Employment Services Utilization and Outcomes among Substance Abusing Offenders Participating in California’s Proposition 36 Drug Treatment Initiative

California drug treatment programs may use funds to address barriers to work faced by Proposition 36 offenders, most of whom are not working at treatment entry, but employment services utilization and related behavioral outcomes have never been studied. This study examined primary data collected on 1,453 offenders by 30 programs during 2004 to explore the characteristics, employment services utilization, and outcomes of those who did and did not receive employment services while in drug treatment. One-year outcomes were mostly similar across groups, however, increases in the proportion of offenders employed, receiving income from employment and family or friends, and being paid for work were significantly greater among the received-employment-services group, and a greater proportion of this group also completed drug treatment. Employment services utilization was less likely for persons recruited from outpatient settings and more likely with greater severity of family/social problems and desire for services. Odds of employment one-year post-treatment entry were higher for those of Hispanic race/ethnicity (vs. White) and for those with treatment completion/longer retention but lower for those who were older, lived in specific counties, had greater employment problem severity at intake, and received other income-related services. Strategies for improving employment services utilization and outcomes among Proposition 36 offenders are discussed

Duration of androgen deprivation therapy with postoperative radiotherapy for prostate cancer: a comparison of long-course versus short-course androgen deprivation therapy in the RADICALS-HD randomised trial

Background Previous evidence supports androgen deprivation therapy (ADT) with primary radiotherapy as initial treatment for intermediate-risk and high-risk localised prostate cancer. However, the use and optimal duration of ADT with postoperative radiotherapy after radical prostatectomy remains uncertain. Methods RADICALS-HD was a randomised controlled trial of ADT duration within the RADICALS protocol. Here, we report on the comparison of short-course versus long-course ADT. Key eligibility criteria were indication for radiotherapy after previous radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to add 6 months of ADT (short-course ADT) or 24 months of ADT (long-course ADT) to radiotherapy, using subcutaneous gonadotrophin-releasing hormone analogue (monthly in the short-course ADT group and 3-monthly in the long-course ADT group), daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as metastasis arising from prostate cancer or death from any cause. The comparison had more than 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 75% to 81% (hazard ratio [HR] 0·72). Standard time-to-event analyses were used. Analyses followed intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov , NCT00541047 . Findings Between Jan 30, 2008, and July 7, 2015, 1523 patients (median age 65 years, IQR 60–69) were randomly assigned to receive short-course ADT (n=761) or long-course ADT (n=762) in addition to postoperative radiotherapy at 138 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 8·9 years (7·0–10·0), 313 metastasis-free survival events were reported overall (174 in the short-course ADT group and 139 in the long-course ADT group; HR 0·773 [95% CI 0·612–0·975]; p=0·029). 10-year metastasis-free survival was 71·9% (95% CI 67·6–75·7) in the short-course ADT group and 78·1% (74·2–81·5) in the long-course ADT group. Toxicity of grade 3 or higher was reported for 105 (14%) of 753 participants in the short-course ADT group and 142 (19%) of 757 participants in the long-course ADT group (p=0·025), with no treatment-related deaths. Interpretation Compared with adding 6 months of ADT, adding 24 months of ADT improved metastasis-free survival in people receiving postoperative radiotherapy. For individuals who can accept the additional duration of adverse effects, long-course ADT should be offered with postoperative radiotherapy. Funding Cancer Research UK, UK Research and Innovation (formerly Medical Research Council), and Canadian Cancer Society

Rushing Roulette – how do learners perform routine tasks under time pressure?

Introduction: Remediating, or preferably, predicting which residents will have difficulty before they need remediating, is a challenging task. Most of us perform better when pumped for an exam. But how do we respond when under routine pressures? Do weaker learners adapt differently, despite coaching? Methods: Using an adaptation of virtual patient software, we explored how learners cope with handling repetitive yet time-sensitive routine tasks. We emulated the performance of routine tasks within a virtual electronic medical record (EMR) environment, tracking individual learner activity and decision pathways, time to act (with and without enforced pressure from programmed time-outs) and their adaptation trajectories over time with coaching. Learners were assessed using Situational Judgement and modified Script Concordance Testing, with reproducible and granular time constraints introduced into the clinical reasoning process. Results: Our case designs introduce a number of competing elements: time pressures, competing priorities and instructions, resource availability and unpredictable outcomes. Learner behaviour is assessed using a variety of metrics including time-stamped decision points, decision pathways and internal counter scores. Clinical reasoning pathways, as compared to a reference peer panel, are in turn compared with and without the time pressures. Conclusions: Predictive analytics have made great promises in diagnosing problems for learners in difficulty but are complex and expensive to deploy widely. Our simpler, rapidly reproducible approach may provide a more practical solution.</jats:p

L’apprentissage autorégulé et expérientiel des comportements professionnels et ses effets transformationnels chez les résidents

