Best Case/Worst Case-ICU: protocol for a multisite, stepped-wedge, randomised clinical trial of scenario planning to improve communication in the ICU in US trauma centres for older adults with serious injury.

INTRODUCTION: Poor communication about serious injury in older adults can lead to treatment that is inconsistent with patient preferences, create conflict and strain healthcare resources. We developed a communication intervention called Best Case/Worst Case-intensive care unit (ICU) that uses daily scenario planning, that is, a narrative description of plausible futures, to support prognostication and facilitate dialogue among patients, their families and the trauma ICU team. This article describes a protocol for a multisite, randomised, stepped-wedge study to test the effectiveness of the intervention on the quality of communication (QOC) in the ICU. METHODS AND ANALYSIS: We will follow all patients aged 50 and older admitted to the trauma ICU for 3 or more days after a serious injury at eight high-volume level 1 trauma centres. We aim to survey one family or 'like family' member per eligible patient 5-7 days following their loved ones' admission and clinicians providing care in the trauma ICU. Using a stepped-wedge design, we will use permuted block randomisation to assign the timing for each site to begin implementation of the intervention and routine use of the Best Case/Worst Case-ICU tool. We will use a linear mixed-effects model to test the effect of the tool on family-reported QOC (using the QOC scale) as compared with usual care. Secondary outcomes include the effect of the tool on reducing clinician moral distress (using the Measure of Moral Distress for Healthcare Professionals scale) and patients' length of stay in the ICU. ETHICS AND DISSEMINATION: Institutional review board (IRB) approval was granted at the University of Wisconsin, and all study sites ceded review to the primary IRB. We plan to report results in peer-reviewed publications and national meetings. TRIAL REGISTRATION NUMBER: NCT05780918.

Evaluating surgeon communication of pancreatic cancer prognosis using the VitalTalk ADAPT framework.

BACKGROUND AND OBJECTIVES: Few data exist to guide optimal communication practices for surgical oncologists. VitalTalk, an evidence-based communication skills training model for clinicians, offers the five-step ADAPT tool for discussing prognosis. This study aimed to characterize surgeon communication of pancreatic cancer prognosis using VitalTalk's ADAPT framework. METHODS: Contemporaneous audio recordings from 12 initial surgeon-patient encounters for borderline resectable pancreatic cancer were transcribed. Directed qualitative content analysis based on ADAPT (Ask, Discover, Anticipate, Provide, and Track) was used to deductively code transcripts. RESULTS: All encounters contained at least one ADAPT step while only one (8%) incorporated four or five steps. Surgeons provided prognostic information (Provide) in all but one encounter (92%); most was qualitative and clustered into themes: serious illness, surgical candidacy, prognostic ambiguity, and cancer recurrence. Surgeons elicited understanding (Ask), requested information preferences (Discover), anticipated ambivalence (Anticipate), and responded to emotion (Track) in a minority of encounters (25%-42%); of 15 patient emotional cues, six were not addressed by surgeons. CONCLUSIONS: During an initial encounter for pancreatic cancer, surgeons focus heavily on providing information but omit critical prognostic communication steps. Future studies are needed to investigate if surgeon training in palliative care-based communication is feasible and impacts patient-perceived quality of communication.

Decreasing Prejudicial Attitudes of Fear and Avoidance Toward Those Who Live with a Mental Illness-A Quasi-Experimental Controlled Study.

The undergraduate mental health nursing course is an optimal time to address stigma and prejudice, while developing positive student attitudes toward those who live with mental health conditions. A quasi-experimental, pretest-posttest, nonequivalent-group study with a sample of undergraduate nursing students in New York City (N = 126) was conducted to determine the impact of an undergraduate mental health nursing course on attitudes toward people living with a general mental illness, depression, or schizophrenia. The intervention resulted in a significant reduction in total prejudice scores toward those with a general mental illness when compared to the control (p = 0.033, partial η2 = 0.062). The intervention had no significant impact on total prejudice scores regarding those with depression, or schizophrenia. Subscale analysis revealed the intervention significantly reduced attitudes of fear/avoidance regarding general mental illness (p = 0.040, partial η2 = 0.058) and schizophrenia (p < 0.001, partial η2 = 0.164). There was no impact on authoritarian or malevolent attitudes. Though some attitudes were not amenable to change, this study provides evidence that positive attitudes can be cultivated through undergraduate nursing education. Curricular reform is needed to reduce all facets of prejudice and best prepare future nurses to care for those with mental health conditions.

