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Methotrexate-induced liver fibrosis is not a well-defined pathology, and many of the reported cases can instead be classified as nonalcoholic fatty liver disease by current diagnostic criteria, which is particularly common in the psoriasis cohort. Liver fibrosis usually takes many years to progress; therefore, screening for liver fibrosis should be done no more regularly than annually at the very most in dermatology practice. An algorithm is presented about how to investigate abnormal liver blood tests and screening tools for liver fibrosis are compared.

Environmental context Toxicity and mobility of antimony and arsenic in aqueous systems are largely determined by their speciation and redox chemistry. In a highly contaminated freshwater system, one antimony species (dissolved SbV) dominated, while dissolved arsenic was more responsive to environmental conditions. Arsenic (as AsV) increased significantly during a drought period; this increase in As mobility presents a threat for first flush events and water contamination in a changing climate. Abstract Aqueous and solid-state antimony (Sb) and arsenic (As) speciation is assessed in an Australian freshwater system contaminated by mining of primary sulfide minerals. The study aims to understand metalloid transformation and mobilisation in the system, and coincides with a severe drought providing the opportunity to examine the influence of extreme low-flow conditions. X-ray absorption spectra identified only SbV in

Background: Despite advances in surgery and pharmacotherapy, there remains significant residual ischemic risk after coronary artery bypass grafting surgery. Methods: In REDUCE-IT (Reduction of Cardiovascular Events With Icosapent Ethyl–Intervention Trial), a multicenter, placebo-controlled, double-blind trial, statin-treated patients with controlled low-density lipoprotein cholesterol and mild to moderate hypertriglyceridemia were randomized to 4 g daily of icosapent ethyl or placebo. They experienced a 25% reduction in risk of a primary efficacy end point (composite of cardiovascular death, myocardial infarction, stroke, coronary revascularization, or hospitalization for unstable angina) and a 26% reduction in risk of a key secondary efficacy end point (composite of cardiovascular death, myocardial infarction, or stroke) when compared with placebo. The current analysis reports on the subgroup of patients from the trial with a history of coronary artery bypass grafting. Results: Of the 8179 patients randomized in REDUCE-IT, a total of 1837 (22.5%) had a history of coronary artery bypass grafting, with 897 patients randomized to icosapent ethyl and 940 to placebo. Baseline characteristics were similar between treatment groups. Randomization to icosapent ethyl was associated with a significant reduction in the primary end point (hazard ratio [HR], 0.76 [95% CI, 0.63–0.92]; P =0.004), in the key secondary end point (HR, 0.69 [95% CI, 0.56–0.87]; P =0.001), and in total (first plus subsequent or recurrent) ischemic events (rate ratio, 0.64 [95% CI, 0.50–0.81]; P =0.0002) compared with placebo. This yielded an absolute risk reduction of 6.2% (95% CI, 2.3%–10.2%) in first events, with a number needed to treat of 16 (95% CI, 10–44) during a median follow-up time of 4.8 years. Safety findings were similar to the overall study: beyond an increased rate of atrial fibrillation/flutter requiring hospitalization for at least 24 hours (5.0% vs 3.1%; P =0.03) and a nonsignificant increase in bleeding, occurrences of adverse events were comparable between groups. Conclusions: In REDUCE-IT patients with a history of coronary artery bypass grafting, treatment with icosapent ethyl was associated with significant reductions in first and recurrent ischemic events. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01492361.

