Integration of oncology and palliative care: setting a benchmark.

BACKGROUND: Integration of oncology and palliative care (PC) should be the standard model of care for patients with advanced cancer. An expert panel developed criteria that constitute integration. This study determined whether the PC service within this Health Service, which is considered to be fully "integrated", could be benchmarked against these criteria. METHODS: A survey was undertaken to determine the perceived level of integration of oncology and palliative care by all health care professionals (HCPs) within our cancer centre. An objective determination of integration was obtained from chart reviews of deceased patients. Integration was defined as >70% of all respondents answered "agree" or "strongly agree" to each indicator and >70% of patient charts supported each criteria. RESULTS: Thirty-four HCPs participated in the survey (response rate 69%). Over 90% were aware of the outpatient PC clinic, interdisciplinary and consultation team, PC senior leadership, and the acceptance of concurrent anticancer therapy. None of the other criteria met the 70% agreement mark but many respondents lacked the necessary knowledge to respond. The chart review included 67 patients, 92% of whom were seen by the PC team prior to death. The median time from referral to death was 103 days (range 0-1347). The level of agreement across all criteria was below our predefined definition of integration. CONCLUSION: The integration criteria relating to service delivery are medically focused and do not lend themselves to interdisciplinary review. The objective criteria can be audited and serve both as a benchmark and a basis for improvement activities.

Implementing practice change in chronic cancer pain management: clinician response to a phase III study of ketamine.

BACKGROUND: An adequately powered, double-blind, multisite, randomised controlled trial has shown no net clinical benefit for subcutaneous ketamine over placebo in the management of cancer pain refractory to combination opioid and co-analgesic therapy. The results of the trial were disseminated widely both nationally and internationally. AIM: To determine whether the trial had impacted on clinical practice in Australasia. METHODS: Members of the Australia and New Zealand Society of Palliative Medicine were sent an online ketamine utilisation survey. RESULTS: A total of 123/392 clinicians responded (31% response rate). The majority of respondents had practised for more than 10 years in a metropolitan hospital setting. Ketamine had been prescribed by 91% of respondents, and 92% were aware of the trial. As a result, 65% of respondents had changed practice (17% no longer prescribed ketamine, 46% used less and 2% more). Thirty-five per cent had not changed practice. Reasons for change included belief in the results of the study, concerns over the toxicity reported or because there were alternatives for pain control. Of those who prescribed less, over 80% were more selective and would now only use the drug in certain clinical situations or pain types, or when all other medications had failed. CONCLUSIONS: Although two-thirds of respondents reported practice change as a result of the randomised controlled trial, a minority remained convinced of the benefit of the drug from their own observations and would require additional evidence.

Quantification of fracture healing from radiographs using the maximum callus index.

UNLABELLED: Callus formation and growth are an essential part of secondary fracture healing. Callus growth can be observed radiographically and measured using the "Callus Index," which is defined as the maximum diameter of the callus divided by the diameter of the bone. We compared three groups of patients with tibial fractures treated by external fixation, intramedullary nailing, and casting to assess the validity of using serial measurements of callus index as a measure of fracture healing. When callus index was plotted against time for each patient, the point at which the fracture began to remodel, indicated by the highest point of the curve, was observed as a consistent feature regardless of fixation method. This occurred on average at 2(1/2) weeks after plaster cast removal (14 weeks post injury), 5 weeks after external fixator removal (22 weeks post injury), and 27 weeks post injury for the intramedullary nailed fractures. Because remodeling only occurs once the fracture is stable, a peak in callus index is a reliable sign that the fracture has united. Serial measurements of callus index would therefore appear to offer a simple method of quantifying secondary fracture healing regardless of the treatment method used. LEVEL OF EVIDENCE: Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Weight bearing after tibial fracture as a guide to healing.

BACKGROUND: Judging when it is safe to remove an external fixator or plaster cast requires clinical and radiological assessment, both of which are subjective. Weight bearing has been shown to increase with time post-fracture and we hypothesised that it could be used as an objective measure of fracture healing. METHODS: Ground reaction force (and hence weight bearing) and fracture stiffness were measured serially in a group of 12 patients with tibial fractures treated by external fixation. Ground reaction force was measured for both fractured and non-fractured limbs using a force plate and the fracture stiffness was measured using the Orthometer, a commercially produced device for measuring the stiffness of fractures treated by external fixation. FINDINGS: In 10 patients who made good recoveries, prior to fixator removal, weight bearing though the injured leg was seen to approach 90% of that through the uninjured leg and the fracture stiffness exceeded 15 Nm/deg. Two patients with delayed union achieved weight bearing of 40% of normal and a fracture stiffness of less than 5 Nm/deg at 20 weeks. INTERPRETATION: Weight bearing correlates reasonably well with fracture stiffness. It is quicker and easier to measure than fracture stiffness and potentially has relevance to other fracture fixation methods.

Audit of the care of the dying in a network of hospitals and institutions in Queensland.

BACKGROUND: Most Australians die in institutions and there is evidence to suggest that the care of these patients is not always optimal. Care pathways for the dying have been designed to transfer benchmarked hospice care to other settings (e.g. acute hospitals and residential age-care facilities) by defining goals of best care, providing guidelines to provide that care and documenting outcome. METHOD: A retrospective audit was undertaken across a network of health-care institutions in Queensland. The 18 goals considered essential for the care of the dying within the Liverpool Care Pathway were taken as a benchmark. Documentation of achievement of each of these goals was sought. RESULTS: The notes of 160 patients who had died in eight institutions (four hospitals, three hospices, one nursing home) were reviewed. Several areas for improvement were identified, particularly in those goals relating to communication, resuscitation orders and care after death. Few units documented the provision of written information to families. Most patients were prescribed medications in anticipation of pain and agitation but less were prescribed drugs for other common symptoms in the dying. Most of the goals were achieved in a higher percentage of cases in hospice units. Marked differences in practice were noted between different institutions. CONCLUSION: The audit identified several aspects in the care of the terminally ill that could be improved. End-stage pathways may provide a model for improving the care of patients dying in hospitals and institutions in Australia.