Implementation of a geriatric care bundle for older adults with acute burns.

BACKGROUND: Frailty and comorbidities are important outcome determinants in older patients (age ≥65) with burns. A Geriatric Burn Bundle (Geri-B) was implemented in 2019 at a regional burn center to standardize care for older adults. Components included frailty screening and protocolized geriatric co-management, malnutrition screening with nutritional support, and geriatric-centered pain regimens. METHODS: This study aimed to qualitatively evaluate the implementation of Geri-B using the Proctor Framework. From June-August 2022, older burn-injured patients, burn nurses, and medical staff providers (attending physicians and advanced practice providers) were surveyed and interviewed. Transcribed interviews were coded and thematically analyzed. From May 2022 to August 2023, the number of inpatient visits aged 65 + with a documented frailty screening was monitored. RESULTS: The study included 23 participants (10 providers, 13 patients). Participants highly rated Geri-B in all implementation domains. Most providers rated geriatric care effectiveness as 'good' or 'excellent' after Geri-B implementation. Providers viewed it as a reminder to tailor geriatric care and a safeguard against substandard geriatric care. Staffing shortages, insufficient protocol training, and learning resources were reported as implementation barriers. Many providers advocated for better bundle integration into the hospital electronic health record (EHR) (e.g., frailty screening tool, automatic admission order sets). Most patients felt comfortable being asked about their functional status with strong patient support for therapy services. The average frailty screening completion rate from May 2022 to August 2023 was 86%. CONCLUSIONS: Geri-B was perceived as valuable for the care of older burn patients and may serve as a framework for other burn centers.

A Systematic Review of the Application of Simulation to Promote Empathy in Nursing Education.

SUMMARY STATEMENT: This systematic review aimed to identify, appraise, and synthesize evidence for the effectiveness of simulation modalities in promoting nursing students' empathy. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis was followed with 20 studies included. The Medical Education Research Study Quality Instrument (MERSQI) was used to evaluate the quality of the publications. The mean MERSQI score was 10.95 with an SD of 1.62, which was above the average in the literature.Five simulation modalities were identified: standardized patient, simulated suit, manikin, virtual simulation, and virtual reality simulation. Most of the studies (n = 15) reported significant differences in the measured outcomes after their simulation activities, including all 5 simulation modalities, but the most effective modality was the simulation suit. The simulation suit replicates the lived experiences of others, which enhances perspective taking by "turning the student into the patient" through the physical and sensory effects of simulated suits. However, outcome measures were limited to self-report instruments in the studies.

A Missed Opportunity to Cultivate Positive Attitudes about Mental Health Recovery among Undergraduate Nursing Students - A Quasi-Experimental Controlled Study.

INTRODUCTION: Mental health recovery is a critical concept that needs to be thoroughly understood and supported by nurses. Undergraduate nurse educators have the opportunity to clarify misconceptions and cultivate positive recovery attitudes. AIM: To assess the impact of an undergraduate nursing course on attitudes toward mental health recovery and the relationship between recovery attitudes and prejudice toward those who experience a mental illness. METHODS: A quasi-experimental pretest-posttest, nonequivalent-control group study was conducted using a sample of undergraduate nursing students in New York City (N = 126). The intervention group was assigned to an undergraduate mental health nursing course and the control group to a pediatric/maternal health nursing course. Attitudes toward mental health recovery and prejudice were measured at the beginning and end of the semester. Two-way mixed analyses of variance were used to determine the differences in students' attitudes. Pearson product-moment correlation analyses were used to assess the relationship between prejudice toward people who experience a mental illness and attitudes toward recovery. RESULTS: The mental health nursing course had no measurable impact on students' recovery attitudes. However, there was a moderate-to-strong inverse relationship between recovery attitudes and prejudice toward those who experience a general mental illness (r = -0.54), depression (r = -0.60), or schizophrenia (r = -0.43). CONCLUSIONS: Curriculum reform is needed to optimize the impact of undergraduate education on students' attitudes. Possible changes include a more holistic approach to mental health that does not over accentuate the biomedical model, the use of nontraditional clinical sites that provide students an opportunity to interact with those further along in their recovery, and the inclusion of those in recovery in curriculum development. As there was a moderate-to-strong inverse relationship between recovery attitudes and prejudice, educational interventions that positively impact one may also impact the other. Further research is needed to investigate if the relationship is causal.