Introduction There are limited reports on the mental health toll associated with the fear of spreading coronavirus disease 2019 (COVID-19) and the associated stay-at-home orders. The goal of the present study was to characterize the self-reported stress of participants from the Kansas City Metropolitan Area (KCMA) and to examine the relation between potential for asymptomatic spread and perceived stress. Methods This prospective convenience sample study enrolled 461 participants from May 4 to May 22, 2020. Participants were consented and surveyed prior to free SARS-CoV-2 testing. Measures employed included the Perceived Stress Scale-10 and a comprehensive COVID-19 questionnaire. During the study period, testing resources were limited. In the community, only symptomatic individuals or close contacts of known positives could be tested. Our program aimed to reach those who were unable to access testing resources due to their asymptomatic status or other barriers to care. Results Worry about asymptomatic spread was associated significantly with greater perceived stress (p < 0.001). Higher stress was reported among women (p < 0.001), Hispanic/Latinx (p = 0.001), non-Black/ African American individuals (p < 0.001), and those reporting the presence of COVID-19 symptoms (p = 0.001). Conclusions The COVID-19 pandemic has caused significant economic, social, and health disruptions around the world. Distress is significantly related to concern over unintentionally contributing to the spread of SARS-CoV-2 through asymptomatic transmission. In addition to examining outcomes like distress, future research should characterize the modifiable psychotherapeutic processes that might be targeted through intervention among those experiencing distress.

Determine the dosimetric quality and the planning time reduction when utilizing a template-based automated planning application.A software application integrated through the treatment planning system application programing interface, QuickPlan, was developed to facilitate automated planning using configurable templates for contouring, knowledge-based planning structure matching, field design, and algorithm settings. Validations are performed at various levels of the planning procedure and assist in the evaluation of readiness of the CT image, structure set, and plan layout for automated planning. QuickPlan is evaluated dosimetrically against 22 hippocampal-avoidance whole brain radiotherapy patients. The required times to treatment plan generation are compared for the validations set as well as 10 prospective patients whose plans have been automated by QuickPlan.The generations of 22 automated treatment plans are compared against a manual replanning using an identical process, resulting in dosimetric differences of minor clinical significance. The target dose to 2% volume and homogeneity index result in significantly decreased values for automated plans, whereas other dose metric evaluations are nonsignificant. The time to generate the treatment plans is reduced for all automated plans with a median difference of 9' 50″ ± 4' 33″.Template-based automated planning allows for reduced treatment planning time with consistent optimization structure creation, treatment field creation, plan optimization, and dose calculation with similar dosimetric quality. This process has potential expansion to numerous disease sites.

As the overweight and obese population increases, one must be mindful of the implications on the delivery of dental care to this group. Appropriate facilities must be available, which may warrant structural and equipment adaptations to clinical and non-clinical areas. The complexity of dental treatment planning and delivery may be compounded by medical comorbidities, and careful consideration must be given to the suitability and safety of conscious sedation and general anaesthesia in order to facilitate treatment. This article aims to discuss how safe provision and equitable access to dental care can be achieved for the bariatric population. CPD/Clinical Relevance: This article aims to discuss the challenges posed by the increase in the overweight and obese population and considerations to be taken for provision of safe and equitable bariatric dental care.

Introduction Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging invasive rescue therapy for treatment of refractory out-of-hospital cardiac arrests (OHCA). We aim to describe the incidence of traumatic and hemorrhagic complications among patients undergoing ECPR for OHCA and examine the association between CPR duration and ECPR-related injuries or bleeding. Methods We examined prospectively collected data from the Extracorporeal Resuscitation Outcomes Database (EROD), which includes ECPR-treated OHCAs from participating hospitals (October 2014 to August 2019). The primary outcome was traumatic or hemorrhagic complications, defined any of the following: pneumothorax, pulmonary hemorrhage, major bleeding, cannula site bleeding, gastrointestinal bleeding, thoracotomy, cardiac tamponade, aortic dissection, or vascular injury during hospitalization. The primary exposure was the cardiac arrest to ECPR initiation interval (CA-ECPR interval), measured as the time from arrest to initiation of ECPR. Descriptive statistics were used to compare demographic, cardiac arrest, and ECPR characteristics among patients with and without CPR-related traumatic or bleeding complications. Multivariable logistic regression was used to examine the association between CA-ECPR interval and traumatic or bleeding complications. Results A total of 68 patients from 4 hospitals receiving ECPR for OHCA were entered into EROD and met inclusion criteria. Median age was 51 (interquartile range 38–58), 81% were male, 40% had body mass index > 30, and 70% had pre-existing medical comorbidities. A total of 65% had an initial shockable cardiac rhythm, mechanical CPR was utilized in at least 29% of patients, and 27% were discharged alive. The median time from arrest to ECPR initiation was 73 min (IQR 60–104). A total of 37% experienced a traumatic or bleeding complication, with major bleeding (32%), vascular injury (18%), and cannula site bleeding (15%) being the most common. Compared to patients with shorter CPR times, patients with a longer CA-ECPR interval had 18% (95% confidence interval — 2–42%) higher odds of suffering a mechanical or bleeding complication, but this did not reach statistical significance (p = 0.08). Conclusions Traumatic injuries and bleeding complications are common among patients undergoing ECPR. Further study is needed to investigate the relation between arrest duration and complications. Clinicians performing ECPR should anticipate and assess for injuries and bleeding in this high-risk population.

