Strengthening Workplace Well-Being in Research Animal Facilities.

In recent years, there has been an increased recognition of the potential cost of caring on the mental well-being of research animal facility personnel. While this issue is considered a normal consequence of caring for others, these stressors must be acknowledged and managed to ensure that the workplace culture remains positive and that employees are engaged. Factors that can contribute to these feelings in those working with animals in research include compassion and moral stress, issues related to staffing and scheduling of work, insufficient communication in the workplace, and public ambivalence toward the use of animals in science. The first step in developing a program is to survey facility personnel about their concerns, either formally (e.g., using a needs analysis) or informally. Two examples are provided to demonstrate different institutional approaches to assessing personnel needs and developing an internal compassion-resiliency program. The best programs are based on the needs and wants of personnel and these can be cost effective and geared at a grassroots level. Social support in the workplace, for example, through peer counseling, can be a highly effective means of helping personnel to build compassion-resiliency. Addressing mental well-being of research animal facility personnel is an important component of ensuring a positive culture of care in the workplace.

Radiation Dose Escalation or Longer Androgen Suppression to Prevent Distant Progression in Men With Locally Advanced Prostate Cancer: 10-Year Data From the TROG 03.04 RADAR Trial.

PURPOSE: To clarify the relative effects of duration of androgen suppression (AS) and radiation dose escalation (RDE) on distant progression (DP) in men with locally advanced prostate cancer. METHODS AND MATERIALS: Participants with locally advanced prostate cancer in the TROG 03.04 RADAR trial were randomized to 6 or 18 months AS ± 18 months zoledronic acid (Z). The trial incorporated a RDE program by stratification at randomization and dosing options were 66, 70, or 74 Gy external beam radiation therapy (EBRT), or 46 Gy EBRT plus high-dose-rate brachytherapy boost (HDRB). The primary endpoint for this study was distant progression (DP). Secondary endpoints included local progression, bone progression, prostate cancer-specific mortality and all-cause mortality. Effect estimates for AS duration and RDE were derived using Fine and Gray competing risk models adjusting for use of Z, age, tumor stage, Gleason grade group, prostate-specific antigen, and treatment center. Cumulative incidence at 10 years was estimated for each RDE group. RESULTS: A total of 1051 out of 1071 randomized subjects were eligible for inclusion in this analysis. Compared with 6 months AS, 18 months AS significantly reduced DP independently of radiation dose (subhazard ratio 0.70; 95% confidence interval [CI], 0.56-0.87; P = .002). No statistically significant interaction between effect of AS duration and RT dose was observed (Wald test P = .76). In subgroup analyses, DP was significantly reduced by the longer duration of AS in the 70 Gy and HDRB groups but not in the 66 Gy and 74 Gy. Compared with 70 Gy, HDRB significantly reduced DP (subhazard ratio 0.68 [95% CI, 0.57-0.80]; P < .0001) independently of AS duration. At 10 years, adjusted cumulative incidences were 26.1% (95% CI, 18.9%-33.2%), 26.7% (22.9%-30.6%), 24.9% (20.0%-29.8%) and 19.7% (15.5%-23.8%) for DPs in the respective radiation dose groups. CONCLUSIONS: Compared with 6 months AS, 18 months AS reduced DP independently of radiation dose. Men treated with HDRB gained a significant benefit from a longer duration of AS. Evidence of improved oncologic outcomes for HDRB compared with dose-escalated EBRT needs to be confirmed in a randomized trial.

Collaborating with the Community: Improving Patient Access to Palliative Radiation Therapy.

PURPOSE: Palliative radiation therapy (PRT) has an essential role in cancer symptom control but is underutilized in Ontario. This initiative aimed to implement an educational outreach intervention to improve knowledge of and access to PRT among interprofessional palliative health care teams across an Ontario Local Health Integration Network. METHODS AND MATERIALS: A needs assessment was completed from June to September 2018 with interprofessional palliative health care teams. Participants completed a survey to identify perceived opportunities, barriers, and enablers to recommending or referring patients for PRT. Thematic analysis informed content of the educational outreach intervention and included how to access PRT, common indications, case studies, and side-effect management after completing PRT. The educational outreach intervention was completed from October 2018 to January 2019. Participants completed a survey, and results were analyzed using descriptive statistics. The number of patients who received PRT was determined by cross-referencing the regional database with the radiation oncology information system. RESULTS: Although 22.9% of participants had previously recommended or referred patients, 96.2% of participants agreed or strongly agreed that they are likely to recommend or refer patients for PRT after the educational outreach intervention (n = 131). An increase was observed in the number of patients receiving PRT from the community during the intervention period. CONCLUSIONS: The educational outreach intervention improved knowledge and the likelihood of interprofessional palliative health care teams providing access to PRT for patients in the community. More patients now receive PRT, conveying improved symptom control and quality of life.

