A catalyst for transforming health systems and person-centred care: Canadian national position statement on patient-reported outcomes.

Background: Patient-reported outcomes (pros) are essential to capture the patient's perspective and to influence care. Although pros and pro measures are known to have many important benefits, they are not consistently being used and there is there no Canadian pros oversight. The Position Statement presented here is the first step toward supporting the implementation of pros in the Canadian health care setting. Methods: The Canadian pros National Steering Committee drafted position statements, which were submitted for stakeholder feedback before, during, and after the first National Canadian Patient Reported Outcomes (canpros) scientific conference, 14-15 November 2019 in Calgary, Alberta. In addition to the stakeholder feedback cycle, a patient advocate group submitted a section to capture the patient voice. Results: The canpros Position Statement is an outcome of the 2019 canpros scientific conference, with an oncology focus. The Position Statement is categorized into 6 sections covering 4 theme areas: Patient and Families, Health Policy, Clinical Implementation, and Research. The patient voice perfectly mirrors the recommendations that the experts reached by consensus and provides an overriding impetus for the use of pros in health care. Conclusions: Although our vision of pros transforming the health care system to be more patient-centred is still aspirational, the Position Statement presented here takes a first step toward providing recommendations in key areas to align Canadian efforts. The Position Statement is directed toward a health policy audience; future iterations will target other audiences, including researchers, clinicians, and patients. Our intent is that future versions will broaden the focus to include chronic diseases beyond cancer.

The physician's Achilles heel-surviving an adverse event.

Background: Of hospitalized patients in Canada, 7.5% experience an adverse event (ae). Physicians whose patients experience aes often become second victims of the incident. The present study is the first to evaluate how physicians in Canada cope with aes occurring in their patients. Methods: Survey participants included oncologists, surgeons, and trainees at the Foothills Medical Centre, Calgary, AB. The surveys were administered through REDCap (Research Electronic Data Capture, version 9.0: REDCap Consortium, Vanderbilt University, Nashville, TN, U.S.A.). The Brief cope (Coping Orientation to Problems Experienced) Inventory, the ies-r (Impact of Event Scale-Revised), the Causal Dimension Scale, and the Institutional Punitive Response scale were used to evaluate coping strategies, prevalence of post-traumatic stress, and institutional culture with respect to aes. Results: Of 51 responses used for the analysis, 30 (58.8%) came from surgeons and 21 (41.2%) came from medical specialists. On the ies-r, 54.9% of respondents scored 24 or higher, which has been correlated with clinically concerning post-traumatic stress. Individuals with a score of 24 or higher were more likely to report self-blame (p = 0.00026) and venting (p = 0.042). Physicians who perceive institutional support to be poor reported significant post-traumatic stress (p = 0.023). On multivariable logistic regression modelling, self-blame was associated with an ies-r score of 24 or higher (p = 0.0031). No significant differences in ies-r scores of 24 or higher were observed between surgeons and non-surgeons (p = 0.15).The implications of aes for physicians, patients, and the health care system are enormous. More than 50% of our respondents showed emotional pathology related to an ae. Higher levels of self-blame, venting, and perception of inadequate institutional support were factors predicting increased post-traumatic stress after a patient ae. Conclusions: Our study identifies a desperate need to establish effective institutional supports to help health care professionals recognize and deal with the emotional toll resulting from aes.

Selective attention in dairy cattle.

In a replication of Reynolds (1961), two cows learned to discriminate between compound stimuli in a forced choice procedure where pushing through a one-way gate marked with a red cross (S+) gave access to food. Pushing through a one-way gate marked with a yellow triangle (S-) gave no access to food. To investigate whether shape or colour was controlling behaviour, probe tests varied either the shape or the colour of the stimuli (e.g., a red vs. a yellow cross, and a red cross vs. a red triangle). Results suggested control by colour rather than shape, as the gate marked with the red stimulus was chosen more than the gate marked with the yellow stimulus regardless of stimulus shape, and when two shapes of the same colour (either red or yellow) were presented, cows chose both equally. Further probe tests with painted red, white, and yellow stimuli showed that the cows had learned to avoid yellow rather than to approach red, suggesting discriminative behaviour was controlled by the colour of the negative stimulus and not by either aspect of the positive stimulus. It is not clear why the negative stimulus was more salient, but it may reflect a tendency for cows to learn to avoid farm handling practices which involve mainly negative stimuli.