Shotgun metagenomics studies have improved our understanding of microbial population dynamics and have revealed significant contributions of microbes to gut homeostasis. They also allow in silico inference of the metagenome. While they link the microbiome with metabolic abnormalities associated with disease phenotypes, they do not capture microbial gene expression patterns that occur in response to the multitude of stimuli that constantly ambush the gut environment. Metatranscriptomics closes that gap, but its implementation is more expensive and tedious. We assessed the metabolic perturbations associated with gut inflammation using shotgun metagenomics and metatranscriptomics. Shotgun metagenomics detected changes in abundance of bacterial taxa known to be SCFA producers, which favors gut homeostasis. Bacteria in the phylum Firmicutes were found at decreased abundance, while those in phyla Bacteroidetes and Proteobacteria were found at increased abundance. Surprisingly, inferring the coding capacity of the microbiome from shotgun metagenomics data did not result in any statistically significant difference, suggesting functional redundancy in the microbiome or poor resolution of shotgun metagenomics data to profile bacterial pathways, especially when sequencing is not very deep. Obviously, the ability of metatranscriptomics libraries to detect transcripts expressed at basal (or simply low) levels is also dependent on sequencing depth. Nevertheless, metatranscriptomics informed about contrasting roles of bacteria during inflammation. Functions involved in nutrient transport, immune suppression and regulation of tissue damage were dramatically upregulated, perhaps contributed by homeostasis-promoting bacteria. Functions ostensibly increasing bacteria pathogenesis were also found upregulated, perhaps as a consequence of increased abundance of Proteobacteria. Bacterial protein synthesis appeared downregulated. In summary, shotgun metagenomics was useful to profile bacterial population composition and taxa relative abundance, but did not inform about differential gene content associated with inflammation. Metatranscriptomics was more robust for capturing bacterial metabolism in real time. Although both approaches are complementary, it is often not possible to apply them in parallel. We hope our data will help researchers to decide which approach is more appropriate for the study of different aspects of the microbiome.

A green carbon capture and conversion technology offering scalability and economic viability for mitigating CO

Objectives To adapt the Cardiac Self-Blame Attributions Scale into the Self-Blame Attributions for Cancer Scale (SBAC) for use in patients with cancer and analyze its psychometric properties. Sample & setting 113 patients receiving radiation therapy at the University of Kansas Cancer Center. Methods & variables The SBAC and other self-report measures were administered during outpatient oncology appointments for radiation therapy to establish the psychometric properties of the SBAC. Results A two-factor structure represented behavioral and characterological self-blame attributions. Reliability estimates for each factor were excellent and evidence of convergent and discriminant validity was found, indicating support for the SBAC as a valid and reliable measure of self-blame attributions in patients with cancer. Implications for nursing The SBAC may help healthcare providers, including nursing staff, to identify the self-blame patterns exhibited by patients with cancer. Future research can assess the reliability and validity of SBAC across stages of treatment and establish the predictive validity of the scale in individuals with cancer.

