Engagement in a statewide oral oncolytic collaborative and practice impact

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Background: The rapid shift to oral oncolytic therapy presents challenges to oncology practitioners. The purpose of this study is to describe how participation in a statewide oral oncolytic improvement collaborative where best practices and resources were shared can readily impact quality of care as measured by national standards. Methods: The Michigan Oncology Quality Consortium (MOQC) hosted a series of learning collaborative sessions focused on topics and deployment of resources specific to oral oncolytic management and quality improvement. Participating practices performed pre/post self-assessments in Oct. 2013 and Apr. 2015 (n = 3). Concordance with national ASCO QOPI and ONS standards was compared, including documentation (5 measures), patient education (7 measures), and follow-up/monitoring (4 measures). A response scale of always, sometimes, and never was used. Specifically, practices were surveyed to assess which evidence-based MOQC resources were implemented: patient intake template, drug-specific self-management guides, start date mailer, medication calendar, primary care physician communication template, Edmonton Symptom Assessment Scale (ESAS), and patient adherence questionnaires. Results: Practice A showed improvement in documentation, patient education, and monitoring. This practice used the initial oral chemotherapy template, ESAS, patient education templates, and patient calendar (Table). Practice B implemented 6 resources and demonstrated improvements in 15 metrics. Practice C implemented 4 resources, namely patient-focused resources, to improve all patient education and monitoring metrics. Conclusions: Use of the collaborative model and supplying oncology teams with scientific evidence, standard workflows, and resources improves concordance with national standards of care. Large-scale deployment of this model program may provide a clinically efficient and effective mechanism to enhance widespread change. [Table: see text]

Changes in initial COPD treatment choice over time and factors influencing prescribing decisions in UK primary care: in UK primary care: a real-world, retrospective, observational

Prescribing patterns in chronic obstructive pulmonary disease (COPD) are often inconsistent with published guidelines. This retrospective, observational study utilised data from the Optimum Patient Care Research Database to examine the changes in COPD prescribing patterns over time and to identify predictors of physician treatment choice for patients newly diagnosed with COPD. Initial therapy was defined as the treatment(s) prescribed at or within 1 year before COPD diagnosis. Changes over time were assessed in three cohorts based on the date of diagnosis: (1) 1997-2001; (2) 2002-2006; and (3) 2007-2010. Factors affecting the odds of being prescribed any initial therapy or any initial maintenance therapy were identified by univariable and multivariable logistic regression. The analysis included 20,154 patients, 45% of whom were prescribed an initial regimen containing an inhaled corticosteroid (ICS), whereas 28% received no initial pharmacological treatment. Prescribing of ICS monotherapy decreased over time, as did the proportion of patients receiving no therapy at or within 1 year before diagnosis. Comorbid asthma, a high exacerbation rate, increased symptoms and poor lung function each increased the likelihood of being prescribed any initial therapy or initial maintenance therapy; comorbid asthma and an annual rate of ⩾3 exacerbations were the strongest predictors. In conclusion, our analyses revealed major differences between actual prescribing behaviour and guideline recommendations for patients with newly diagnosed COPD, with many patients receiving no treatment and large numbers of patients receiving ICS-containing regimens. Predictors of initial therapy were identified.

Approaching the Heisenberg Limit without Single-Particle Detection

We propose an approach to quantum phase estimation that can attain precision near the Heisenberg limit without requiring single-particle-resolved state detection. We show that the "one-axis twisting" interaction, well known for generating spin squeezing in atomic ensembles, can also amplify the output signal of an entanglement-enhanced interferometer to facilitate readout. Applying this interaction-based readout to oversqueezed, non-Gaussian states yields a Heisenberg scaling in phase sensitivity, which persists in the presence of detection noise as large as the quantum projection noise of an unentangled ensemble. Even in dissipative implementations-e.g., employing light-mediated interactions in an optical cavity or Rydberg dressing-the method significantly relaxes the detection resolution required for spectroscopy beyond the standard quantum limit.

Accumulation of plutonium in mammalian wildlife tissues following dispersal by accidental-release tests

We examined the distribution of plutonium (Pu) in the tissues of mammalian wildlife inhabiting the relatively undisturbed, semi-arid former Taranaki weapons test site, Maralinga, Australia. The accumulation of absorbed Pu was highest in the skeleton (83% ± 6%), followed by muscle (10% ± 9%), liver (6% ± 6%), kidneys (0.6% ± 0.4%), and blood (0.2%). Pu activity concentrations in lung tissues were elevated relative to the body average. Foetal transfer was higher in the wildlife data than in previous laboratory studies. The amount of Pu in the gastrointestinal tract was highly elevated relative to that absorbed within the body, potentially increasing transfer of Pu to wildlife and human consumers that may ingest gastrointestinal tract organs. The Pu distribution in the Maralinga mammalian wildlife generally aligns with previous studies related to environmental exposure (e.g. Pu in humans from worldwide fallout), but contrasts with the partitioning models that have traditionally been used for human worker-protection purposes (approximately equal deposition in bone and liver) which appear to under-predict the skeletal accumulation in environmental exposure conditions.