Guidelines on the use of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal surface malignancy arising from colorectal or appendiceal neoplasms.

To meet the needs of patients, Canadian surgical and medical oncology leaders in the treatment of peritoneal surface malignancies (psms), together with patient representatives, formed the Canadian HIPEC Collaborative Group (chicg). The group is dedicated to standardizing and improving the treatment of psm in Canada so that access to treatment and, ultimately, the prognosis of Canadian patients with psm are improved. Patients with resectable psm arising from colorectal or appendiceal neoplasms should be reviewed by a multidisciplinary team including surgeons and medical oncologists with experience in treating patients with psm. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy should be offered to appropriately selected patients and performed at experienced centres. The aim of this publication is to present guidelines that we recommend be applied across the country for the treatment of psm.

Centrifugal spreader mass and nutrients distribution patterns for application of fresh and aged poultry litter.

A spin-type centrifugal spreader was evaluated using fresh and aged poultry litter upon dry mass, product nitrogen (N), phosphorus (P) and potassium (K), incubation study soil available N and particle size distribution patterns. Relative to the aged litter (37% moisture content), the fresh litter (17% moisture content) had greater <1.00 mm particle size fraction weights and atmospheric particulate was launched, which posed as a potential fallout to adjacent fields, waterways and residences. Relative to the aged litter, the broadcast fresh litter resulted in higher coefficients of variation (CV) over its transverse distance, a narrower calculated space distance between passes for uniform spread and lower soil available N concentrations. For nitrogen application over the broadcast transverse distance the fresh litter displayed a high R(2) best fit 4th order polynomial distribution pattern, while the aged litter showed high R(2) best fit 6th order polynomial distribution pattern. A soil incubation study of the fresh and aged broadcast litter resulted in a more variable or lower R(2) best fit 2nd order polynomial distribution pattern. For both the fresh and aged litter, the calculated distance between passes to achieve a uniform mass distribution was greater than that required for the broadcast of soil available N. For the fresh litter, the soil available N and litter P concentration levels strongly correlated (relatively high p and R(2) values) with the <1.00 mm fraction weight, while for the aged litter this relationship was not as significant. In addition to reducing the health risk (i.e. pathogens, antibiotic residues and resistant bacteria) and/or environment issues (particulate fallout onto waterways, adjacent fields and/or residences) our study mass, particulate and N distribution patterns results suggest that poultry litter should be allowed to age before broadcast application is attempted.

Object/picture recognition in hens.

Two experiments examined whether hens, Gallus gallus domesticus, would respond to photographs in the same way they do to the real objects depicted in the photographs. Experiment 1 assessed whether hens transferred a discrimination of differently coloured three-dimensional objects to two-dimensional photographs of those objects, and vice versa. All hens learned to discriminate between the stimuli and showed transfer to the alternative stimuli when the colour cues were present. In Experiment 2 transfer with stimuli that differed in shape only was examined. It was found that only three of the six hens learned to discriminate the stimuli to any degree, and that these three hens did not transfer this discrimination to the alternative stimuli. It was also found that previously learning an object discrimination did not aid the hens in learning to discriminate between photographs of the objects. These data suggest that the hens did not respond to the objects depicted in pictures in the same way they did to the real objects. The authors argue it cannot be assumed that all animals respond to two-dimensional pictures of stimuli in the same way as they do to the real three-dimensional stimuli and this should be established before researchers use two-dimensional stimuli as representatives of real world stimuli.

Synoptic operative record for point of care outcomes: a leap forward in knowledge translation.

INTRODUCTION: Modern information technology coupled with synoptic methodology allows point of care, real time outcomes generation. Our objective was to review province-wide breast cancer surgery outcomes from a prospective synoptic operative record to demonstrate its value in knowledge translation. METHODS: All synoptic reports for breast cancer procedures from 2006 until March 2010 were reviewed and descriptively analyzed. Key outcomes included frequency of breast cancer procedures captured over time, methods of breast cancer detection, clinical staging, method of axillary staging, breast conservation and reconstruction rates. Further analysis involved important decision-making for mastectomy and resource allocation for surgery. RESULTS: Four thousand nine hundred fifty-five breast cancer procedures were recorded synoptically; greater than 80% of cases provincially. Method of breast cancer detection was 49%, 45% and 4% by screening radiology, patient or family, and physician, respectively. Pathologic diagnoses were via core or mammotome biopsy in 94%; nearly half of all patients were clinical Stage I at time of operation. Overall rate of breast conservation was 48%. Of the 65% who had no contra-indication to breast conservation surgery, 76% had breast conservation and 4% had primary reconstruction. Of those having mastectomy, one third were due to patient choice. Seventy-nine percent had sentinel node staging, 18% had full axillary dissection and 3% had no axillary staging. CONCLUSION: A new paradigm of creating medical records using synoptic electronic templates allows prospective outcomes generation at point of care by the surgeon which is unparalleled in its depth of surgical detail capturing surgical decision-making.