Canadian Stroke Best Practice Recommendations: Managing transitions of care following Stroke, Guidelines Update 2016.

Every year, approximately 62,000 people with stroke and transient ischemic attack are treated in Canadian hospitals. For patients, families and caregivers, this can be a difficult time of adjustment. The 2016 update of the Canadian Managing Transitions of Care following Stroke guideline is a comprehensive summary of current evidence-based and consensus-based recommendations appropriate for use by clinicians who provide care to patients following stroke across a broad range of settings. The focus of these recommendations is on support, education and skills training for patients, families and caregivers; effective discharge planning; interprofessional communication; adaptation in resuming activities of daily living; and transition to long-term care for patients who are unable to return to or remain at home. Unlike other modules contained in the Canadian Stroke Best Practice Recommendations (such as acute inpatient care), many of these recommendations are based on consensus opinion, or evidence level C, highlighting the absence of conventional evidence (i.e. randomized controlled trials) in this area of stroke care. The quality of care transitions between stages and settings may have a direct impact on patient and family outcomes such as coping, readmissions and functional recovery. While many qualitative and non-controlled studies were reviewed, this gap in evidence combined with the fact that mortality from stoke is decreasing and more people are living with the effects of stroke, underscores the need to channel a portion of available research funds to recovery and adaptation following the acute phase of stroke.

Elements of patient-health-care provider communication related to cardiovascular rehabilitation referral.

Cardiovascular rehabilitation has been designed to decrease the burden of cardiovascular disease. This study described (1) patient-health-care provider interactions regarding cardiovascular rehabilitation and (2) which discussion elements were related to patient referral. This was a prospective study of cardiovascular patients and their health-care providers. Discussion utterances were coded using the Roter Interaction Analysis System. Discussion between 26 health-care providers and 50 patients were recorded. Cardiovascular rehabilitation referral was related to greater health-care provider interactivity (odds ratio = 2.82, 95% confidence interval = 1.01-7.86) and less patient concern and worry (odds ratio = 0.64, 95% confidence interval = 0.45-0.89). Taking time for reciprocal discussion and allaying patient anxiety may promote greater referral.

Radiation dose escalation or longer androgen suppression for locally advanced prostate cancer? Data from the TROG 03.04 RADAR trial.

BACKGROUND: The relative effects of radiation dose escalation (RDE) and androgen suppression (AS) duration on local prostatic progression (LP) remain unclear. METHODS: We addressed this in the TROG 03.04 RADAR trial by incorporating a RDE programme by stratification at randomisation. Men were allocated 6 or 18 months AS±18 months zoledronate (Z). The main endpoint was a composite of clinically diagnosed LP or PSA progression with a PSA doubling time ⩾6 months. Fine and Gray competing risk modelling with adjustment for site clustering produced cumulative incidence estimates at 6.5 years for each RDE group. RESULTS: Composite LP declined coherently in the 66, 70 and 74 Gy external beam dosing groups and was lowest in the high dose rate brachytherapy boost (HDRB) group. At 6.5 years, adjusted cumulative incidences were 22%, 15%, 13% and 7% respectively. Compared to 6 months AS, 18 months AS also significantly reduced LP (p<0.001). Post-radiation urethral strictures were documented in 45 subjects and increased incrementally in the dosing groups. Crude incidences were 0.8%, 0.9%, 3.8% and 12.7% respectively. CONCLUSION: RDE and increasing AS independently reduce LP and increase urethral strictures. The risks and benefits to the individual must be balanced when selecting radiation dose and AS duration.

Patterns of failure after iodine-125 seed implantation for prostate cancer.

PURPOSE: To determine the site of relapse when biochemical failure (BF) occurs after iodine-125 seed implantation for prostate cancer. MATERIALS AND METHODS: From 2001-2009, 500 men underwent implantation in Wellington, New Zealand. Men who sustained BF were placed on relapse guidelines that delayed restaging and intervention until the prostate-specific antigen (PSA) was ⩾20 ng/mL. RESULTS: Most implants (86%) had a prostate D90 of ⩾90%, and multivariate analysis showed that this parameter was not a variable that affected the risk of BF. Of 21 BFs that occurred, the site of failure was discovered to be local in one case and distant in nine cases. Restaging failed to identify the site of relapse in two cases. In nine cases the trigger for restaging had not been reached. CONCLUSIONS: If post-implant dosimetry is generally within the optimal range, distant rather than local failure appears to be the main cause of BF. Hormone treatment is therefore the most commonly indicated secondary treatment intervention (STI). Delaying the start of STI prevents the unnecessary treatment of men who undergo PSA 'bounce' and have PSA dynamics initially mimicking those of BF.

