Implanted intrathecal drug delivery systems may be associated with improved survival in patients with cancer.

Background: Intrathecal Drug Delivery Systems (IDDS) are underused in the management of cancer-related pain despite evidence of both efficacy and survival benefit. There is currently limited evidence to indicate which patients might benefit most from IDDS. Aim: The aim of the study was to describe the baseline characteristics and survival outcomes of patients who accepted IDDS, patients who declined IDDS and patients who wished to go ahead with IDDS but whose condition deteriorated before they could do so. Design/participants: The survival data for 75 consecutive patients who had been offered intrathecal drug delivery were examined as part of a retrospective cohort study. Survival data was compared between three groups: those who accepted intrathecal drug delivery and went on to receive it (n = 41), those who accepted it but whose condition deteriorated before it commenced (n = 17) and those who declined this treatment modality (n = 17). Results: Patients who received IDDS survived significantly longer after assessment compared to those who declined IDDS (hazard ratio (HR) for the IDDS group relative to the declined group 0.29 (95% CI 0.16 to 0.53), and 0.23 (95% CI 0.12 to 0.44) after adjustment for gender and baseline functional status. In patients who accepted IDDS but who were unable to commence treatment, survival after assessment was not significantly different from those who declined the IDDS (HR for the deteriorated group relative to the declined group 1.28 (95% CI 0.65 to 2.53), and 0.80 (95% CI 0.65 to 2.53) after adjustment for gender and baseline functional status). Conclusion: In this retrospective analysis, an improvement in survival may be associated with patients who accept ongoing pain management with an implanted intrathecal drug delivery system compared to those patients who either declined intrathecal drug delivery or deteriorated before it could be commenced.

More time in a community setting: A service evaluation of the impact of intrathecal drug delivery systems on place of care of patients with cancer pain.

BACKGROUND: Intrathecal Drug Delivery Systems are underutilised in the management of refractory cancer pain despite evidence of their efficacy. Not all patients who are offered this treatment modality accept it. There is no current evidence that indicates if the use of intrathecal drug delivery systems impacts on place of care for patients with cancer related pain. AIMS: This service evaluation compared place of care, place of death and morphine equivalent daily dose at end of life for patients in whom Intrathecal Drug Delivery was successfully established versus those who chose comprehensive medical management. SETTING/PARTICIPANTS: A retrospective longitudinal cohort study of 45 patients with cancer pain comparing those who had ongoing analgesia successfully delivered via an implanted Intrathecal Drug Delivery System (n = 28) with those who continued to receive comprehensive medical management (n = 17). RESULTS: There was a markedly greater time spent in the community in the intrathecal group than the medical management group (median 126.5vs 25.5 days; p = 0.002) and a lower morphine equivalent daily dose at end of life (median 127.5vs 440.0 p = 0.022). CONCLUSION: In patients with advanced cancer, the successful establishment of intrathecal analgesia is associated with more time in the community and a lower morphine equivalent daily dose at end of life. The study has low numbers, and the sample was retrospectively selected. Nevertheless, these findings suggest the initial investment of time in an inpatient setting may be beneficial. Further research is required, using larger, prospective studies of patient outcomes in this setting.

Improving Delivery of Secondary Prophylaxis for Rheumatic Heart Disease in a High-Burden Setting: Outcome of a Stepped-Wedge, Community, Randomized Trial.

BACKGROUND: Health system strengthening is needed to improve delivery of secondary prophylaxis against rheumatic heart disease. METHODS AND RESULTS: We undertook a stepped-wedge, randomized trial in northern Australia. Five pairs of Indigenous community clinics entered the study at 3-month steps. Study phases comprised a 12 month baseline phase, 3 month transition phase, 12 month intensive phase and a 3- to 12-month maintenance phase. Clinics received a multicomponent intervention supporting activities to improve penicillin delivery, aligned with the chronic care model, with continuous quality-improvement feedback on adherence. The primary outcome was the proportion receiving ≥80% of scheduled penicillin injections. Secondary outcomes included "days at risk" of acute rheumatic fever recurrence related to late penicillin and acute rheumatic fever recurrence rates. Overall, 304 patients requiring prophylaxis were eligible. The proportion receiving ≥80% of scheduled injections during baseline was 141 of 304 (46%)-higher than anticipated. No effect attributable to the study was evident: in the intensive phase, 126 of 304 (41%) received ≥80% of scheduled injections (odds ratio compared with baseline: 0.78; 95% confidence interval, 0.54-1.11). There was modest improvement in the maintenance phase among high-adhering patients (43% received ≥90% of injections versus 30% [baseline] and 28% [intensive], P<0.001). Also, the proportion of days at risk in the whole cohort decreased in the maintenance phase (0.28 versus 0.32 [baseline] and 0.34 [intensive], P=0.001). Acute rheumatic fever recurrence rates did not differ between study sites during the intensive phase and the whole jurisdiction (3.0 versus 3.5 recurrences per 100 patient-years, P=0.65). CONCLUSIONS: This strategy did not improve adherence to rheumatic heart disease secondary prophylaxis within the study time frame. Longer term primary care strengthening strategies are needed. CLINICAL TRIAL REGISTRATION: URL: www.anzctr.org.au. Unique identifier: ACTRN12613000223730.