Purpose: Postgraduate trainees (‘residents”) are required to convey professional behaviours as they navigate complex clinical environments. However, little is known about experiential learning for professionalism. Thus, we asked residents about professionalism challenges within the clinical learning environment: 1) how challenges were identified, 2) what supported successfully addressing challenges and 3) the impact of addressing challenges to further inform resident education. Method: From 2015-2016, twenty-five residents across specialties and multiple university affiliated teaching hospitals participated in appreciative inquiry informed audio-taped semi-structured interviews. Transcripts were categorized deductively for the 2015 CanMEDS Professional Role element addressed (commitment to patients, society, the profession, and physician health).  A pragmatic research paradigm focussed descriptive data analysis on actions and outcomes.  Results: Residents actively identify opportunities for experiential learning of professionalism within the clinical workplace– addressing conflicting priorities with interprofessional clinicians to ensure excellent patient care, providing informal feedback regarding peers’ and other healthcare clinicians’ professionalism lapses and by gaining self-awareness and maintaining wellness. There were no descriptions of commitment to society. Values, relationships, and reflection supported professional behaviours. Many described transformative personal and professional growth as an outcome of addressing professionalism challenges. Conclusions: Residents self-regulated experiential learning for professionalism often results in transformational changes personally and professionally. Elucidation of how residents successfully navigate power dynamics and conflict to provide excellent patient care and feedback for professional regulatory behaviour will support professionalism education. An interprofessional research lens will be valuable to explore how best to incorporate commitment to society within clinical environments. Résumé Objectif : Il est attendu des stagiaires postdoctoraux (résidents) d’adopter des comportements professionnels dans les environnements cliniques complexes dans lesquels ils évoluent. Cependant, on sait peu de choses sur l’apprentissage expérientiel des comportements professionnels. Nous avons donc interrogé les résidents sur les défis qu’ils rencontrent en lien avec le professionnalisme dans leur environnement d’apprentissage clinique : 1) quels sont les problèmes qu’ils considèrent comme étant liés au professionnalisme, 2) qu’est-ce qui les a aidés à relever ces défis avec succès et 3) quels sont les effets de leur réaction à ces problématiques et quelles leçons peut-on tirer de ces résultats pour mieux adapter la formation des résidents. Méthode : Entre 2015 et 2016, 25 résidents de diverses spécialités et hôpitaux universitaires ont participé à des entretiens semi-structurés qui ont été menés selon une méthode d’interrogation appréciative et qui ont été enregistrés sur bande audio. Les transcriptions ont été catégorisées de manière déductive par rapport au rôle du professionnel du référentiel CanMEDS 2015 (engagement envers les patients, la société, la profession et la santé des médecins). Fondée sur un paradigme de recherche pragmatique, l’analyse des données descriptives ciblait les actions et les résultats. Résultats : Les résidents décèlent activement les occasions d’apprentissage expérientiel du professionnalisme dans le milieu de travail clinique et ils réagissent par exemple en abordant les priorités divergentes avec les cliniciens d’équipes interprofessionnelles de façon à assurer l’excellence des soins aux patients, en fournissant des commentaires informels à leurs pairs et à d’autres cliniciens sur les comportements non professionnels de ces derniers, en prenant conscience d’eux-mêmes et en privilégiant le bien-être. Ils n’ont pas proposé de description de l’engagement envers la société. Les valeurs, les relations et la réflexion sont les facteurs qui ont soutenu l’adoption de comportements professionnels. Un grand nombre de répondants ont déclaré avoir vécu une croissance personnelle et professionnelle transformatrice grâce à l’action qu’ils ont prise pour résoudre un problème de professionnalisme. Conclusions : L’apprentissage expérientiel autorégulé du professionnalisme par les résidents entraîne souvent des changements transformationnels pour eux sur les plans personnel et professionnel. Une compréhension approfondie de la gestion réussie des rapports de pouvoir et des conflits par les résidents leur permettant d’assurer la qualité des soins aux patients et de donner une rétroaction à leurs collègues sur la conformité de leur comportement professionnel contribuerait grandement à l’enseignement du professionnalisme. L’adoption d’une approche de recherche interprofessionnelle serait utile pour explorer la meilleure façon d’intégrer l’engagement envers la société dans l’environnement clinique

Comparison of date palm leaves with barley straw for friesian and holstein cows given a high concentrate diet in kuwait

In Kuwait there is a high demand for forage and roughage to meet the livestock needs for the production of milk and meat. Kuwait dairymen are obliged to feed their animals a diet with high concentrate and low roughage content for economic reasons, i.e. the unit cost of roughage is greater than that of concentrates due to a government policy of subsidising imported concentrates, but not roughages. There is a need to find a locally produced source of roughage to encourage higher levels of inclusion and to reduce feed costs.This experiment was designed to compare the effects of feeding locally produced date palm leaves rather than imported barley straw to Friesian and Holstein cows given a high concentrate diet.</jats:p