Impact of androgen suppression and zoledronic acid on bone mineral density and fractures in the Trans-Tasman Radiation Oncology Group (TROG) 03.04 Randomised Androgen Deprivation and Radiotherapy (RADAR) randomized controlled trial for locally advanced prostate cancer.

OBJECTIVE: To study the influence of adjuvant androgen suppression and bisphosphonates on incident vertebral and non-spinal fracture rates and bone mineral density (BMD) in men with locally advanced prostate cancer. PATIENTS AND METHODS: Between 2003 and 2007, 1071 men with locally advanced prostate cancer were randomly allocated, using a 2 × 2 trial design, to 6 months i.m. leuprorelin (androgen suppression [AS]) before radiotherapy alone ± 12 months additional leuprorelin ± 18 months zoledronic acid (ZdA), commencing at randomization. The main endpoint was incident thoraco-lumbar vertebral fractures, which were assessed radiographically at randomization and at 3 years, then reassessed by centralized review. Subsidiary endpoints included incident non-spinal fractures, which were documented throughout follow-up, and BMD, which was measured in 222 subjects at baseline, 2 years and 4 years. RESULTS: Incident vertebral fractures at 3 years were observed in 132 subjects. Their occurrence was not increased by 18 months' AS, nor reduced by ZdA. Incident non-spinal fractures occurred in 72 subjects and were significantly related to AS duration but not to ZdA. Osteopenia and osteoporosis prevalence rates at baseline were 23.4 and 1.4%, respectively, at the hip. Treatment for 6 and 18 months with AS caused significant reductions in hip BMD at 2 and 4 years (P < 0.01) and ZdA prevented these losses at both time points. CONCLUSION: In an AS-naïve population, 18 months of ZdA treatment prevented the sustained BMD losses caused by 18 months of AS treatment; however, the study power was insufficient to show that AS duration or ZdA influenced vertebral fracture rates.

Quality improvements in prostate radiotherapy: outcomes and impact of comprehensive quality assurance during the TROG 03.04 'RADAR' trial.

INTRODUCTION: The Trans-Tasman Radiation Oncology Group 03.04 'Randomised Androgen Deprivation and Radiotherapy' multicentre prostate cancer trial examined the optimal duration of androgen deprivation in combination with dose-escalated radiotherapy. Rigorous quality assurance (QA) processes were undertaken to ensure the validity and reliability of the radiation therapy treatment plan data. METHOD: QA processes included a planning benchmarking exercise and a periodic audit of target and normal tissue delineation. Centralised electronic review of digital plan data for external-beam radiotherapy was undertaken to detect protocol variations. The impact of clinical factors and feedback to submitting centres during the trial on variation rates was investigated. RESULTS: Twenty-three centres across Australia and New Zealand recruited 1071 participants to the trial. Treatment plans for 754 participants receiving external-beam treatment alone were reviewed. From these, 1185 minor and 86 major variations were identified, leading to feedback to treating centres to reduce variations for subsequent patients' treatment and plans, suggesting improvement in treatment quality through these QA programs. Participant anatomical factors (delineated clinical target volume and rectal volume) and treatment planning factors (beam energy, beam definition and patient position orientation) were found to significantly impact variation rates. The dummy run demonstrated disagreement in identification of the base of the prostate and the superior extent of the rectum. Feedback from the periodic audit led to a change of practice at five contributing centres. CONCLUSION: The application of a suite of complementary QA activities allows the quality of trial data to be optimised and quantified, and can provide a catalyst for reforming treatment practices.

Inter-professional Education in the Acute-Care Setting: The Clinical Instructor's Point of View.