The Effects of Mindfulness Meditation on Nursing Students' Stress and Anxiety Levels.

AIM: The aim of this study was to evaluate the effects of a virtual mindfulness meditation intervention on stress and anxiety levels of 145 nursing students. BACKGROUND: Because of the twin demands of classroom and clinical workloads, nursing students experience greater amounts of stress and anxiety than the average college student. Mindfulness meditation is a promising method to alleviate stress and anxiety. METHOD: A pretest-posttest randomized controlled design was used. Participants received either weekly mindfulness meditation recordings or recordings on nursing information. Participants completed the Perceived Stress Scale and the Generalized Anxiety Disorder-7 Scale. RESULTS: A two-way mixed analysis of variance and follow-up simple main effects tests revealed that participants in the experimental group, who received meditation recordings, experienced significantly lower levels of stress and anxiety on posttest surveys than the control group. CONCLUSION: Mindfulness meditation can reduce stress and anxiety levels in nursing students. This can improve students' overall mental and physical well-being.

ICU Readmission in Injured Older Adults: Modifiable Risk Factors and Implications.

BACKGROUND: Prior evaluations of ICU readmission among injured older adults have inconsistently identified risk factors, with findings limited by use of sub-analyses and small sample sizes. This study aimed to identify risk factors for and implications of ICU readmission in injured older adults. METHODS: This retrospective, single-center cohort study was conducted at a High-Volume Level 1 Trauma Center and included injured older adult patients (>65 years old) requiring at least one ICU admission during hospitalization between 2013-2018. Patients who died <48 hours of admission were excluded. Exposures included patient demographics and clinical factors. The primary outcome was ICU readmission. Multi-variable regression was used to identify risk factors for ICU readmission. RESULTS: 6,691 injured adult trauma patients were admitted from 2013-2018, 55.4% (n = 3,709) of whom were admitted to the ICU after excluding early deaths. Of this cohort, 9.1% (n = 339) were readmitted to the ICU during hospitalization. Readmitted ICU patients had a higher median Injury Severity Score (21 (IQR: 14-26) vs 16 (IQR: 10-24)), with similar mechanisms of injury between the two groups. Readmitted ICU patients had a significantly higher mortality (19.5%) compared to single ICU admission patients (9.9%) (p < 0.001) and higher rates of developing any complication, including delirium (61% vs 30%, p < 0.001). On multivariable analysis, the factors associated with the highest risk of readmission were delirium (RR = 2.6, 95% CI 2.07 - 3.26) and aspiration (RR = 3.04, 95% CI 1.67- 5.54). More patients in the single ICU admission cohort received comfort-focused care at the time of their death as compared to the ICU readmission cohort (93% vs 85%, p = 0.035). CONCLUSIONS: Readmission to the ICU is strongly associated with higher mortality for injured older adults. Efforts targeted at preventing respiratory complications and delirium in the geriatric trauma population may decrease the rates of ICU readmission and related mortality risk. LEVEL OF EVIDENCE: III/Epidemiologic.

Becoming a Palliative Care Physician During Surgical Residency.

This Viewpoint describes the option of integrating hospice and palliative medicine training into surgical training.

Using Meditation to Reduce Stress, Anxiety, and Depression in Nursing Students.

BACKGROUND: Nursing students experience higher rates of mental health issues than other college students. This study examined the effect of a mindfulness meditation intervention on nursing students' levels of self-reported depression, stress, and anxiety. METHOD: This randomized, experimental study implemented an online mindfulness meditation intervention for an experimental group of nursing students and provided nursing news modules for a control group of nursing students. Participants in experimental and control groups completed the Depression, Anxiety, and Stress Scale online before and after completing 4 weeks of audio modules. RESULTS: Results showed a statistically significant decrease in reported scores for depression, stress, and anxiety in the experimental group. CONCLUSION: This study demonstrated the potential benefits of implementing an online mindfulness meditation intervention to support and improve mental health for nursing students. [J Nurs Educ. 2023;62(8):443-449.].

When Did They Start? Age of Onset of Toileting Behaviors and Urinary Cues as Reported by Older Women.