Electrophysiologic Study of a Method of Euthanasia Using Intrathecal Lidocaine Hydrochloride Administered during Intravenous Anesthesia in Horses

Background

An intravenous (IV) overdose of pentobarbital sodium is the most commonly used method of euthanasia in veterinary medicine. However, this compound is not available in many countries or rural areas resulting in usage of alternative methods such as intrathecal lidocaine administration after IV anesthesia. Its safety and efficacy as a method of euthanasia have not been investigated in the horse.

Hypothesis/Objectives

To investigate changes in mean arterial blood pressure and electrical activity of the cerebral cortex, brainstem, and heart during intrathecal administration of lidocaine. Our hypothesis was that intrathecal lidocaine affects the cerebral cortex and brainstem before affecting cardiovascular function.

Animals

Eleven horses requiring euthanasia for medical reasons.

Methods

Prospective observational study. Horses were anesthetized with xylazine, midazolam, and ketamine; and instrumented for recording of electroencephalogram (EEG), electrooculogram (EOG), brainstem auditory evoked response (BAER), and electrocardiogram (ECG). Physical and neurological (brainstem reflexes) variables were monitored. Mean arterial blood pressure was recorded throughout the study.

Results

Loss of cerebro‐cortical electrical activity occurred up to 226 seconds after the end of the infusion of lidocaine solution. Cessation of brainstem function as evidenced by a lack of brainstem reflexes and disappearance of BAER occurred subsequently. Undetectable heart sounds, nonpalpable arterial pulse, and extremely low mean arterial blood pressure supported cardiac death; a recordable ECG was the last variable to disappear after the infusion (300–1,279 seconds).

Conclusions and Clinical Importance

Intrathecal administration of lidocaine is an effective alternative method of euthanasia in anesthetized horses, during which brain death occurs before cardiac death.

The Use of Recombinant Tissue Plasminogen Activator (rTPA) in The Treatment of Fibrinous Pleuropneumonia in Horses: 25 Cases (2007-2012)

Background

Information about treatment protocols, adverse effects and outcomes with intrapleural recombinant tissue plasminogen activator (rTPA) use in horses with fibrinous pleuropneumonia is limited.

Hypothesis/Objectives

Describe factors that contribute to clinical response and survival of horses treated with rTPA intrapleurally.

Animals

Horses with bacterial pneumonia and fibrinous pleural effusion diagnosed by ultrasonography, that were treated with rTPA intrapleurally.

Methods

Retrospective multicenter case series from 2007–2012. Signalment, history, clinical and laboratory evaluation, treatment, and outcome obtained from medical records. Regression analysis used to identify associations between treatments and outcomes.

Results

Thirty three hemithoraces were treated in 25 horses, with 55 separate treatments. Recombinant tissue plasminogen activator (375–20,000 μg/hemithorax) was administered 1–4 times. Sonographically visible reduction in fibrin mat thickness, loculations, fluid depth, or some combination of these was seen in 32/49 (65%) treatments. Response to at least 1 treatment was seen in 17/20 (85%) horses with sonographic follow‐up evaluation after every treatment. Earlier onset of rTPA treatment associated with increased survival odds. No association was found between cumulative rTPA dose or number of rTPA doses and survival, development of complications, duration of hospitalization or total charges. Clinical evidence of hypocoagulability or bleeding was not observed. Eighteen horses (72%) survived to discharge.

Conclusions and clinical importance

Treatment with rTPA appeared safe and resulted in variable changes in fibrin quantity and organization within the pleural space. Recombinant tissue plasminogen activator could be a useful adjunct to standard treatment of fibrinous pleuropneumonia, but optimal case selection and dosing regimen remain to be elucidated.

Continuously tunable modulation scheme for precision control of optical cavities with variable detuning

We present a scheme for locking optical cavities with arbitrary detuning by many linewidths from resonance using an electro-optic modulator that can provide arbitrary ratios of amplitude-to-phase modulation. We demonstrate our scheme on a Fabry-Perot cavity, and show that a well-behaved linear error signal can be obtained by demodulating the reflected light from a cavity that is detuned by several linewidths.