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) is a rescue therapy for treatment of refractory out-of-hospital cardiac arrests (OHCA). We describe the incidence of traumatic and hemorrhagic complications among patients undergoing ECPR for OHCA and the association between CPR duration and ECPR-related injuries or bleeding. Methods: We examined prospectively collected data from the Extracorporeal Resuscitation Outcomes Database (EROD), which includes ECPR-treated OHCAs from participating hospitals (Oct 2014 - Aug 2019). The primary outcome was traumatic or hemorrhagic complications, defined as injury to the chest, abdomen, or vasculature, or bleeding requiring transfusion or surgery. The primary exposure was the cardiac arrest to ECPR initiation interval (CA-ECPR interval), measured as the time from arrest to initiation of ECPR. Descriptive statistics were used to compare demographic, cardiac arrest, and ECPR characteristics among patients with and without CPR-related traumatic or bleeding complications. Multivariable logistic regression was used to examine the association between CPR duration and traumatic or bleeding complications. Results: A total of 68 patients from 4 hospitals received ECPR for OHCA were entered into EROD and met inclusion criteria. Median age was 51 (IQR 38-58), 81% were male, 40% had BMI > 30, and 70% had pre-existing medical comorbidities. A total of 65% had an initial shockable cardiac rhythm, mechanical CPR was utilized in at least 29% of patients, and 27% were discharged alive. A total of 37% experienced a traumatic or bleeding complication, with major bleeding (32%), vascular injury (18%), and cannula site bleeding (15%) being the most common. Compared to patients with shorter CPR times, patients with a 10 minute longer CA-ECPR interval had 18% (95% CI -2-42%) higher odds of suffering a mechanical or bleeding complication, but this did not reach statistical significance (p=0.08). Conclusions: Traumatic injuries and bleeding complications are common among patients undergoing ECPR. Further study is needed to investigate the relation between arrest duration and complications. Clinicians performing ECPR should anticipate and assess for injuries and bleeding in this high-risk population.

Background Coronavirus disease (COVID-19) is a global pandemic that has placed a significant burden on health care systems in the United States. Michigan has been one of the top states affected by COVID-19. Objective We describe the emergency center curbside testing procedure implemented at Beaumont Hospital, a large hospital in Royal Oak, MI, and aim to evaluate its safety and efficiency. Methods Anticipating a surge in patients requiring testing, Beaumont Health implemented curbside testing, operated by a multidisciplinary team of health care workers, including physicians, advanced practice providers, residents, nurses, technicians, and registration staff. We report on the following outcomes over a period of 26 days (March 12, 2020, to April 6, 2020): time to medical decision, time spent documenting electronic medical records, overall screening time, and emergency center return evaluations. Results In total, 2782 patients received curbside services. A nasopharyngeal swab was performed on 1176 patients (41%), out of whom 348 (29.6%) tested positive. The median time for the entire process (from registration to discharge) was 28 minutes (IQR 17-44). The median time to final medical decision was 15 minutes (IQR 8-27). The median time from medical decision to discharge was 9 minutes (IQR 5-16). Only 257 patients (9.2%) returned to the emergency center for an evaluation within 7 or more days, of whom 64 were admitted to the hospital, 11 remained admitted, and 4 expired. Conclusions Our curbside testing model encourages the incorporation of this model at other high-volume facilities during an infectious disease pandemic.