Qualitative Evaluation of a Complex Intervention to Improve Rheumatic Heart Disease Secondary Prophylaxis.

BACKGROUND: Rheumatic heart disease is a high-burden condition in Australian Aboriginal communities. We evaluated a stepped-wedge, community, randomized trial at 10 Aboriginal communities from 2013 to 2015. A multifaceted intervention was implemented using quality improvement and chronic care model approaches to improve delivery of penicillin prophylaxis for rheumatic heart disease. The trial did not improve penicillin adherence. This mixed-methods evaluation, designed a priori, aimed to determine the association between methodological approaches and outcomes. METHODS AND RESULTS: An evaluation framework was developed to measure the success of project implementation and of the underlying program theory. The program theory posited that penicillin delivery would be improved through activities implemented at clinics that addressed elements of the chronic care model. Qualitative data were derived from interviews with health-center staff, informants, and clients; participant observation; and project officer reports. Quantitative data comprised numbers and types of "action items," which were developed by participating clinic staff with project officers to improve delivery of penicillin injections. Interview data from 121 health-center staff, 22 informants, and 72 clients revealed barriers to achieving the trial's aims, including project-level factors (short trial duration), implementation factors (types of activities implemented), and contextual factors (high staff turnover and the complex sociocultural environment). Insufficient actions were implemented addressing "self-management support" and "community linkage" streams of the chronic care model. Increased momentum was evident in later stages of the study. CONCLUSIONS: The program theory underpinning the study was sound. The limited impact made by the study on adherence was attributable to complex implementation challenges.

Exploring the Dimensionality of Morphological Knowledge for Adolescent Readers.

This study examined the dimensionality of morphological knowledge. The performance of 371 seventh- and eighth-graders on seven morphological knowledge tasks was investigated using confirmatory factor analysis. Results suggested that morphological knowledge was best fit by a bifactor model with a general factor of morphological knowledge and seven specific factors, representing tasks that tap different facets of morphological knowledge. Next, structural equation modelling was used to explore links to literacy outcomes. Results indicated the general factor and the specific factor of morphological meaning processing showed significant positive associations with reading comprehension and vocabulary. Also, the specific factor of generating morphologically related words showed significant positive associations with vocabulary, while specific factors of morphological word reading and spelling processing showed small negative relationships to reading comprehension and vocabulary. Findings highlight the complexity of morphological knowledge and suggest the importance of being cognizant of the nature of morphology when designing and interpreting studies.

Examining General and Specific Factors in the Dimensionality of Oral Language and Reading in 4th-10th Grades.

The objective of this study was to explore dimensions of oral language and reading and their influence on reading comprehension in a relatively understudied population-adolescent readers in 4th through 10th grades. The current study employed latent variable modeling of decoding fluency, vocabulary, syntax, and reading comprehension so as to represent these constructs with minimal error and to examine whether residual variance unaccounted for by oral language can be captured by specific factors of syntax and vocabulary. A 1-, 3-, 4-, and bifactor model were tested with 1,792 students in 18 schools in 2 large urban districts in the Southeast. Students were individually administered measures of expressive and receptive vocabulary, syntax, and decoding fluency in mid-year. At the end of the year students took the state reading test as well as a group-administered, norm-referenced test of reading comprehension. The bifactor model fit the data best in all 7 grades and explained 72% to 99% of the variance in reading comprehension. The specific factors of syntax and vocabulary explained significant unique variance in reading comprehension in 1 grade each. The decoding fluency factor was significantly correlated with the reading comprehension and oral language factors in all grades, but, in the presence of the oral language factor, was not significantly associated with the reading comprehension factor. Results support a bifactor model of lexical knowledge rather than the 3-factor model of the Simple View of Reading, with the vast amount of variance in reading comprehension explained by a general oral language factor.

Audit of intrathecal drug delivery for patients with difficult-to-control cancer pain shows a sustained reduction in pain severity scores over a 6-month period.

