapped to TDF and TFA domains. Key TDF domains driving behaviour change included reinforcement, skills, and social influences. Examples of exercise enablers included regular physiotherapy phone consultations and activity tracking tools. Barriers to exercise included symptoms, poor weather, and competing priorities. Perceived effectiveness was a key TFA domain driving intervention acceptability. Most participants felt the program improved their physical health, exercise self-efficacy and capacity, and physical activity levels. Minor areas for improving acceptability included increased flexibility/tailoring and exercise supervision/demonstration. Conclusion The program was acceptable to participants and facilitated meaningful behaviour change. Qualitative findings aligned with quantitative RCT findings, particularly regarding improvements to exercise self-efficacy and capacity at program discharge. Trial registration Australian New Zealand Clinical Trials Registry (http://anzctr.org.au). Registered on 06/09/2017. Identifier: ACTRN12617001283369.

Intensive care unit acquired weakness (ICUAW) is common in critically ill patients, contributing to substantial morbidity. Major trials and novel mechanistic findings published over the past years have advanced knowledge for the prevention and treatment of ICUAW. To streamline future research priorities, a multinational, interdisciplinary group of ICU clinicians, researchers, and people with lived experience convened to develop this evidence-based research agenda. Using a stepwise process including a systematic review with meta-analysis, two expert panel meetings, and a two-round modified Delphi method, we identified the top ten research priorities for ICUAW. Our report highlights the lack of reliable prognostic markers and mechanistic understanding that limit early diagnosis and treatment. Current evidence to treat ICUAW supports enhanced physical rehabilitation versus no rehabilitation, while higher dose enterally-delivered protein alone does not improve patient outcomes. However, the direct effects on muscles or appropriate dosing for patients with comorbidities remain largely unknown. The proposed ten key priority research questions integrate pathophysiology, diagnostics, treatment, and follow-up and emphasise personalised medicine and patient-centred outcomes over the continuum of recovery. Future research should focus on early prognostic markers, mechanisms of ICUAW, and identification of treatment responders allowing individualised dosing strategies tailored across the recovery trajectory. Defining meaningful outcomes, improving follow-up care, and integrating patient, family and caregiver priorities are essential. Advancing this agenda will require interdisciplinary collaboration and the use of emerging methods, including artificial intelligence, to support personalised and effective ICUAW care.

Rationale: Post–intensive care syndrome is a significant challenge for survivors of critical illness. However, little is understood about fear of falls and the concern for falls. Objective: This study sought to quantify the prevalence of fear of falls within the first year after hospital discharge and identify factors associated with high fear of falls. Methods: Using a mixed-methods approach, fear of falls was assessed using the Falls Efficacy Scale International short-form questionnaire with participants dichotomized into low/moderate (7-12) and high (13-28) fear of falls. Persistence was defined as high fear of falls across at least 2 assessment time points. Data were also collected on physical parameters, frailty, cognition, mood, quality of life, and physical activity levels. Participants were assessed at hospital discharge and at 3, 6, and 12 months postdischarge. Results: A high fear of falls was reported in 66 participants in the first 12 months with 41% reporting persistent high fear. High fear primarily commenced at hospital discharge (79%). Hospital discharge factors associated with reduced odds of experiencing high fear of falls in the first 12 months were higher cognition, strength, physical function, balance, and health-related quality of life. Increased odds of experiencing high fear were shown with older age, comorbidities, ICU delirium, frailty, delayed quadriceps time to peak force, and mental health impairments. The final multivariate model found that intensive care unit (ICU) survivors who had ICU delirium were more likely to have high fear of falls (odds ratio [OR], 4.67 [95% CI, 1.18-18.48]) whereas those with better balance were less likely to have high fear (OR, 0.83 [95% CI, 0.74-0.94]). High fear of falls was not predictive of physical activity or function at 6 months; however, it was a significant predictor of depression. Qualitative data highlighted participant concern for further incapacitation through injury and loss of independence. Perceived causes were reduced strength, balance, and fatigue. Participants described strategies they adopted to reduce their risk of falling, including environmental scanning, gait aid use, and slow, deliberate movement. Conclusions: Fear of falls is a significant and persistent challenge for ICU survivors. Modifiable discharge factors exist such as strength, physical function/balance, ICU-related delirium, and mood, which could be the target of future posthospital interventions. Clinical Trials Registration: NCT03141762