Rupture of the quadriceps tendon: an association with a patellar spur.

We reviewed the records of 107 consecutive patients who had undergone surgery for disruption of the knee extensor mechanism to test whether an association existed between rupture of the quadriceps tendon and the presence of a patellar spur. The available standard pre-operative lateral radiographs were examined to see if a patellar spur was an indicator for rupture of the quadriceps tendon in this group of patients. Of the 107 patients, 12 underwent repair of a ruptured patellar tendon, 59 had an open reduction and internal fixation of a patellar fracture and 36 repair of a ruptured quadriceps tendon. In the 88 available lateral radiographs, patellar spurs were present significantly more commonly (p < 0.0005) in patients operated on for rupture of the quadriceps tendon (79%) than in patients with rupture of the patellar tendon (27%) or fracture of the patella (15%). In patients presenting with failure of the extensor mechanism of the knee in the presence of a patellar spur, rupture of the quadriceps tendon should be considered as a possible diagnosis.

Strain induced half-metal to semiconductor transition in GdN.

We investigate the electronic structure and magnetic properties of GdN as a function of unit cell volume. Based on the first-principles calculations of GdN, we observe that there is a transformation in the conduction properties associated with the volume increase: first from half-metallic to semimetallic, then ultimately to semiconducting. We show that applying stress can alter the carrier concentration as well as mobility of the holes and electrons in the majority spin channel. In addition, we found that the exchange parameters depend strongly on lattice constant, thus the Curie temperature of this system can be enhanced by applying stress or doping impurities.

Phase transition in single crystal Cs2Nb4O11.

We studied temperature dependence of complex capacitance, impedance, and polarized Raman spectra of single crystal Cs2Nb4O11. First, we observed a sharp lambda-shaped peak at 165 degrees C in the complex capacitance, then found drastic changes in the Raman spectra in the same temperature range. Utilizing the pseudosymmetry search of structure space group, we attributed the observed anomalies to a structural change from the room temperature orthorhombic Pnn2 to another orthorhombic Imm2. We also measured room temperature polarized Raman spectra in different symmetries of normal vibrations and assigned high wavenumber Raman bands to the internal vibrations of NbO6 octahedra and NbO4 tetrahedra.

Bacterial contamination of surgical gloves by water droplets spilt after scrubbing.

Wound infection and deep sepsis can have disastrous consequences, particularly in orthopaedic surgery. Strict protocols, ultra-clean air, prophylactic antibiotics, and impervious gowns and drapes, have all been shown to diminish wound infection. However it remains a common and significant problem. The water droplets spilt from the surgeons hands after meticulous scrubbing with povidone iodine were cultured. The permeability of the surgical glove packaging to Gram-positive bacteria was also investigated. The water droplets from the surgeon's arms contained environmental and potentially pathogenic bacteria including a micrococcus, a coliform and coagulase-negative staphylococci. The paper packaging for the range of sterile surgical gloves tested was discovered to be permeable to Gram-positive bacteria. In conclusion accidental water droplet contamination of surgical gloves is a potential source of infection. Alternative recommendations are made.

A phase II study to establish the efficacy and toxicity of sodium valproate in patients with cancer-related neuropathic pain.

The efficacy and toxicity of sodium valproate for cancer-related neuropathic pain was evaluated in a phase II study at this cancer center. Twenty-five patients entered the study over a 13 month period. Pain was assessed using a pain scale based on the Brief Pain Inventory at days 0, 8 and 15. Nineteen patients completed the two week study period, one patient discontinued treatment because of toxicity, and five discontinued because of progressive disease. The most frequently observed side effects were drowsiness, unsteadiness, nausea, and decreased appetite. Response was defined as a decrease in pain score in the absence of increased need for analgesic medication. The response rate for average pain at day 15 in assessable patients was 55.6% (30.8-78.5%, 95% CI), but response rates varied considerably depending on the mode of analysis. Baseline efficacy data have been gained on which to base future comparative studies against antidepressants.

A prospective survey of the use of dexamethasone on a palliative care unit.

One hundred and six consecutive patients started on glucocorticosteroids (steroids) according to a defined prescription policy were surveyed each week to document the indications for use, any beneficial effect, any toxicity incurred and the reason for stopping. All patients had advanced malignant disease and survived for a median of 40.5 days (range 1-398+ days) from the start of steroid treatment. Fifty-seven per cent of patients completed three or more assessments. The most common specific indications for starting steroids were spinal cord compression, cerebral metastases, lymphangitis carcinomatosa and intestinal obstruction. The most common non-specific indications were anorexia, nausea, low mood, pain and vomiting. The median duration of steroid use was 21.5 days (range 1-89 days). The most common reason for the discontinuation of steroids was death or deteriorating condition. Symptom scores improved at some stage for the majority of patients started on steroids for anorexia, nausea, pain, low mood, vomiting and weakness but not in patients complaining of dyspnoea or poor mobility. The most common side-effects that were most probably attributable to steroid therapy were oral candidosis and proximal myopathy. The benefits of steroids when used according to defined guidelines were thought to outweigh toxicity.