BACKGROUND: Intrathecal drug delivery is known to be effective in alleviating cancer pain in patients for whom the conventional World Health Organization approach has proved insufficient. A multidisciplinary interventional cancer pain service was established in the West of Scotland in 2008 with the aim of providing a safe and effective intrathecal drug delivery service for patients with difficult-to-control cancer pain. AIM: The aim of the intrathecal drug delivery service is to improve pain scores as evaluated by pain scores before and after insertion of an intrathecal drug delivery device. DESIGN: Pain is monitored before and after intrathecal drug delivery implantation using the Brief Pain Inventory. Following implantation, pumps are refilled fortnightly and repeat Brief Pain Inventory assessments are undertaken. This prospective case series analyses change in Brief Pain Inventory domains for patients who had an intrathecal drug delivery implanted using a paired sample t-test. RESULTS: Data are presented from 2008-2013 for 22 patients receiving an intrathecal drug delivery system who experienced an immediate improvement in their pain that was both clinically and statistically significant. One week after insertion, the average pain score on the Brief Pain Inventory fell from 6.8 (pre-intrathecal drug delivery) to 3.0 (post-intrathecal drug delivery). Improvement in pain scores was sustained over a 6-month period. CONCLUSION: Evaluation of results of this case series shows that with the appropriate use of intrathecal drug delivery systems, patients with difficult-to-control cancer pain can benefit from effective pain relief for many months.

The Structure of Oral Language and Reading and Their Relation to Comprehension in Kindergarten through Grade 2.

This study examined the structure of oral language and reading and their relation to comprehension from a latent variable modeling perspective in Kindergarten, Grade 1, and Grade 2. Participants were students in Kindergarten (n = 218), Grade 1 (n = 372), and Grade 2 (n = 273), attending Title 1 schools. Students were administered phonological awareness, syntax, vocabulary, listening comprehension, and decoding fluency measures in mid-year. Outcome measures included a listening comprehension measure in Kindergarten and a reading comprehension test in Grades1 and 2. In Kindergarten, oral language (consisting of listening comprehension, syntax, and vocabulary) shared variance with phonological awareness in predicting a listening comprehension outcome. However, in Grades 1 and 2, phonological awareness was no longer predictive of reading comprehension when decoding fluency and oral language were included in the model. In Grades 1 and 2, oral language and decoding fluency were significant predictors of reading comprehension.

Improving the Reliability of Student Scores from Speeded Assessments: An Illustration of Conditional Item Response Theory Using a Computer-Administered Measure of Vocabulary.

A growing body of literature suggests that response latency, the amount of time it takes an individual to respond to an item, may be an important factor to consider when using assessment data to estimate the ability of an individual. Considering that tests of passage and list fluency are being adapted to a computer administration format, it is possible that accounting for individual differences in response times may be an increasingly feasible option to strengthen the precision of individual scores. The present research evaluated the differential reliability of scores when using classical test theory and item response theory as compared to a conditional item response model which includes response time as an item parameter. Results indicated that the precision of student ability scores increased by an average of 5 % when using the conditional item response model, with greater improvements for those who were average or high ability. Implications for measurement models of speeded assessments are discussed.

The effect of vocabulary knowledge on novel word identification.

The study investigated the relationship between vocabulary knowledge and novel word reading. Fourth-grade students were assessed on standardized measures of word identification, decoding, and receptive vocabulary, as well as on an experimental word identification measure using words that students in the fourth grade are unlikely to have seen before in print. In the experimental measure, pairs of words were matched on printed frequency and orthographic pattern (with a variety of spelling patterns represented), but differed in terms of the frequency of expected oral exposure for children (i.e., higher vs. lower). Results showed that students' receptive vocabulary knowledge was significantly related to performance on both the standardized and experimental measures of word identification, even after accounting for the substantial amount of variance explained by decoding ability. Students performed better reading the words with higher expected oral frequencies on the experimental task than on those items with lower expected oral frequencies. The results point to the benefits, albeit modest, of oral word familiarity for reading words when they are first encountered in print and suggest that this top-down effect is not limited to exception words, as has been suggested, but has a wider scope.

Impact of sulfate pollution on anaerobic biogeochemical cycles in a wetland sediment.