Background: The province of Saskatchewan, Canada represents a large geographic territory with 1.2 million residents. Approximately 2000 Saskatchewan residents per year are hospitalized due to stroke, with care being provided at a variety of facilities. Method: The Saskatchewan Acute Stroke Pathway (ASP) was established to implement Canadian Stroke Best Practice Recommendations (CSBPR) province wide. Recommendations included: creation of primary and comprehensive stroke centers, expansion of emergency medical service (EMS) stroke alert bypass window, increased use of telehealth technologies, twenty-four-hour access to computer tomography and angiography, standardized assessment, and diagnostic and treatment tools that integrate best practice guidelines into workflow. All stroke centres are accountable to report key metrics. Results: A significant improvement in access to acute stroke care was achieved. Eight primary stroke centres (PSC) and 1 comprehensive stroke centre (CSC) were established, and a 12 hour EMS bypass window was implemented. EMS adopted the FAST tool to correctly identify stroke patients 78% of the time. Sixty-eight percent of patients arrived at the stroke centre within 4.5 hours of symptom onset, in 2016. The median provincial door to needle time decreased from 82 minutes to 66 minutes. Pathway implementation saw an increase in mechanical thrombectomy from 42, in 2016 to 70 per year in 2017. Conclusion: Standard processes were adopted by all stroke centers. Lower volume centres continue to experience challenges in meeting CSBPRs resulting in ongoing improvement work. The primary limitation has been resistance to CTA and limited use of existing telestroke resources. Transfer of patients requiring endovascular therapy has improved provincial mechanical thrombectomy numbers to 58 patients per 1 million population. Further process improvements are focusing on increasing access to this service from more remote centers. Our results show that the implementation of a comprehensive provincial acute stroke pathway leads to significant improvements in access to optimal care.

OBJECTIVE Within a 2-way text messaging study in AYAs who recently completed treatment for cancer, we sought to evaluate text message responsivity across different types of text messages. METHODS AYAs who recently completed treatment for cancer (n=26; mean age=16 years; 62% female, 16/26 participants) received 2-way text messages about survivorship health topics over a 16-week period. Using participants’ text message log data, we coded responsivity to text messages and evaluated trends in responsivity to unprompted text messages and prompted text messages of varying content (eg, medication reminders, appointment reminders, and texts about personal experiences as a cancer survivor). RESULTS Across prompted and unprompted text messages, responsivity rapidly decreased (P ≤.001 and =.01, respectively) and plateaued by the third week of the intervention. However, participants were more responsive to prompted text messages (mean responsivity=46% by week 16) than unprompted messages (mean responsivity=10% by week 16). They also demonstrated stable responsivity to certain prompted content: medication reminders, appointment reminders, goal motivation, goal progress, and patient experience texts. CONCLUSIONS Our methodology of evaluating text message responsivity revealed important patterns of engagement in a 2-way text message intervention for AYA cancer survivors.

Background Patients with cancer have increased rates of clinical distress compared to healthy individuals. Programs are needed to screen patients for distress and make appropriate psychosocial referrals. Objectives The purpose of this study was to describe the distress levels and psychosocial needs of a large, diverse sample of patients with cancer. Methods More than 1,200 adult patients, attending their second appointment with a medical or radiation oncologist, were screened for distress and psychosocial needs. Electronic health records were reviewed to collect demographic data. Findings Almost half of the sample reported a clinically meaningful level of distress. Younger age, single status, and female gender were significant predictors of a greater distress score and/or more psychosocial needs. Results suggest that demographic variables may be useful in identifying patients with cancer who are more likely to report higher levels of distress or greater psychosocial needs; these patients should be offered interventions and support services earlier in the treatment process, which may improve outcomes.

OBJECTIVE The prevalence of increased distress among cancer patients has been well established and is known to be associated with negative consequences. Limited research has examined the association between distress and utilization of services, however, which is critical to understanding whether measurements of distress are being used to optimize patient care in the context of cancer. METHODS One thousand two hundred thirteen adult cancer patients completed the Distress Thermometer and Patient Needs Assessment early in their cancer care. Electronic medical record (EMR)-abstracted data included psychosocial service utilization in the 12 months following the completion of these psychosocial metrics. Logistic regressions followed by t tests were completed to assess if distress or unmet needs were affiliated with service utilization rates. RESULTS When controlling for age, distress significantly predicted service utilization rates overall. Follow-up t tests suggest that use of social work and registered dietician services was higher among those with distress scores greater than 6. When assessing unmet needs, utilization rates were positively associated with number of unmet needs, specifically for social work and dieticians. CONCLUSIONS Distress and unmet needs were related to higher rates of psychosocial service utilization during the 12 months following assessment of symptoms. These results support the continued mandate for evaluation of distress and suggest that psychosocial screening may be assisting in directing referrals and enhancing comprehensive care for patients. As psychosocial services grow, the need for continued evaluation is recommended to determine if psychology and chaplaincy services are utilized at higher rates as available providers increase.