"Boring" family routines reduce non-communicable diseases: a commentary and call for action

As global donors shift their efforts from infectious diseases to non-communicable diseases (NCD), it is critical to capitalize on our prior mistakes and successes. Policy makers and public health administrators are often looking for magic bullets: drugs or treatments to eradicate disease. Yet, each potential magic bullet requires consistent, daily implementation and adherence to a new set of habits to actually work. Families’ and communities’ daily, interlocking routines will be the battlefield on which scientific and technological breakthroughs will be implemented and succeed or not.

Currently, there are many evidence-based interventions (EBI) which have been demonstrated to shift specific habits which account for most NCD (eating, drinking, moving, and smoking). Yet, securing sustained uptake of these programs is rare – suggesting different intervention strategies are needed. Structural changes, policy nudges, and partnerships with private enterprise may be able to shift the health behaviors of more citizens faster and at a lower cost than existing EBI. Addressing concurrent risk and protective factors at the community level and intervening to shape new cultural routines may be useful to reduce NCD.

Indigenous cancer patient and staff attitudes towards unmet needs screening using the SCNAT-IP

INTRODUCTION

Indigenous Australians have a higher cancer incidence, worse mortality and are less likely to receive optimal cancer treatment compared with non-Indigenous Australians. Culturally appropriate supportive care helps ensure that Indigenous patients engage in and receive optimal care. However, many existing supportive care needs tools lack cultural relevance for Indigenous people, and their feasibility with Indigenous people has not been demonstrated. The Supportive Care Needs Assessment Tool for Indigenous People (SCNAT-IP) assesses the unmet supportive care needs of Indigenous cancer patients.

PURPOSE

This descriptive study evaluates the clinical implementation of the SCNAT-IP in routine care.

METHODS

Two large tertiary cancer treatment centres and two regional oncology clinics participated. Participants included 10 clinical staff and 36 adult Indigenous cancer patients (mean age 54 years). Patients and clinicians completed brief, purpose-designed questionnaires and interviews.

RESULTS

Patients reported high ratings (means >8/10) for acceptability, helpfulness and timing items. The majority (≥80%) of staff agreed that the SCNAT-IP was useful to clinical practice, should be used in routine care and was acceptable to their patients.

CONCLUSIONS

The study provides empirical support for the feasibility and acceptability of the SCNAT-IP in routine cancer care with Indigenous Australians. Routine screening with the SCNAT-IP has the potential to improve cancer care for Indigenous people with cancer.

The Role of Community Health Workers in the Re-Engineering of Primary Health Care in Rural Eastern Cape

BACKGROUND

Primary Health Care in South Africa is being re-engineered to create a model of integrated care across different levels of the health care system. From hospitals to clinics, in the community and in the home, health care will focus more on prevention, health-promotion and advocacy for healthy lifestyles and wellbeing, in addition to clinical services. We provide a best practise model of integrating community health workers (CHWs) trained as generalists into a multi-level health system in the Oliver Tambo district of the rural Eastern Cape.

METHODS

Based at Zithulele Hospital, a health care network between the hospital, 13 clinics, and 50 CHWs has been created. The functions of each tier of care are different and complementary. This article describes the recruitment, training, supervision, monitoring, and outcomes when CHWs who deliver maternal, child health, nutrition and general care through home visits.

RESULTS

CHWs, especially in rural settings, can find and refer new TB/HIV cases, ill children and at-risk pregnant women; rehabilitate malnourished children at home; support TB and HIV treatment adherence; treat diarrhoea, worm infestation and skin problems; and, distribute Vitamin A. CHWs provide follow-up after clinic and hospital care, support families to apply health information, problem-solve the health and social challenges of daily living, and assist in accessing social grants. Case examples of how this model functions are provided.

CONCLUSION

This generalist CHW home intervention is a potential model for the re-engineering of the primary health care system in South Africa.

The structure of alanine racemase from Acinetobacter baumannii

Acinetobacter baumannii is an opportunistic Gram-negative bacterium which is a common cause of hospital-acquired infections. Numerous antibiotic-resistant strains exist, emphasizing the need for the development of new antimicrobials. Alanine racemase (Alr) is a pyridoxal 5'-phosphate dependent enzyme that is responsible for racemization between enantiomers of alanine. As D-alanine is an essential component of the bacterial cell wall, its inhibition is lethal to prokaryotes, making it an excellent antibiotic drug target. The crystal structure of A. baumannii alanine racemase (AlrAba) from the highly antibiotic-resistant NCTC13302 strain has been solved to 1.9 Å resolution. Comparison of AlrAba with alanine racemases from closely related bacteria demonstrates a conserved overall fold. The substrate entryway and active site of the enzymes were shown to be highly conserved. The structure of AlrAba will provide the template required for future structure-based drug-design studies.