Opening the black box of cancer surgery quality: WebSMR and the Alberta experience.

A web-based synoptic operative report, the WebSMR (Surgical Medical Record), was developed to define and improve the quality of cancer surgery. Surgeons accurately record the essential steps of an operation including important decision-making in an analyzable format. Outcomes can be reviewed with provincial aggregates for quality improvement and maintenance of certification. Future synoptic pathology and follow-up templates will open the "black box" of surgical processes to define quality indicators for the improvement of cancer outcomes.

Polypharmacy: misleading, but manageable.

The percentage of the population described as elderly is growing, and a higher prevalence of multiple, chronic disease states must be managed concurrently. Healthcare practitioners must appropriately use medication for multiple diseases and avoid risks often associated with multiple medication use such as adverse effects, drug/drug interactions, drug/disease interactions, and inappropriate dosing. The purpose of this study is to identify a consensus definition for polypharmacy and evaluate its prevalence among elderly outpatients. The authors also sought to identify or develop a clinical tool which would assist healthcare practitioners guard against inappropriate drug therapy in elderly patients. The most commonly cited definition was a medication not matching a diagnosis. Inappropriate was part of definitions used frequently. Some definitions placed a numeric value on concurrent medications. Two common definitions (ie, 6 or more medications or a potentially inappropriate medication) were used to evaluate polypharmacy in elderly South Carolinians (n = 1027). Data analysis demonstrates that a significant percentage of this population is prescribed six or more concomitant drugs and/or uses a potentially inappropriate medication. The findings are 29.4% are prescribed 6 or more concurrent drugs, 15.7% are prescribed one or more potentially inappropriate drugs, and 9.3% meet both definitions of polypharmacy used in this study. The authors recommend use of less ambiguous terminology such as hyperpharmacotherapy or multiple medication use. A structured approach to identify and manage inappropriate polypharmacy is suggested and a clinical tool is provided.

An investigation of colour discrimination with horses (Equus caballus).

The ability of four horses (Equus caballus) to discriminate coloured (three shades of blue, green, red, and yellow) from grey (neutral density) stimuli, produced by back projected lighting filters, was investigated in a two response forced-choice procedure. Pushes of the lever in front of a coloured screen were occasionally reinforced, pushes of the lever in front of a grey screen were never reinforced. Each colour shade was randomly paired with a grey that was brighter, one that was dimmer, and one that approximately matched the colour in terms of brightness. Each horse experienced the colours in a different order, a new colour was started after 85% correct responses over five consecutive sessions or if accuracy showed no trend over sessions. All horses reached the 85% correct with blue versus grey, three horses did so with both yellow and green versus grey. All were above chance with red versus grey but none reached criterion. Further analysis showed the wavelengths of the green stimuli used overlapped with the yellow. The results are consistent with histological and behavioural studies that suggest that horses are dichromatic. They differ from some earlier data in that they indicate horses can discriminate yellow and blue, but that they may have deficiencies in discriminating red and green.

Preoperative chemoradiation and flap reconstruction provide high local control and low wound complication rates for patients undergoing limb salvage surgery for upper extremity tumors.

BACKGROUND AND OBJECTIVES: Neoadjuvant protocols in the management of upper extremity sarcoma have improved local control rates but have been associated with high complication rates. We present a refinement of the Eilber protocol using judicious preoperative chemoradiation, limb salvage surgery, and flap coverage to achieve high local control rates with acceptable wound healing complications. METHODS: Patients presenting with upper extremity neoplasms from 1986 to 2002 were treated with a modified Eilber protocol, consisting of 3 days of adriamycin (30 mg/day) and sequential radiotherapy (300 cGy/day for 10 days). Limb salvage surgery with flap coverage where needed was performed 4-8 weeks later. Patients were followed prospectively for recurrence. RESULTS: Fifty-three consecutive patients with upper extremity tumors were treated and followed for a mean of 6.1 years. This cohort included 44 sarcomas and nine non-metastasizing, locally aggressive tumors. There were two local recurrences (3.8%). Limb salvage was achieved in all patients. Flaps were required in 43.4% of patients. Major complications occurred in 11%, were all flap related (partial flap loss, venous congestion), and went on to heal promptly with treatment. CONCLUSION: This modified Eilber protocol achieved 96% local control for upper extremity tumors with a wound complication rate of 11%. The liberal use of flaps of resulted in healed, stable wounds in all patients.