Background: Lower urinary tract symptoms (LUTS) are prevalent across women's life course. Evidence shows toileting behaviors (TBs) and urinary urge cues are related to LUTS. It is unknown when women start using these behaviors and responding to urinary cues. Methods: An online survey was administered to 338 women, 65 years of age and older, to assess the age of onset for 20 TBs from the Toileting Behaviors-Women's Elimination Behavior (TB-WEB) questionnaire, 10 urinary urge cues from the Urinary Cues Questionnaire, and urinary urgency and leakage items from the International Consultation on Incontinence Questionnaire-Overactive Bladder (ICIQ-OAB) Short Form. Descriptive statistics were reported for each TB and urinary cue. A timeline was generated with the average earliest age of onsets for each type of TB, urinary cues, and urinary urgency and leakage symptoms. Results: Place preference, delayed voiding, and hovering over toilets away from home were reported to have the earliest ages of onset. Urinary urge cues, premature voiding, and straining to void tended to start after 45 years of age, as did the symptoms of urinary urgency and leakage. The timeline indicated that the earliest place preference and position preference TBs started before 20 years of age. Conclusion: Some TBs begin early in life and persist into old age, while other TBs and urinary cues begin later. Bladder health promotion may depend on intervening at specific times in the life course to alter TBs and responses, and potentially making environmental changes.

Acknowledging Stigma: Levels of Prejudice among Undergraduate Nursing Students toward People Living with a Mental Illness-A Quasi-Experimental Single-Group Study.

INTRODUCTION: The undergraduate mental health nursing course may be an optimal time to cultivate students' positive attitudes toward people living with a mental illness. AIM: To determine the impact of an undergraduate mental health nursing course on students' attitudes toward people living with a mental illness, depression, and schizophrenia. METHOD: A quasi-experimental single-group pretest posttest study was conducted using a sample of undergraduate nursing students in New York City (N = 44). Self-reported measures of prejudice toward those living with a mental illness were collected at the beginning of a mental health nursing course and again at its conclusion. RESULTS: A statistically significant decrease in prejudice scores was found concerning mental illness (p = .03, d = 0.23), depression (p = .01, d = 0.31), and schizophrenia (p = .013, d = 0.34). Subscale analysis revealed significant decreases in the fear/avoidance and unpredictability subscales. Yet no significant change was found in the subscales of authoritarianism and malevolence for any of the three conditions. DISCUSSION: A mental health course led to a modest decrease in prejudice. However, certain facets of prejudice remain unchanged. IMPLICATIONS FOR PRACTICE: Major curricular reform is needed to optimize the impact of undergraduate nursing education.

Long-term health-related quality of life and independence among older survivors of serious injury.

BACKGROUND: Little is known about the recovery experiences of older trauma intensive care unit (TICU) survivors and the relationship between geriatric trauma care and long-term functional ability and health-related quality of life (HRQOL). METHODS: We conducted a prospective cohort study of 218 patients (age, ≥65 years) admitted to a Level 1 regional trauma center TICU before versus after implementation of a geriatric care bundle with protocolized geriatrics consultations (Geri-T). Survivors or their proxies were interviewed approximately 1 year after hospitalization. Outcomes included the Katz Index of Independence in Activities of Daily Living (ADLs), Lawton Instrumental Activities of Daily Living (IADLs), and EQ-5D-5L HRQOL survey. Two investigator-developed questions regarding recovery experiences were included. Differences in outcomes among survivors admitted before versus after Geri-T were analyzed using multivariable linear regression. Responses to questions about recovery experiences were qualitatively assessed using content analysis. RESULTS: We reached 67% (146/218) of hospital survivors or their proxies across both groups; 126 patients were still alive and completed the survey. Mean age was 76 (SD, 8), 36% were female, and 90% were independent with ADLs preinjury. At follow-up, independence with ADLs was 76% and IADLs was 63%. The mean EQ-5D-5L index score was 0.78 (SD, 0.18). Most patients (65%) reported having not returned to preinjury functional status. Neither functional ability or HRQOL differed significantly among patients admitted before versus after Geri-T. Content analysis of open-ended questions revealed themes of activity limitations, persistent pain, and cognitive dysfunction. CONCLUSION: Nearly one-fifth of TICU survivors experienced loss of ADL function 1 year after injury, and most reported having not returned to preinjury functional status. Nonetheless, patient-reported HRQOL was comparable to age-adjusted norms. Geri-T was not associated with differences in HRQOL or functional ability. Survivors reported persistent difficulty with activities beyond those of daily living, pain, and cognition. LEVEL OF EVIDENCE: Prognostic and Epidemiologic, Level III.

Toileting behaviors, urinary cues, overactive bladder, and urinary incontinence in older women.