Psychologists' views of inter-disciplinary psychosocial communication within the cancer care team

BACKGROUND

Little is known about how psychologists working in cancer care centres communicate clinical information to other members of the multidisciplinary team or what information is communicated.

PURPOSE

This study surveyed Australian cancer care psychologists regarding their communication practices and their views on barriers to and facilitators of effective inter-disciplinary communication.

METHODS

Psychologists were invited to complete an online survey containing purpose-designed items that addressed study aims.

RESULTS

Forty-four psychologists completed the survey. Psychologists' most common method of recording initial consultations was in patient medical records, with 69 % of respondents recording notes in either most of the time or all of the time. Twenty-two percent of psychologists said they did not regularly feedback the results of an initial assessment to a referrer and more than 40 % used verbal and e-mail communication to do so.

CONCLUSIONS

This study provides data that will assist in the development of guidelines for inter-professional communication between psychologists and other members of the cancer care team.

Saccharin derivatives as inhibitors of interferon-mediated inflammation

A series of novel, saccharin-based antagonists have been identified for the interferon signaling pathway. Through in vitro high-throughput screening with the Colorado Center for Drug Discovery (C2D2) Pilot Library, we identified hit compound 1, which was the basis for extensive structure–activity relationship studies. Our efforts produced a lead anti-inflammatory compound, tert-butyl N-(furan-2-ylmethyl)-N-{4-[(1,1,3-trioxo-2,3-dihydro-1λ⁶,2-benzothiazol-2-yl)methyl]benzoyl}carbamate CU-CPD103 (103), as a potent inhibitor using an established nitric oxide (NO) signaling assay. With further studies of its inhibitory mechanisms, we demonstrated that 103 carries out this inhibition through the JAK/STAT1 pathway, providing a drug-like small molecule inflammation suppressant for possible therapeutic uses.

Plutonium in wildlife and soils at the Maralinga legacy site: persistence over decadal time scales

The mobility of plutonium (Pu) in soils, and its uptake into a range of wildlife, were examined using recent and ∼25 year old data from the Taranaki area of the former Maralinga weapons test site, Australia. Since its initial deposition in the early 1960s, the dispersed Pu has been incorporated into the soil profile and food chain through natural processes, allowing for the study of Pu sequestration and dynamics in relatively undisturbed semi-arid conditions. The data indicate downward mobility of Pu in soil at rates of ∼0.2-0.3 cm per year for the most mobile fraction. As a result, while all of the Pu was initially deposited on the ground surface, approximately 93% and 62% remained in the top 0-2 cm depth after 25- and 50-years respectively. No large-scale lateral spreading of the Taranaki plume was observed. Pu activity concentrations in 0-1 cm soils with biotic crusts were not elevated when compared with nearby bare soils, although a small number of individual data suggest retention of Pu-containing particles may be occurring in some biotic crusts. Soil-to-animal transfer, as measured by concentration ratios (CRwo-soil), was 4.1E-04 (Geometric Mean (GM)) in mammals, which aligns well with those from similar species and conditions (such as the Nevada Test Site, US), but are lower than the GM of the international mammal data reported in the Wildlife Transfer Database (WTD). These lower values are likely due to the presence of a low-soluble, particulate form of the Pu in Maralinga soils. Arthropod concentration ratios (3.1E-03 GM), were similar to those from Rocky Flats, US, while values for reptiles (2.0E-02 GM) were higher than the WTD GM value which was dominated by data from Chernobyl. Comparison of uptake data spanning approximately 30 years indicates no decrease over time for mammals, and a potential increase for reptiles. The results confirm the persistence of bioavailable Pu after more than 50 years since deposition, and also the presence of larger-sized particles which currently affect CRwo-soil calculations, and which may serve as an ongoing source of bioavailable Pu as they are subjected to weathering into the future.

Observation of edge instability limiting the pedestal growth in tokamak plasmas

With fusion device performance hinging on the edge pedestal pressure, it is imperative to experimentally understand the physical mechanism dictating the pedestal characteristics and to validate and improve pedestal predictive models. This Letter reports direct evidence of density and magnetic fluctuations showing the stiff onset of an edge instability leading to the saturation of the pedestal on the Alcator C-Mod tokamak. Edge stability analyses indicate that the pedestal is unstable to both ballooning mode and kinetic ballooning mode in agreement with observations.