Introduction One area in which high levels of distress among cancer patients is consistently found is the SCT population, with over 50% of patients demonstrating clinically significant levels of distress. Research has also found that caregivers across cancer diseases endorse even higher levels of distress than patients, particularly in SCT population with higher or equal caregiver distress compared to patients’ pre-transplant. The emotional and physical health of the caregiver ineveitably impacts care for the patient, making the measuring and assessing of caregiver distress, particularly in the SCT population, necessary and critical. However, many barriers to caregiver distress screening have been identified in this population. Objectives Successfully and efficiently implement caregiver distress screening at this NCI accredited Cancer Center and assist others in learning challenges that may be encountered and how to address them. Methods Implementation of caregiver screening was met with several barriers including engaging key stakeholders, identifying time point for screening, legal medical concerns for documentation, and workflow of caring for patients and caregivers. Overarching all of these barriers is the utility of the electronic medical record system and its capabilities. Results The first barrier in this process was identifying the key stakeholders. A multi-disciplinary team was created which included physicians, psychologists, nurses, nursing leadership, program administrators, quality coordinator, and informatics specialists. With the multi-disciplinary team came buy-in and distribution of responsibilities in the adaptation of the workflow for caregiver screening. When defining the workflow, a standard screening opportunity presented itself at initial consult and survivorship appointment. Collaborating with internal policy makers, the team obtained approval for documentation of caregiver distress in patient chart with legal medical records. A workflow to have a phone triage for caregiver needs and scheduling was created to allow the caregiver a safe space to self-report desired referrals for self-care. The backdrop to all of these barriers was the limitations and strengths of our electronic medical records (EPIC). The informatics specialists cooperation in this project was a vital component in its implementation. Conclusion Currently the final electronic medical record system requests have been initiated and the plan for implementation is on-going. The project will be piloted in our Bone Marrow Transplant and Hematology ambulatory settings. The pilot will identify additional barriers and these will be addressed as needed. This implementation process will provide a comprehensive distress screening program at this NCI accredited Cancer Center, that also focuses on caregivers.

Bites by the European adder (Vipera berus) are a rare medical emergency in the UK with 20 to 50% of an estimated 50 to 200 cases per year necessitating treatment with antivenom. We present a case demonstrating both severe systemic and local effects necessitating out of hospital resuscitation, vasopressor support, and prolonged rehabilitation. Hemodynamic stability was restored promptly after administration of ViperaTAb antivenom, the first published case of its use in the UK.

Parents (n = 46) of children admitted to an inpatient psychiatric facility voluntarily completed demographic information, the Barriers to Treatment Participation Scale, and 3 open-ended questions about their child's prior outpatient treatment. Families with a prior referral for family therapy reported significantly more barriers to treatment. The main categories that emerged from open-ended questions included access issues, family discord or crises, and treatment not meeting expectations. Participants' advice to others in similar circumstances suggested that parents should be proactive and persistent and improve communication with caregivers. The findings are discussed, and recommendations are presented.