PURPOSE: The purpose of this study was to gain an understanding of the opportunities and challenges involved in providing clinical inter-professional education (IPE) to physical therapy (PT) students in the acute-care setting from the perspective of PT clinical instructors (CIs). METHODS: Focus groups were conducted in four acute-care hospitals in Toronto. Participants were recruited using a purposive and convenience sampling approach in order to enhance our understanding of the perceptions of acute-care PT CIs. Eighteen full-time PT CIs with an average of 11 years in practice participated. A constant comparative process was employed to identify recurrent issues and themes within and between groups. RESULTS: Three main themes emerged from the focus groups: (1) Clinical IPE happens when inter-professional collaboration (IPC) occurs; however, IPC differs according to setting, access to other professions, time, support, and structure. (2) IPE is a lifelong learning process that applies to both CIs and students. (3) Student preparedness is a prerequisite for clinical IPE. CONCLUSIONS: IPC is an integral part of clinical IPE that requires ongoing commitment and reflection by CIs to ensure that they are ready to instruct students who have some preparation in formal IPE. More knowledge about providing clinical IPE in a structured manner, through academic and health institutions, will allow CIs to become role models for future generations of PT students.

Gleason scoring: a comparison of classical and modified (international society of urological pathology) criteria using nadir PSA as a clinical end point.

AIM: To compare the distribution and predictive performance of Gleason grade and scores derived using classical and modified (International Society of Urological Pathology) criteria. METHODS: Classical and modified Gleason grades and scores were assigned to cases of prostate carcinoma accessioned by the Trans-Tasman Radiation Oncology Group RADAR trial. Separate scores were derived for each grading system based on the percentage of each Gleason grade per case (area-based score) and the score of the highest scoring core. The predictive performance of each of the four Gleason scores assigned to each case was evaluated using nadir prostate specific antigen (nPSA) as a clinical end point. RESULTS: Modified Gleason scoring resulted in an upward shift of scores, primarily resulting from the reclassification of classical pattern 3 to modified pattern 4. On re-grading classical Gleason score 7 cores, there was a 64% decrease in the number of cores with < 25% Gleason pattern 4 tumour, while the number of cores with 75-100% Gleason pattern 4 tumour increased by 96%. All four scoring models performed reasonably well as predictors of nPSA; however, on comparison of the prognostic gradients of the grade groupings, classical Gleason scoring outperformed modified Gleason scoring. CONCLUSION: The overlap of the predictive performance of Gleason pattern 3 with Gleason pattern 4, suggests that review of the defining features of modified pattern 4 may improve the prognostic prediction of modified Gleason scoring.

Threshold Berg balance scale scores for gait-aid use in elderly subjects: a secondary analysis.

PURPOSE: To determine the threshold Berg Balance Scale (BBS) scores that discriminate among levels of gait-aid use in elderly subjects. METHODS: A secondary analysis of data combined from two projects was performed. Both projects determined BBS performance, self-selected gait speed, and gait-aid use in samples of community-dwelling, independently ambulant individuals older than 65 years of age. Receiver operating characteristic curves were used to identify BBS scores that optimized identification of individuals with different levels of ambulation. RESULTS: Previously determined associations between BBS score and various indicators of ambulatory ability were reproduced with the combined data set. Threshold BBS scores were identified for ability to walk without an aid (≥49/56) and ability to walk without a four-wheeled walker (≥43/56). The percent agreement values for the identified threshold scores ranged from 51% to 87%. CONCLUSIONS: Although some threshold BBS scores could be determined, the accuracies of the scores render them of limited use for guiding gait-aid prescription in individual clients.

Assuring high quality treatment delivery in clinical trials - Results from the Trans-Tasman Radiation Oncology Group (TROG) study 03.04 "RADAR" set-up accuracy study.

BACKGROUND AND PURPOSE: A multi-centre clinical trial for prostate cancer patients provided an opportunity to introduce conformal radiotherapy with dose escalation. To verify adequate treatment accuracy prior to patient recruitment, centres submitted details of a set-up accuracy study (SUAS). We report the results of the SUAS, the variation in clinical practice and the strategies used to help centres improve treatment accuracy. MATERIALS AND METHODS: The SUAS required each of the 24 participating centres to collect data on at least 10 pelvic patients imaged on a minimum of 20 occasions. Software was provided for data collection and analysis. Support to centres was provided through educational lectures, the trial quality assurance team and an information booklet. RESULTS: Only two centres had recently carried out a SUAS prior to the trial opening. Systematic errors were generally smaller than those previously reported in the literature. The questionnaire identified many differences in patient set-up protocols. As a result of participating in this QA activity more than 65% of centres improved their treatment delivery accuracy. CONCLUSIONS: Conducting a pre-trial SUAS has led to improvement in treatment delivery accuracy in many centres. Treatment techniques and set-up accuracy varied greatly, demonstrating a need to ensure an on-going awareness for such studies in future trials and with the introduction of dose escalation or new technologies.

Prostate cancer--are ethnic minorities disadvantaged?

