Implicit Bias Training: Improving Outcomes for Patients With Cancer Who Have Substance Use Disorders.

Being mindful of one's implicit bias in the treatment of patients with cancer who have substance use disorders is fundamental to quality of care and good patient outcomes. Implicit bias held by healthcare professionals could negatively affect patient assessment, diagnosis and treatment decisions, and follow-ups at discharge.

Pain Assessment: Use of the Defense and Veterans Pain Rating Scale in Patients With Cancer.

BACKGROUND: Thorough, consistent pain assessment and reassessment are critical to guide and evaluate interventions designed to improve pain. OBJECTIVES: Based on a literature review about functional pain assessment, clinicians selected and then implemented the Defense and Veterans Pain Rating Scale (DVPRS) as a pain assessment instrument option in a comprehensive cancer center. METHODS: The DVPRS was added as a pain assessment instrument in clinical oncology practice. From postimplementation chart review and clinician satisfaction surveys, the DVPRS was evaluated for the following. FINDINGS: Seventy-eight percent of nurses surveyed (N = 64) preferred the DVPRS over any other pain assessment tool. Inpatient and ambulatory patients surveyed (N = 144) agreed that a Likert-type scale in the DVPRS was easier to understand, easier to use, and better in describing their pain than the numeric rating scale.

Advances in the Treatment of Metastatic Renal Cell Carcinoma.

The treatment landscape for metastatic renal cell carcinoma has constantly been in flux. In 2005, with the advent of vascular endothelial growth factor (VEGF) tyrosine kinase inhibitor (TKI) therapy, the standard of care shifted to agents such as sunitinib and pazopanib. However, more recently there have been datasets, suggesting that next-generation TKIs such as cabozantinib may play an important role in therapy. Furthermore, immunotherapy has had resurgence with the FDA approval of nivolumab with ipilimumab. In the current chapter, we attempt to contextualize available frontline therapies for metastatic renal cell carcinoma with a focus on the CABOSUN and CheckMate 214 clinical trials.

Implementation of a standardized pathway for the treatment of cardiac arrest patients using therapeutic hypothermia: "CODE ICE".

Out-of-hospital cardiac arrest is common and is associated with high mortality. The majority of in-hospital deaths from resuscitated victims of cardiac arrest are due to neurologic injury. Therapeutic hypothermia (TH) is now recommended for the management of comatose survivors of cardiac arrest. The rapid triage and standardized treatment of cardiac arrest patients can be challenging, and implementation of a TH program requires a multidisciplinary team approach. In 2010, we revised our institution's TH protocol, creating a "CODE ICE" pathway to improve the timely and coordinated care of cardiac arrest patients. As part of CODE ICE, we implemented comprehensive care pathways including measures such as a burst paging system and computerized physician support tools. "STEMI on ICE" integrates TH with our regional ST-elevation myocardial infarction network. Retrospective data were collected on 150 consecutive comatose cardiac arrest victims treated with TH (n = 82 pre-CODE ICE and n = 68 post-CODE ICE) from 2007 to 2011. After implementation of CODE ICE, the mean time to initiation of TH decreased from 306 ± 165 minutes to 196 ± 144 minutes (P < 0.001), and the time to target temperature decreased from 532 ± 214 minutes to 392 ± 215 minutes (P < 0.001). There was no significant change in survival or neurologic outcome at hospital discharge. Through the implementation of CODE ICE, we were able to reduce the time to initiation of TH and time to reach target temperature. Additional studies are needed to determine the effect of CODE ICE and similar pathways on clinical outcomes after cardiac arrest.

Violence against women in South Africa: policy position and recommendations.

Violence against women (VAW) in South Africa remains rampant, irrespective of human rights- focused laws passed by the government. This article reflects on the position of two acts: the Domestic Violence Act No 116 of 1998 and Criminal Law (Sexual Offense and Related Matters) Act No 32 of 2007. Both are framed to protect women against all forms of violence. The article discusses the prisms of the two laws, an account of the position taken or interpreted by the reviewed literature regarding the acts, and the findings and recommendations regarding the infrastructure and supports needed to appropriately implement the two acts.

A protocol for a systematic review of knowledge translation strategies in the allied health professions.

BACKGROUND: Knowledge translation (KT) aims to close the gap between knowledge and practice in order to realize the benefits of research through (a) improved health outcomes, (b) more effective health services and products, and (c) strengthened healthcare systems. While there is some understanding of strategies to put research findings into practice within nursing and medicine, we have limited knowledge of KT strategies in allied health professions. Given the interprofessional nature of healthcare, a lack of guidance for supporting KT strategies in the allied health professions is concerning. Our objective in this study is to systematically review published research on KT strategies in five allied health disciplines. METHODS: A medical research librarian will develop and implement search strategies designed to identify evidence that is relevant to each question of the review. Two reviewers will perform study selection and quality assessment using standard forms. For study selection, data will be extracted by two reviewers. For quality assessment, data will be extracted by one reviewer and verified by a second. Disagreements will be resolved through discussion or third party adjudication. Within each profession, data will be grouped and analyzed by research design and KT strategies using the Effective Practice and Organisation of Care Review Group classification scheme. An overall synthesis across professions will be conducted. SIGNIFICANCE: A uniprofessional approach to KT does not represent the interprofessional context it targets. Our findings will provide the first systematic overview of KT strategies used in allied health professionals' clinical practice, as well as a foundation to inform future KT interventions in allied healthcare settings.