Healthcare delivery in America is extremely complex because it is comprised of a fragmented and nonsystematic mix of stakeholders, components, and processes. Within the US healthcare structure, the federal healthcare system is poised to lead American medicine in leveraging health information technology to improve the quality of healthcare. We posit that through developing, adopting, and refining health information technology, the federal healthcare system has the potential to transform federal healthcare quality by managing the complexities associated with healthcare delivery. Although federal mandates have spurred the widespread use of electronic health records, other beneficial technologies have yet to be adopted in federal healthcare settings. The use of health information technology is fundamental in providing the highest quality, safest healthcare possible. In addition, health information technology is valuable in achieving the Agency for Healthcare Research and Quality's implementation goals.We conducted a comprehensive literature search using the Google Scholar, PubMed, and Cochrane databases to identify an initial list of articles. Through a thorough review of the titles and abstracts, we identified 42 articles as having relevance to health information technology and quality. Through our exclusion criteria of currency of the article, citation frequency, applicability to the federal health system, and quality of research supporting conclusions, we refined the list to 11 references from which we performed our analysis.The literature shows that the use of computerized physician order entry has significantly increased accurate medication dosage and decreased medication errors. The use of clinical decision support systems have significantly increased physician adherence to guidelines, although there is little evidence that indicates any significant correlation to patient outcomes. Research shows that interoperability and usability are continuing challenges for implementation.The Veterans Administration is the only entity within the federal health system that has published research on the use of health information technology to improve quality. The federal healthcare system has existing systems in place with computerized physician order entry systems and clinical decision support systems, but these should be advanced.Particular focus and attention should be placed on data mining capabilities, integrating the electronic health record across all aspects of care, using the electronic health record to improve quality at the point of care, and developing interoperable and usable health information technology.

Background Releasing Time to Care: The Productive Ward™ (RTC) is a method for conducting continuous quality improvement (QI). The Saskatchewan Ministry of Health mandated its implementation in Saskatchewan, Canada between 2008 and 2012. Subsequently, a research team was developed to evaluate its impact on the nursing unit environment. We sought to explore the influence of the unit’s existing QI capacity on their ability to engage with RTC as a program for continuous QI. Methods We conducted interviews with staff from 8 nursing units and asked them to speak about their experience doing RTC. Using qualitative content analysis, and guided by the Organizing for Quality framework, we describe the existing QI capacity and impact of RTC on the unit environment. Results The results focus on 2 units chosen to highlight extreme variation in existing QI capacity. Unit B was characterized by a strong existing environment. RTC was implemented in an environment with a motivated manager and collaborative culture. Aided by the structural support provided by the organization, the QI capacity on this unit was strengthened through RTC. Staff recognized the potential of using the RTC processes to support QI work. Staff on unit E did not have the same experience with RTC. Like unit B, they had similar structural supports provided by their organization but they did not have the same existing cultural or political environment to facilitate the implementation of RTC. They did not have internal motivation and felt they were only doing RTC because they had to. Though they had some success with RTC activities, the staff did not have the same understanding of the methods that RTC could provide for continuous QI work. Conclusions RTC has the potential to be a strong tool for engaging units to do QI. This occurs best when RTC is implemented in a supporting environment. One size does not fit all and administrative bodies must consider the unique context of each environment prior to implementing large-scale QI projects. Use of an established framework, like Organizing for Quality, could highlight the distinctive supports needed in particular care environments to increase the likelihood of successful engagement. Electronic supplementary material The online version of this article (doi:10.1186/s12913-014-0642-x) contains supplementary material, which is available to authorized users.

We examined in a series of studies the mechanism that may underlie the relationship between Rapid Automatized Naming (RAN) and reading (accuracy and fluency) in Mandarin Chinese. Study 1 examined the "arbitrary" connections hypothesis in a sample of Grade 2 children (N=182). Study 2 contrasted the phonological processing, orthographic processing, and speed of processing hypotheses in a sample of Grade 2 children followed until Grade 5 (N=72). Finally, Study 3 contrasted the same hypotheses in a sample of Grade 4 children with dyslexia (n=30) and chronological-age controls (n=30). The results indicated that (a) RAN is unrelated to Paired Associate Learning (PAL) tasks that tap the ability to form arbitrary connections between characters and their pronunciation, (b) controlling for nonverbal IQ and orthographic processing was sufficient to explain the RAN-reading accuracy relationship but not the RAN-reading fluency relationship, and (c) the observed differences between dyslexics and controls in RAN diminished after controlling for orthographic processing. Taken together, these findings suggest that RAN is related to reading accuracy (and partly to reading fluency) because children must access orthographic representations from long-term memory. Although accessing these representations is sufficient for accurate word recognition, it is not sufficient for fluent reading, which also requires efficient parafoveal processing.

