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Objective: With increasing evidence from controlled trials on benefits of early palliative care, there is a need for studies examining implementation in real-world settings. The INTEGRATE Project was a 3-year real-world project that promoted early identification and support of patients with cancer who may benefit from palliative care. This study assesses feasibility, stakeholder experiences, and early impact of the INTEGRATE Project METHODS: The INTEGRATE Project was implemented in four cancer centers in Ontario, Canada, and consisted of interdisciplinary provider education and an integrated care model. Providers used the Surprise Question to identify patients for inclusion. A mixed methods evaluation of INTEGRATE was conducted using descriptive data, interviews with providers and managers, and provider surveys., Results: A total of 760 patients with cancer (lung, glioblastoma, head and neck, gastrointestinal) were included. Results suggest improvement in provider confidence to deliver palliative care and to initiate the Advanced Care Planning (ACP) conversation. The majority of patients (85%) had an ACP or goals of care (GOC) conversation initiated within a mean time to conversation of 5-46 days (SD 20-93) across centers. A primary care report was transmitted to family doctors 48-100% of the time within a mean time to transmission of 7-54 days (SD 9-27) across centers. Enablers and barriers influencing success of the model were also identified., Conclusions: A standardized model for the early introduction of palliative care for patients with cancer can be integrated into the routine practice of oncology providers, with appropriate education, integration into existing clinical workflows, and administrative support., (© 2019 John Wiley & Sons, Ltd.)

The application of industrial residuals in agriculture may raise concerns about soil and crop metal accumulation. A complete study using a fractionation scheme would reveal build-up in metal pools occurring after material addition and predict the transformation of metals in soil between the different forms and potential metal release into the environment. An experimental study was conducted from 2000 to 2008 on a loamy soil at Yamachiche, Quebec, Canada, to evaluate the effects of repeated annual addition of combined paper mill biosolids when applied alone or with several liming by-products on soil Cu, Zn, and Cd fractions. Wet paper mill biosolids at 0, 30, 60, or 90 Mg ha and calcitic lime, lime mud, or wood ash, each at 3 Mg ha with 30 Mg paper mill biosolids ha, were surface applied after seeding. The soils were sampled after 6 (soybean [ (L.) Merr.]) and 9 [corn ( L.)] crop years and analyzed using the Tessier fractionation procedure. Results indicated that biosolids addition increased exchangeable Zn and Cd, carbonate-bound Cd, Fe-Mn oxide-bound Zn and Cd, organically bound Cu and Zn, and total Zn and Cd fractions but decreased Fe-Mn oxide-bound Cu in the uppermost 30-cm layer. With liming by-products, there was a shift from exchangeable to carbonate-bound forms. Even with very small metals addition, paper mill and liming materials increased the mobility of soil Zn and Cd after 9 yr of application, and this metal redistribution resulted into higher crop grain concentrations., (Copyright © by the American Society of Agronomy, Crop Science Society of America, and Soil Science Society of America, Inc.)

Land application of residuals from the forest industry can help to restore soil fertility, but few studies have assessed the effects of metal accumulation in plants. An experimental study was initiated in 2000 on a loamy soil at Yamachiche, QC, Canada, to evaluate the effects of repeated annual applications of combined paper mill biosolids, when applied alone or with several liming by-products. This study assessed the accumulation of Cu, Zn, Mo, and Cd in plants and soil after 6 (soybean [ (L.) Merr.]) and 9 [corn ( L.)] crop yr. Wet paper mill biosolids at 0, 30, 60, or 90 Mg ha were surface applied after seeding. Calcitic lime, lime mud, and wood ash were applied wet each at 3 Mg ha with 30 Mg wet paper mill biosolids ha. Repeated applications of paper mill biosolids increased plant and soil metal concentrations after 6 and 9 yr in the order of Cd > Mo (soybean) > Zn > Cu. Liming increased soil pH and Mo availability and decreased Zn and Cd availability. Metals in crop stover responded more positively to applications than those in grains, but the concentrations in plant tissues were generally well below critical values. The Cu/Mo ratio of soybean plants at pH > 6.8 fell below 2:1, however, and may pose a risk for inducing Cu metabolism disorder in ruminants. Results of this study indicate that paper mill biosolids and alkaline residuals, when applied with respect to regulations and soil pH, have a limited effect on metal accumulation in plants and soil., (Copyright © by the American Society of Agronomy, Crop Science Society of America, and Soil Science Society of America, Inc.)