The aim of this review was to develop a methodological framework that could be applied during the design and conduct of cross-cultural qualitative research with people from culturally and linguistically diverse backgrounds in health contexts or settings. Developing the methodological framework in this study consisted of three phases. In Phase 1, a literature review was undertaken to identify relevant evidence by searching bibliographic databases, online sources and relevant journals. In Phase 2, methodological and ethical concepts, issues and considerations were summarized, synthesized and consolidated into a framework. In Phase 3, the methodological framework was refined by applying it to a cross-cultural qualitative study. The resulting methodological framework proposes two stages (preparation and action) and eleven key steps for designing, conducting and reporting cross-cultural qualitative research. Other practical resources (i.e. glossary of terms and detailed prompt tool) for health researchers that can be used with the framework are also presented. This article presents a methodological framework that can guide high-quality cross-cultural qualitative research and is intended for use by health researchers, especially those new to cross-cultural qualitative research. It has the potential to improve the inclusivity and cultural responsiveness of qualitative research.

Purpose: This review sought to synthesise the existing qualitative literature to answer the question: “What are the experiences of people with lung cancer, caregivers, and/or providers regarding participation in or delivery of exercise programs?”. Methods: A qualitative evidence synthesis. Published literature from databases EMBASE (Ovid), MEDLINE (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), Cochrane Library, Scopus, PEDro, and Web of Science and grey literature using thesis repositories and Google Scholar were searched on 18th February 2022 and updated on 8th October 2024. Included studies’ methodological limitations were evaluated using the Critical Appraisal Skills Programme (CASP) checklist by two independent researchers. First- and second-order qualitative data were extracted, cross-checked, and combined in thematic synthesis by one researcher, with another coding 10%, and they collaborated to determine the final themes, subthemes, and findings. Two independent researchers assessed the confidence in the findings using the GRADE-CERqual approach. Results: Twenty-four studies were included comprising 23 unique exercise programs (10 supervised centre-based and 13 unsupervised, home-based programs.). All studies included patients’/participants’ perspectives; six included clinicians, and two included caregivers. Forty-one findings were organised under four broad themes: 1) components of exercise program design, 2) providers of exercise programs, 3) the value of exercise programs, and 4) facilitating behaviour change. Overall, key stakeholders viewed exercise programs as effective and acceptable and valued individualised and tailored programs. Most findings were of moderate-to-high confidence. Conclusion: Based on the experiences of key stakeholders, 15 specific recommendations were generated that may improve the acceptability and effectiveness of lung cancer exercise programs.

Introduction: Significant heterogeneity exists in the outcomes and instruments used in clinical practice to evaluate lung cancer rehabilitation. This study aimed to develop a lung cancer rehabilitation clinical core outcome set and establish consensus on accompanying outcome measurement instruments. Methods: An international modified Delphi consensus study was carried out following recommended guidelines, involving patients and carers, healthcare professionals and researchers. Two survey rounds, in each study phase, rated the importance of a range of outcomes to include in the core outcome set (Phase One) and measurement instruments for each core outcome (Phase Two). Online consensus meetings ratified survey findings through discussion and voting. Results: Phase One: 27 outcomes were included in round one (113 participants), with an additional two outcomes in round two (95 participants, 84% retention). Outcomes reaching consensus as “critical to include” were breathlessness, activities of daily living, physical function, health-related quality of life (HRQoL), emotional and mental wellbeing, and pain. Phase Two: 21 instruments were included (round one, 64 participants), with eight added in round two (60 participants (one patient), 94% retention). The 6-min walk test and European Organisation for Research and Treatment of Cancer core questionnaire reached consensus to measure physical function and HRQoL, respectively. No further consensus was achieved on instruments following online consensus meetings (10 participants). Conclusion: Consensus was achieved regarding six core outcomes to be used to standardise the evaluation of lung cancer rehabilitation in clinical practice. Measurement instruments were agreed upon for use when evaluating physical function and HRQoL.