The impact of sulfate pollution is increasingly being seen as an issue in the management of inland aquatic ecosystems. In this study we use sediment slurry experiments to explore the addition of sulfate, with or without added carbon, on the anaerobic biogeochemical cycles in a wetland sediment that previously had not been exposed to high levels of sulfate. Specifically we looked at the cycling of S (sulfate, dissolved and particulate sulfide--the latter measured as acid volatile sulfide; AVS), C (carbon dioxide, bicarbonate, methane and the short chain volatile fatty acids formate, acetate, butyrate and propionate), N (dinitrogen, ammonium, nitrate and nitrite) and redox active metals (Fe(II) and Mn(II)). Sulfate had the largest effects on the cycling of S and C. All the added S at lower loadings were converted to AVS over the course of the experiment (30 days). At the highest loading (8 mmol) less than 50% of consumed S was converted to AVS, however this is believed to be a kinetic effect. Although sulfate reduction was occurring in sediments with added sulfate, dissolved sulfide concentrations remained low throughout the study. Sulfate addition affected methanogenesis. In the absence of added carbon, addition of sulfate, even at a loading of 1 mmol, resulted in a halving of methane formation. The initial rate of formation of methane was not affected by sulfate if additional carbon was added to the sediment. However, there was evidence for anaerobic methane oxidation in those sediments with added sulfate and carbon, but not in those sediments treated only with carbon. Surprisingly, sulfate addition had little apparent impact on N dynamics; previous studies have shown that sulfide can inhibit denitrification and stimulate dissimilatory nitrate reduction to ammonia. We propose that because most of the reduced sulfur was in particulate form, levels of dissolved sulfide were too low to interfere with the N cycle.

Development of Dual Language Information Cards as a Tool for Communication Between Radiation Therapists and Cantonese-Speaking Patients Undergoing Radiation Treatments for Head-and-Neck Cancer.

The establishment of an effective relationship between patient and provider is dependent upon effective communication. However, this can be difficult to achieve with patients who do not speak English as their first language. Language barriers are associated with adverse effects on quality of care, treatment outcomes, and patient and provider satisfaction. These patients are more likely to experience acute side effects and more likely to use emergency room services for problems that are treatable in primary care settings. Interpreter services and dual language providers are often used to overcome these barriers, but they are often limited by their cost and availability. The radiation therapy environment provides further challenges to overcoming these barriers by virtue of the outpatient setting and high volume of appointments. As part of their efforts to improve patient care, the British Columbia Cancer Agency (BCCA)-Vancouver Centre radiation therapy department introduced dual language cards as a tool to facilitate communication between Cantonese-speaking patients and radiation therapists. This paper outlines the method of devising and evaluating a dual language tool.

The standardization of radiation skin care in British Columbia: a collaborative approach.

PURPOSE/OBJECTIVES: To develop evidence-based practice guidelines for and standardize the care of radiation skin reactions. DATA SOURCES: Peer-reviewed scientific journals and texts and a survey of the guidelines in use at leading cancer treatment facilities in Canada, the United States, the United Kingdom, and Australia. DATA SYNTHESIS: A formal reference document with recommended guidelines was developed. Consensus was obtained from all relevant disciplines, and the guidelines were implemented successfully into practice. CONCLUSIONS: The document introduced a major change in practice from the maintenance of a dry radiation treatment area to the promotion of skin cleanliness and hydration, as well as the adoption of the principles of moist wound healing. Annual review indicated that dissemination of (94%) and compliance with (78%) the guidelines were good. IMPLICATIONS FOR NURSING: The process to develop, obtain consensus for, and implement evidence-based practice guidelines was an exemplary demonstration of teamwork and interdisciplinary collaboration.

A single infusion of intravenous ketamine improves pain relief in patients with critical limb ischaemia: results of a double blind randomised controlled trial.

We report the first double blind randomised controlled trial of regular opioids and an infusion of low dose (0.6 mg/kg) intravenous ketamine compared with opioids and placebo in patients with allodynia, hyperalgesia and hyperpathia secondary to critical limb ischaemia. Thirty-five patients completed the study, 18 received regular opioids plus ketamine, while 17 received regular opioids plus placebo. Using the Brief Pain Inventory, the % pain relief that the patients in the ketamine group attributed to their medication improved significantly from 50% immediately pre-infusion to 65% 24 h post-infusion and 69% 5 days post infusion. Over the same period, the pain relief achieved by the placebo group rose from 58% pre-infusion to 56% 24 h post infusion and then 50% relief 5 days later. This was statistically significant (P<0.05) using both the t-test and the Wilcoxon Rank Sum test. The ketamine group also showed a statistically significant difference 24 h post infusion of the effect of pain on their general activity (P=0.03) and on their enjoyment of life (P=0.004). This study shows that combining a single infusion of low dose ketamine with regular opioid analgesia can result in a significant improvement in pain relief for this patient group.