Background: Intrathecal opioid infusion therapy has been increasingly utilized in patients with severe malignant and nonmalignant pain syndromes in the past few decades. By infusing small amount of analgesics directly into the cerebrospinal fluid (CSF) in close proximity to the receptor site in the spinal cord, spinally mediated analgesia may be achieved while sparing some of the side effects due to systemic opioids. Traditionally, the most commonly infused analgesic for intrathecal infusion is an opioid. Morphine represents the only FDA-approved opioid for intrathecal administration, although other opioids may also be used off-label. However, in patients who have demonstrated intolerance to oral opioid(s), alternative analgesics may be tried to achieve satisfactory analgesia. Objective: To present a case report of a 73-year old male with intractable low back and pelvic pain due to invasive prostate cancer, unable to tolerate any opioid, being successfully treated by intrathecal infusion of clonidine and baclofen. Case Report: A 73-year-old male with intractable low back pain and pelvic pain due to invasive prostate cancer was referred to our clinic for pain management. The patient had undergone hormonal therapy, radiation therapy, radical prostectomy, and rectal resection. Trial of non-opioid analgesics was unsuccessful in controlling his pain. Multiple opioids trials were complicated by persistent nausea and vomiting. Other interventional techniques were attempted, but only offered short-term efficacy. Intraspinal drug delivery (IDD) therapy was considered and attempted. Considering his intolerance to various oral opioids despite meticulous opioid dose titration, an outpatient continuous epidural infusion of clonidine was conducted, which provided satisfactory analgesia. The patient subsequently underwent permanent IDD pump placement. Results: The intrathecal infusion of clonidine was initiated at 50 mcg/day. Over the following 4 months, the dosage was gradually titrated up to 350 mcg/day, with satisfactory pain relief. However, he did report frequent drowsiness during daytime, which was felt to be due to intrathecal clonidine. The decision to add low dose baclofen to the intrathecal infusion and simultaneously lower the clonidine dose was made. The intrathecal regimen was changed to clonidine 150 mcg/day and baclofen 50 mcg/day. His daytime sleepiness improved significantly and his pain control remained satisfactory. Over the following 3 months, his intrathecal regimen was further titrated to clonidine 200 mcg/day and baclofen 100mcg/day. He remained on this regimen for over 12 months with satisfactory pain relief and without experiencing excessive sedation. Addition of baclofen to intrathecal clonidine infusion led to improved analgesia without affecting his alertness, probably via a synergistic mechanism. Conclusion: Under certain circumstance when intrathecal opioid infusion cannot be tolerated, intrathecal clonidine and baclofen may be used as alternatives to provide spinally mediated antinociception.

Background Unexplained variation in clinical practice can be an indicator of poor quality of care. In Saskatchewan, Canada the Variation and Appropriateness Working Group (VAWG) engaged three clinical working groups (CWG) to consider the causes of variation in surgical practice. Objectives Using the Model for Understanding Success in Quality Improvement (MUSIQ) framework, we conducted a qualitative study aimed at exploring VAWG9s successes and barriers. Methods We used semi-structured interviews, meetings notes, and VAWG project documents as data for understanding the functioning and context of the CWGs. Results Our comparison of the CWGs highlights the similarities and differences between these groups. All groups identified next steps for understanding the root causes of variation; however, even in the CWG that exhibited positive micro contextual attributes and that made the most progress, success was limited due to the external environment common to all three CWGs. The external environment, the Saskatchewan health care system, did not signal that this work was a priority and physicians did not have the structural support needed to fully engage and advance this work. Conclusions Our research highlights the importance of both micro and macro contextual factors critical to the success of physician-driven quality improvement. The MUSIQ framework identifies features of the Saskatchewan context that can be built upon, and areas were significant work and investment is needed to increase the likelihood of success in future projects. Lessons learned are impacting the implementation of subsequent work; however, there are still critical factors to be addressed in Saskatchewan.