Objective: Delirium is a highly prevalent and deleterious disorder in terminally ill cancer patients. We assessed whether a multicomponent preventive intervention was effective in decreasing delirium incidence and severity among cancer patients receiving end-of-life care., Methods: A cohort of 1516 patients was followed from admission to death at seven Canadian palliative care centers. In two of these centers, routine care included a delirium preventive intervention targeting physicians (written notice on selective delirium risk factors and inquest on intended medication changes), patients, and their family (orientation to time and place, information about early delirium symptoms). Delirium frequency and severity were compared between patients at the intervention (N = 674) and usual-care (N = 842) centers based on thrice-daily symptom assessments with the Confusion Rating Scale., Results: The overall rate of adherence to the intervention was 89.7%. The incidence of delirium was 49.1% in the intervention group, compared with 43.9% in the usual-care group (odds ratio [OR] 1.23, P = 0.045). When confounding variables were controlled for, no difference was observed between the intervention and the usual-care groups in delirium incidence (OR 0.94, P = 0.66), delirium severity (1.83 vs. 1.92; P = 0.07), total days in delirium (4.57 vs. 3.57 days; P = 0.63), or duration of first delirium episode (2.9 vs. 2.1 days; P = 0.96). Delirium-free survival was similar in the two groups., Conclusion: A simple multicomponent preventive intervention was ineffective in reducing delirium incidence or severity among cancer patients receiving end-of-life care. Delirium prevention remains a difficult challenge in terminally ill cancer patients., (Copyright © 2010 John Wiley & Sons, Ltd.)

Background: Delirium is a common neuropsychiatric complication in patients with advanced cancer. The Memorial Delirium Assessment Scale (MDAS) is a recently developed 10-item severity rating instrument. The purpose of the current prospective study was to further assess the clinical utility, factor structure, and validity of the MDAS in a relatively homogeneous population of patients with advanced cancer., Methods: Study entry of 104 patients occurred on their consecutive admission to a tertiary-level, acute palliative care unit in a university-affiliated teaching hospital. Patients underwent regular cognitive screening using the Mini-Mental State Examination, and serial monitoring of delirium using standardized semistructured interviews and MDAS ratings, up to the study endpoints of either patient discharge or death., Results: Seventy-one patients met Diagnostic and Statistical Manual (of Mental Disorders)-IV criteria for a first episode of delirium. In 15 of 71 (21%) patients with a first episode of delirium, the first MDAS ratings were prorated because of dyspnea, fatigue, or profound delirium. In the remaining 56 patients (79%), the first MDAS ratings were rated fully and therefore evaluable. Correlations among the scale items ranged from moderate to low (correlation coefficient [r] = 0.68-0.02). Analysis of the pattern of factor loadings identified two primary correlated factors: global cognitive (Factor I) and neurobehavioral (Factor II) (r = 0.33). Cronbach alpha coefficients for Factors I and II were 0.8 and 0.66, respectively, indicating a relatively high level of correlation for items within each. The Cronbach alpha coefficient for all 10 items was 0.78, suggesting a general underlying factor. In a larger sample of complete MDAS ratings (n = 330) a cutoff total MDAS score of 7 of 30 yielded the highest sensitivity (98%) and specificity (96%) for delirium diagnosis. The MDAS was correlated moderately with the Mini-Mental State Examination (r = 0.55)., Conclusions: The authors concluded that the MDAS structure is representative of the many features of delirium, broadly grouped as global cognitive and neurobehavioral dimensions. Prorating item scores is necessary in approximately 20% of advanced cancer patients with delirium. This poses potential limitations on the applicability of the MDAS in research. Conversely, the ability to prorate item scores confers a clinical advantage to the instrument when assessing delirium in a patient population with advanced cancer., (Copyright 2000 American Cancer Society.)