Use of tissue expanders and pre-operative external beam radiotherapy in the treatment of retroperitoneal sarcoma.

INTRODUCTION: We report our experience of treating retroperitoneal sarcoma (RPS) using pre-operative external beam radiotherapy (EBRT) in combination with radical resectional surgery from 1990 to 2005. METHODS: Twenty-eight primary and 10 recurrent tumors were identified from a prospective database. RESULTS: The resection rate was 71% overall; 82% in primary (23/28) and 40% (4/10) in recurrent cases. EBRT was administered preoperatively in 25 patients, postoperatively in 1, and palliatively in 11. In 33 patients a saline-filled tissue expander was inserted into the abdomen before radiotherapy to displace small bowel from the radiation field. 4,500-5,000 cGy was administered in fractions of 180-200 cGy over a 5-week period; surgery followed 6-8 weeks later. Expander insertion was associated with minimal morbidity; 31/37 patients received a dose of 4,000 cGy or more (median 4,650 cGy). Median resected tumor diameter was 13 cm, and a median of three adjacent organs was resected per patient. Complete macroscopic resection was achieved in 25/27 patients (93%); R0 in 9 (33%) and R1 in 13 (48%) (microscopic margins unclear in 5). There was no postoperative mortality. Tumors were high-grade in 20 patients, low-grade in 14 and ungraded in 4. Actuarial 5- and 10-year survival for all patients was 74 and 60%. For operable primary tumors, the 5-year survival and disease-free rates were 90 and 80%. In four patients with operable recurrent tumors, median disease-free interval was 91 months (27-160). In the 11 inoperable cases, median survival after radiotherapy was 48 months (9-77). CONCLUSIONS: We conclude that a combination of pre-operative tissue expander placement, high-dose EBRT and radical resectional surgery can achieve acceptable morbidity, extended survival and low long-term recurrence in patients with RPS. STATISTICS: Median (interquartile range).

Autologous diaphragm reconstruction with the pedicled latissimus dorsi flap.

The latissimus dorsi (LD) muscle has been previously described to repair diaphragmatic defects, but as a "reverse" flap, relying on secondary blood supply from the perforating lumbar vessels rather than primary inflow from the dominant thoracodorsal artery. We report resection of a retroperitoneal synovial sarcoma, with reconstruction of the hemidiaphragm using the LD rotated on its primary neurovascular bundle. By using the dominant pedicle, the vascularity of the flap is improved, minimizing the chance of flap tip loss. Maintaining an intact nerve supply prevents atrophy. As the distal origin of the LD is broad and flat, it is ideally suited for diaphragm repair. A latissimus-sparing thoracotomy incision is required to enable this method of diaphragm reconstruction.

Concurrent second-order schedules: some effects of variations in response number and duration.

To examine the effects on concurrent performance of independent manipulations of response-unit duration and number, 6 hens were exposed to concurrent second-order schedules of reinforcement. Each first-order operant unit required completion of a fixed-ratio schedule within the time specified by a fixed-interval schedule, with one further response completing the fixed-interval schedule. The fixed-ratio and fixed-interval requirements comprising the first-order operant units were systematically and independently varied under three pairs of concurrent variable-interval schedules to produce differences in the first-order response and duration requirements (response and duration differentials). These manipulations produced consistent changes in response, time, and operant-unit biases. A 1:4 response differential biased the time and operant-unit measures towards the smaller fixed ratio, but to a degree less than the imposed response differential. The response-based biases favored the larger fixed ratio. Duration differentials of 4:1 and 8:1 biased the response and operant-unit measures towards the shorter fixed interval, again less than the imposed duration differential, but the time biases remained close to zero. Both sorts of differentials acted to bias operant-unit completions more systematically than the other measures, but undermatching to the differentials occurred. The undermatching appears to have arisen from a pattern of fix and sample (in which visits to the less preferred alternative involved only a single completed operant unit) under combinations of unequal operant-unit requirements and reinforcer rates. The response and time bias measures appeared to arise as by-products of the changes in operant-unit completions.