The rapidly changing location of death in Canada, 1994-2004.

This 2008 study assessed location-of-death changes in Canada during 1994-2004, after previous research had identified a continuing increase to 1994 in hospital deaths. The most recent (1994-2004) complete population and individual-level Statistics Canada mortality data were analyzed, involving 1,806,318 decedents of all Canadian provinces and territories except Quebec. A substantial and continuing decline in hospitalized deaths was found (77.7%-60.6%). This decline was universal among decedents regardless of age, gender, marital status, whether they were born in Canada or not, across urban and rural provinces, and for all but two (infrequent) causes of death. This shift occurred in the absence of policy or purposive healthcare planning to shift death or dying out of hospital. In the developed world, recent changing patterns in the place of death, as well as the location and type of care provided near death appear to be occurring, making location-of-death trends an important topic of investigation. Canada is an important case study for highlighting the significance of location-of-death trends, and suggesting important underlying causal relationships and implications for end-of-life policies and practices.

Evaluation of a new pulse oximeter sensor.

BACKGROUND: A new forehead noninvasive oxygen saturation sensor may improve signal quality in patients with low cardiac index. OBJECTIVES: To examine agreement between oxygen saturation values obtained by using digit-based and forehead pulse oximeters with arterial oxygen saturation in patients with low cardiac index. METHODS: A method-comparison study was used to examine the agreement between 2 different pulse oximeters and arterial oxygen saturation in patients with low cardiac index. Readings were obtained from a finger and a forehead sensor and by analysis of a blood sample. Bias, precision, and root mean square differences were calculated for the digit and forehead sensors. Differences in bias and precision between the 2 noninvasive devices were evaluated with a t test (level of significance P<.05). RESULTS: Nineteen patients with low cardiac index (calculated as cardiac output in liters per minute divided by body surface area in square meters; mean 1.98, SD 0.34) were studied for a total of 54 sampling periods. Mean (SD) oxygen saturations were 97% (2.4) for blood samples, 96% (3.2) for the finger sensor, and 97% (2.8) for the forehead sensor. By Bland Altman analysis, bias +/- precision was -1.16 +/- 1.62% for the digit sensor and -0.36 +/- 1.74% for the forehead sensor; root mean square differences were 1.93% and 1.70%, respectively. Bias and precision differed significantly between the 2 devices; the forehead sensor differed less from the blood sample. CONCLUSIONS: In patients with low cardiac index, the forehead sensor was better than the digit sensor for pulse oximetry.

Fundamental flaws of hormesis for public health decisions.

Hormesis (defined operationally as low-dose stimulation, high-dose inhibition) is often used to promote the notion that while high-level exposures to toxic chemicals could be detrimental to human health, low-level exposures would be beneficial. Some proponents claim hormesis is an adaptive, generalizable phenomenon and argue that the default assumption for risk assessments should be that toxic chemicals induce stimulatory (i.e., "beneficial") effects at low exposures. In many cases, nonmonotonic dose-response curves are called hormetic responses even in the absence of any mechanistic characterization of that response. Use of the term "hormesis," with its associated descriptors, distracts from the broader and more important questions regarding the frequency and interpretation of nonmonotonic dose responses in biological systems. A better understanding of the biological basis and consequences of nonmonotonic dose-response curves is warranted for evaluating human health risks. The assumption that hormesis is generally adaptive is an oversimplification of complex biological processes. Even if certain low-dose effects were sometimes considered beneficial, this should not influence regulatory decisions to allow increased environmental exposures to toxic and carcinogenic agents, given factors such as interindividual differences in susceptibility and multiplicity in exposures. In this commentary we evaluate the hormesis hypothesis and potential adverse consequences of incorporating low-dose beneficial effects into public health decisions. Key words: biphasic dose response, hormesis, individual susceptibility, low-dose exposures, nonmonotonic dose response, nonlinear dose response, public health, regulation, risk assessment.

"Hormesis"--an inappropriate extrapolation from the specific to the universal.

Although it is generally accepted that some chemicals may have beneficial effects at low doses, incorporating these effects into risk assessments generally ignores well-established factors related to exposure and human susceptibility. The authors argue against indiscriminate application of hormesis in assessments of chemical risks for regulatory purposes.