INTRODUCTION AND HYPOTHESIS: Overactive bladder (OAB) and urinary incontinence (UI) are prevalent in older women. We investigated relations of toileting behaviors and urinary urge cues to OAB and UI in women ≥ 65 years. We tested mediation hypotheses that toileting behaviors lead to higher sensitivity to urinary urge cues (the mediator), which leads to both OAB and UI. METHODS: An e-panel was recruited to respond to an electronic survey that included demographic information, Urinary Cues Scale version 2, Toileting Behaviors-Women's Elimination Behaviors (TB-WEB) scale, and the International Consultation on Incontinence Questionnaire Short Forms for Urinary Incontinence (ICIQ-SF-UI) and Overactive Bladder (ICIQ-SF-OAB). Descriptive statistics were conducted; correlation matrices were created to explore relationships among major variables. Regression analyses were conducted to test our mediation hypotheses. RESULTS: There were 338 respondents with average age 70.9 (SD + 5.55) years. Most were white, overweight or obese, and had UI. Urinary urge cues fully mediated the relationship of TB-WEB with OAB. Urinary urge cues partially mediated the relationship of TB-WEB with UI; the direct effect of toileting behaviors on UI remained significant. Age and body mass index had significant partial correlations with UI but not with OAB. DISCUSSION: Toileting behaviors appear to contribute to sensitivity to urinary cues, which are related to both OAB and UI. Toileting behaviors have indirect effects on OAB and both indirect and direct effects on UI. Interventions to change toileting behaviors and extinguish urinary cues are needed. CONCLUSIONS: Behavioral and conditioning factors contribute to UI in older women.

Interpersonal violence affecting the pediatric population: Patterns of injury and recidivism.

PURPOSE: We aim to describe interpersonal violence-related injury patterns in the pediatric trauma population and to identify predictors of recidivism. METHODS: In this retrospective analysis from a single institution, we included pediatric patients (≤17 years) treated (2006-2020) for traumatic injury related to interpersonal violence (IPV). Patient characteristics were compared among mechanism types and between recidivists and non recidivists using two sample t-tests, Wilcoxon rank-sum tests, and Pearson's chi-squared. Multivariate analysis was performed using logistic regression to identify predictors of repeat injury. RESULTS: We identified 635 pediatric patients who sustained injuries owning to IPV: firearm (N = 266), assault (stab/blunt; N = 243), and abuse (N = 126). The average age of the firearm, assault, and abuse groups was 15.5, 14.7, and 1.1 years (SD = 2.2, 3.4, 2.4 years), respectively. Majority of the overall cohort was male (77.5%) and publicly- or un insured (67.8%), with 28.0% being Black. Of the 489 firearm and assault patients who survived the first injury, 30 (6.1%) had repeat injury owning to IPV requiring treatment at our center with a median time of 40 months (IQR 17-62 months) between first and second injury. The majority of recidivists (83.3%) were victims of gun violence whereas the distribution between assault and firearm in the non recidivists was more even at 51 and 49%, respectively (p < 0.001). Eighteen (60.0%) of the recidivist patients had the same mechanism between the first and second injury. In the logistic regression analysis, Black race and firearm injury were associated with greater than 3-fold higher likelihood of repeat injury compared to white race after adjusting for age, sex, insurance, and child opportunity index. CONCLUSIONS: We found that survivors of firearm injuries and assault comprise a vulnerable patient cohort at risk for repeat injury, and Black race is an independent predictor of repeat injury owning to IPV. These findings provide guidance for developing violence prevention programs. TYPE OF STUDY: Retrospective Comparative Study LEVEL OF EVIDENCE: Level III.

Isolated Internuclear Ophthalmoplegia as an Embolic Complication of Transcatheter Aortic Valve Implantation.

An 83-year-old male developed horizontal diplopia immediately following elective transfemoral transcatheter aortic valve implantation (TAVI). On right gaze, left eye adduction was impaired while there was horizontal nystagmus of the abducting right eye, representative of internuclear ophthalmoplegia (INO). The remainder of the neurological examination was normal. Computer tomography (CT) imaging of the brain and CT angiogram of the head and neck were normal. Magnetic resonance imaging (MRI) of the brain showed five small foci of restricted diffusion affecting both the anterior and posterior circulation bilaterally. One such tiny infarct was seen in the left parasagittal upper pontine tegmentum and was attributed to his presentation. While all symptoms rapidly improved, minimal residual signs of INO were still detectable at the six-month follow-up. Isolated intra-nuclear ophthalmoplegia is a rare stroke syndrome and an unusual cardio-embolic complication of minimally invasive cardiac procedures. TAVI is an increasingly popular technique, although has been associated with a higher incidence of micro-embolic cerebrovascular events evident on MRI than surgical repairs. While the use of embolic protection devices has high-quality evidence in reducing the burden of these usually silent cerebrovascular events, their role in preventing long-term neurocognitive sequala has not been demonstrated.