Establishing and maintaining an operant research facility with brushtail possums (Trichosurus vulpecula).

The common brushtail possum (Trichosurus vulpecula) is a readily accessible marsupial that has been shown to adapt relatively well to captivity. The aim of this paper is to outline the husbandry procedures, experimental equipment, and methodologies used successfully within our possum colony since 1995.

Education is the key to quality of surgery for rectal cancer.

Surgical quality assurance is a central issue in the treatment of rectal cancer and has led to substantial improvements in sphincter preservation, local control, and overall survival. Education or training as well as volume of practice are often cited as the major predictors of quality outcomes. While volume is a simple measure to analyze, it is likely a superficial or surrogate measure of quality surgery. It has been conclusively demonstrated that education, from total mesorectum excision workshops to nation-wide educational initiatives are effective methods of improving quality of care for the rectal cancer patient. New methods of quality assurance and improvement are being developed including prospective quality registers, the synoptic operative report, and pathology audits. It is imperative that improved measures of quality, other than volume, be implemented to audit our own practices, hospitals and regions with the goal of identifying issues that will improve outcomes for rectal cancer patients.

Determination of auditory thresholds in the brushtail possum (Trichosurus vulpecula).

The auditory abilities of the brushtail possum (Trichosurus vulpecula) have been measured by cochlear potential readings, but no behavioural determinations of their auditory abilities have been published. Six experimentally naive possums were trained to perform a two-response conditional discrimination between the presence and absence of an 880-Hz tone (at 80 dB). All six possums readily learned this task. The behavioural threshold for this tone was determined using a modified tracking procedure and found to be similar to that reported using cochlear microphonic potentials. One concern with the current method was the communal nature of the experimental environment so a further threshold determination in a sound-attenuating chamber was conducted. No substantial difference was noted between the results obtained in the two threshold determinations. The success of the current method means that a full, behavioural audiogram for the brushtail possum, which would complement the existing cochlear potential data, is now possible.

Long-term results of a prospective surgical trial comparing 2 cm vs. 4 cm excision margins for 740 patients with 1-4 mm melanomas.

BACKGROUND: The Intergroup Melanoma Surgical Trial began in 1983 to examine the optimal surgical margins of excision for primary melanomas of intermediate thickness (i.e., 1-4 mm). There is now a median 10-year follow-up. METHODS: There were two cohorts entered into a prospective multi-institutional trial: (1) 468 patients with melanomas on the trunk or proximal extremity who randomly received a 2 cm or 4 cm radial excision margin and (2) 272 patients with melanomas on the head, neck, or distal extremities who received a 2 cm radial excision margin. RESULTS: A local recurrence (LR) was associated with a high mortality rate, with a 5-year survival rate of only 9% (as a first relapse) or 11% (anytime) compared with an 86% survival for those patients who did not have a LR (P < .0001). The 10-year survival for all patients with a LR was 5%. The 10-year survival rates were not significantly different when comparing 2 cm vs. 4 cm margins of excision (70% vs. 77%) or comparing the management of the regional lymph nodes (observation vs. elective node dissection). The incidences of LR were the same for patients having a 2 cm vs. 4 cm excision margin regardless of whether the comparisons were made as first relapse (0.4% vs. 0.9%) or at anytime (2.1% vs. 2.6%). When analyzed by anatomic site, the LR rates were 1.1% for melanomas arising on the proximal extremity, 3.1% for the trunk, 5.3% for the distal extremities, and 9.4% for the head and neck. The most profound influence on LR rates was the presence or absence of ulceration; it was 6.6% vs. 1.1% in the randomized group involving the trunk and proximal extremity and was 16.2% vs. 2.1% in the non-randomized group involving the distal extremity and head and neck (P < .001). A multivariate (Cox) regression analysis showed that ulceration was an adverse and independent factor (P = .0001) as was head and neck melanoma site (P = .01), while the remaining factors were not significant (all with P > .12). CONCLUSION: For this group of melanoma patients, a local recurrence is associated with a high mortality rate, a 2-cm margin of excision is safe and ulceration of the primary melanoma is the most significant prognostic factor heralding an increased risk for a local recurrence.