BACKGROUND: This study, investigating ethnic differences in the diagnosis and treatment of prostate cancer, was performed because of a perceived paucity of Maori men receiving treatment for localised prostate cancer in the greater Wellington region. It was considered that if real differences could be demonstrated between Maori and non-Maori, it would raise questions as to whether cancer services were equally accessible to all sections of the population, one of the main objectives of the New Zealand Cancer Control Strategy. PATIENTS AND METHODS: The database for this study includes men from the greater Wellington region, presenting with clinically localised prostate cancer between 1996 and 2007, who were treated using three defined protocols. There were 271 men with low-risk prostate cancer treated with brachytherapy (permanent iodine seed implantation), and 188 men with intermediate- or high-risk prostate cancer who were entered into sequential clinical trials run by the Trans-Tasman Radiology Oncology Group (96.01 and RADAR 03.04) and treated with radical external beam radiotherapy. Each man on the database was allocated to a major ethnic group based on ethnic categories defined in the 2006 New Zealand Census. Comparisons were then made of the observed ethnic mix of men in the low- and intermediate/high-risk groups with the expected percentages derived from Census and Cancer Registry data. RESULTS: Ten Maori men were on the database, compared to 44 expected, and one Pacific man, compared to 37 expected. The same pattern of under-representation of these ethnic minorities was seen for both low-risk and intermediate/high-risk localised prostate cancer. CONCLUSION: As Cancer Registry data indicate that Maori have a lower incidence of prostate cancer compared to non-Maori, but a higher mortality rate and ratio (deaths/registrations), it is probable that during the period covered by this study, Maori were more likely to present with advanced cancer no longer confined to the prostate. The most likely explanation for this is that Maori have a cultural reluctance to present for health care until forced to by disabling symptoms. Longstanding negative messages from government agencies on the value of prostate cancer screening have done little to encourage the attitudinal change necessary for earlier, and more beneficial, engagement with health services.

Insufficiency fracture of the tibial plateau: an often missed diagnosis.

The authors have performed a retrospective study of 8 patients, all elderly females, seen in the period 2002-2004 with insufficiency fractures of the tibial plateau. Their mean age was 74 years (range 70-84). There was a history of trivial trauma in all patients, except one. Three of the patients were referred to the orthopaedic department, as a fracture line was visible on the plain radiographs taken 3 to 6 weeks after the trauma. The remaining five patients presented immediately after the trauma, which explains why their radiographs were still negative or only showed osteoarthritis. In the same 5 patients a diagnosis of tibial plateau fracture was made by CT-scan in 3, and by MRI-scan in 2 patients. All patients except one had a DEXA-scan, which revealed osteopenia in 4 and osteoporosis in 3 patients; all 7 were treated with bisphosphonates. All 8 patients were treated conservatively with a cast brace, for 6 to 12 weeks, with a good result. Insufficiency fracture of the tibial plateau is an often missed diagnosis. Plain radiographs are frequently negative in the beginning. Delayed diagnosis can cause pain and disability to the patient and can lead to deformity of the knee joint, due to structural collapse. MRI is sensitive to bone marrow oedema/ bone bruising, even in the osteoporotic tibial condyle. Once the diagnosis is made, the results are good with non-operative treatment.

Prevalence of smoking associated with pregnancy in three Southern Ontario Health Units.

OBJECTIVES: The objectives of this study were to determine the prevalence of pregnancy-associated smoking among women residing in three Southern Ontario Health Units and to examine potential risk factors for smoking during pregnancy, using an existing data collection mechanism. METHODS: During May 2001, questions about pregnancy-associated smoking were asked during the telephone follow-up of postpartum women living in the three health units in Southern Ontario; this follow-up is routinely conducted by public health nurses. Sociodemographic data were also obtained. Data from 1,134 women were analyzed concerning smoking before and after the occurrence of the pregnancy was known, during each trimester, and immediately postpartum. RESULTS: The rates of smoking before and after the pregnancy was known, in the first, second, and third trimesters, and immediately postpartum were 17.8%, 10.4%, 9.6%, 8.7%, 8.1%, and 7.9%, respectively. For all six estimates of smoking, Canadian-born women had rates 2.5 to 4 times higher than those of women born outside Canada. Age less than 25 years and lower educational attainment were also independent risk factors for smoking during pregnancy. CONCLUSIONS: The Ontario Tobacco Strategy goal of eliminating smoking in pregnancy has not yet been realized. Ongoing smoking cessation programs among pregnant women are needed as part of a comprehensive strategy to reduce the overall prevalence of smoking. In planning such programs, particular attention should be paid to the needs of women who are Canadian-born, have lower educational attainment, and are under the age of 25.