Treatment of multiple synchronous canine mast cell tumours using intratumoural tigilanol tiglate.

Mast cell tumours (MCTs) are common canine skin neoplasia. While they generally occur as single tumours, multiple synchronous MCTs (msMCTs) of de novo/non-metastatic origin are reported in a proportion of the patient population. Where there is no evidence of metastasis or lymphatic spread, MCTs are effectively controlled by surgery and other local therapies. However, treatment of de novo msMCTs can be more challenging, especially when they occur in surgically difficult locations. Here, we report the use of tigilanol tiglate, a novel small molecule registered as a veterinary pharmaceutical for the local treatment of non-metastatic MCTs, in the treatment of patients with msMCTs presenting at three Australian specialist referral centres. We also present a meta-analysis of the literature to provide a better understanding of the prevalence of canine msMCTs. Notably, nine patients with a total of 32 MCTs were treated during the study. A complete response was recorded in 26 (81%) of the individual MCTs on Day 28 after a single tigilanol tiglate injection. Of the 6 initially non-responsive MCTs, one achieved a complete response after a further tigilanol tiglate treatment. A complete response was reported at 6 months in all 22 of the tumours that were evaluable and that had recorded a complete response at Day 84. For the literature meta-analysis, 22 studies were found with prevalence estimates of msMCTs ranging from 3 to 40%; when combined, these studies yielded 3,745 patients with a prevalence of 13% (95% CI 10; 16). Overall, the results demonstrate the utility of intratumoural tigilanol tiglate as an option for the treatment of multiple MCTs where multiple surgical resections would have been required.

Reciprocal SOX2 regulation by SMAD1-SMAD3 is critical for anoikis resistance and metastasis in cancer.

Growth factors in tumor environments are regulators of cell survival and metastasis. Here, we reveal the dichotomy between TGF-ß superfamily growth factors BMP and TGF-ß/activin and their downstream SMAD effectors. Gene expression profiling uncovers SOX2 as a key contextual signaling node regulated in an opposing manner by BMP2, -4, and -9 and TGF-ß and activin A to impact anchorage-independent cell survival. We find that SOX2 is repressed by BMPs, leading to a reduction in intraperitoneal tumor burden and improved survival of tumor-bearing mice. Repression of SOX2 is driven by SMAD1-dependent histone H3K27me3 recruitment and DNA methylation at SOX2's promoter. Conversely, TGF-ß, which is elevated in patient ascites, and activin A can promote SOX2 expression and anchorage-independent survival by SMAD3-dependent histone H3K4me3 recruitment. Our findings identify SOX2 as a contextual and contrastingly regulated node downstream of TGF-ß members controlling anchorage-independent survival and metastasis in ovarian cancers.

Procarbazine, prednisolone and cyclophosphamide oral combination chemotherapy protocol for canine lymphoma.

Orally administered daily chemotherapy offers a novel treatment approach for canine lymphoma in a population of dogs that have failed or not tolerated maximum tolerable dose chemotherapy. A multidrug oral chemotherapy protocol was designed and implemented for the treatment of 50 dogs with multicentric lymphoma with minimal side effects. The protocol consisted of oral procarbazine, prednisolone and cyclophosphamide (PPC) administered daily. Efficacy and toxicity were evaluated by clinical and laboratory evaluation. An overall response rate of 70% was achieved, with 24% and 46% of dogs having a partial and complete response, respectively, to treatment with the PPC protocol. Response to the PPC protocol (complete or partial) and age were the only factors identified as prognostic for time from initiation of the PPC chemotherapy until death. Overall, the protocol was very well tolerated with only one dog requiring protocol discontinuation due to grade 4 thrombocytopenia. Eight dogs recorded gastrointestinal toxicities, seven grade I and one grade II toxicity. These findings demonstrate that the administration of a continuous oral combination chemotherapy can provide comparable survival times in the rescue setting in dogs with multicentric lymphoma with minimal side effects.