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BackgroundOlder adults (people aged 65 years and older) face many difficult decisions. Patient decision aids (PtDAs) can help them and their families make informed value-congruent decisions. Some PtDAs have been developed for the home care context, but little is known about scaling them for use with older adults in a different culture. ObjectiveThis study aims to (1) assess the scalability of existing PtDAs for older adults in the home care context; (2) prioritize those that best match the decisional needs of older adults in home care; and (3) culturally adapt the prioritized PtDAs so they can be scaled successfully to the Quebec health care system. MethodsThis multimethod study includes 3 phases. All phases will be overseen by a steering committee of older adults, caregivers, health professionals, decision makers, community organization representatives, and researchers with the needed expertise. In phase 1, we will use the Innovation Scalability Self-administered Questionnaire, a validated scalability self-assessment tool, to assess the scalability of 33 PtDAs previously identified in a systematic review. Based on their scalability, their quality (based on the International Patient Decision Aids Standards), and the importance of the decision point, we will retain approximately a third of these. In phase 2, we will conduct a 2-round web-based Delphi to prioritize the PtDAs selected in phase 1. Using a snowball recruitment strategy, we aim to recruit 60 Delphi participants in the province of Quebec, including older adults, caregivers, health professionals, decision makers involved in home care services, and PtDA experts. In the first round, we will ask participants to rate the importance of several PtDA decision points according to various criteria such as prevalence and difficulty on a 5-point Likert scale (1=not important to 5=very important). Approximately 6 of the highest-rated PtDAs will be retained for presentation in the second round, and we will select up to 3 PtDAs judged as having the highest priority for cultural adaptation. In phase 3, using the Chenel framework and user-centered design methods, we will update and adapt the PtDAs to the Quebec health care system and integrate these PtDAs into an interprofessional shared decision-making training program for home care teams. The adapted PtDAs will respect the International Patient Decision Aids Standards criteria. ResultsThis study was funded in March 2022 by the Canadian Institutes of Health Research. Data collection for the web-based Delphi began in October 2023. Results are expected to be published in May 2024. ConclusionsThis project will provide relevant and culturally appropriate decision support tools for older adults making difficult decisions and their home care teams that will be ready for scaling across the province of Quebec. International Registered Report Identifier (IRRID)PRR1-10.2196/53150

Introduction As a result of the common belief that professionals in academic medicine make less money than their private practice counterparts, as well as the rising cost of medical school and subsequent loans, medical students and residents alike are dissuaded from pursuing careers in academia. However, with greater knowledge of loan repayment programs and financial planning, students can make informed decisions about entering the field of academia. Methods Using the Kern model, a workshop was developed to educate medical students considering an academic career about financial resources, loan repayment, student debt, and the importance of budgets. The workshop also encouraged reflection on personal and financial factors that influence career choice. Results The workshop was implemented at five regional conferences with a total of 113 participants. After participating in the workshop, survey data showed that participants were statistically less likely to agree with the statement “Student debt will hinder my ability to pursue an academic medicine career,” and more likely to agree with the statement “Academic medicine is a financially viable career choice for me” and “A career in academic medicine will provide a comfortable salary.” Over 95% of respondents agreed or strongly agreed that each objective was met. Discussion This workshop provided an interactive and reflective method to increase participants' awareness of factors that influence financial considerations when considering postgraduate career choices. It highlighted factors that may be particularly relevant for an academic career choice and of resources available, especially loan repayment programs, to ensure a financially viable academic career.

Background: Patient and family advisors (PFAs) contributed to the development of the Ontario Cancer Plan IV (OCP IV), a 4-year strategic plan for Ontario, Canada’s cancer system produced by Cancer Care Ontario. Objective: To understand the barriers and facilitators PFAs experience when they are engaged in health-care system planning and provide recommendations for future engagement. Method: Patient and family advisors who had an ongoing involvement in the development of the OCP IV were invited to take part in an interview. Qualitative data were analyzed for emergent themes and recommendations were generated. Results: Key emergent themes highlighted necessary elements for effective engagement of PFAs. These included rapport (feeling valued, included as an equal and having supportive interpersonal relationships), communication (clarity and transparency, shared language and understanding, feeling heard, and effective teleconferencing), and leadership (from PFAs and staff). Recommendations for optimizing PFA engagement in health-care system planning were generated. Conclusion: Patient and family advisors can be effectively engaged in system-level strategic planning by building reciprocal rapport, effective communication, and strong leadership. Notably, developing “systems literacy” in PFAs is key to ensuring the voices of patients and their families are heard and reflected in health-care system plans.

Introduction: Breast cancer is detected through screening or through signs and symptoms. In Canada, mammograms for breast cancer screening are offered in organized programs or independently (opportunistic screening). Province of Ontario breast Diagnostic Assessment Units (DAUs) are facility-based programs that provide coordinated breast cancer diagnostic services, as opposed to usual care, in which the primary care provider arranges the tests and consultations. This study describes breast cancer detection method, diagnostic interval and DAU use across Ontario. Methods: The study cohort consisted of 6898 women with invasive breast cancer diagnosed in 2011. We used the Ontario Cancer Registry linked to administrative health care databases. We determined the detection method using the Ontario Breast Screening Program (OBSP) data and physician claims. The diagnostic interval was the time between the initial screen, specialist referral or first diagnostic test and the cancer diagnosis. The diagnostic route (whether through DAU or usual care) was determined based on the OBSP records and biopsy or surgery location. We mapped the diagnostic interval and DAU coverage geographically by women’s residence. Results: In 2011, 36% of Ontario breast cancer patients were screen-detected, with a 48% rate among those aged 50 to 69. The provincial median diagnostic interval was 32 days, with county medians ranging from 15 to 65 days. Provincially, 48.4% were diagnosed at a DAU, and this ranged from zero to 100% across counties. Conclusion: The screening detection rate in age-eligible breast cancer patients was lower than published population-wide screening rates. Geographic mapping of the diagnostic interval and DAU use reveals regional variations in cancer diagnostic care that need to be addressed.

Introduction. Le cancer du sein est détecté soit par un examen de dépistage, soit à l’aide de signes et symptômes. Au Canada, les mammographies pour le dépistage du cancer du sein sont offertes dans le cadre de programmes organisés ainsi qu'en contexte indépendant (dépistage opportuniste). Les unités d’évaluation diagnostique (UED) de la province de l’Ontario sont des programmes en établissement qui fournissent des services diagnostiques coordonnés pour le cancer du sein, à la différence des soins habituels où le fournisseur de soins de première ligne organise les examens et les consultations. Cette étude décrit les méthodes de détection, l’intervalle diagnostique et l’utilisation des UED pour le cancer du sein en Ontario. Méthodologie. L’étude a porté sur une cohorte de 6 898 femmes ayant reçu un diagnostic de cancer du sein envahissant en 2011. Nous avons utilisé le Registre d’inscription des cas de cancer de l’Ontario jumelé à des bases de données administratives sur les soins de santé. Nous avons déterminé la méthode de détection à l’aide des données du Programme ontarien de dépistage du cancer du sein (PODCS) et des demandes de règlement des médecins. L’intervalle diagnostique a été défini comme le temps écoulé entre le dépistage initial, l’aiguillage vers un spécialiste ou la première épreuve diagnostique et le diagnostic de cancer lui-même. Le parcours diagnostique (qu'il passe par les UED ou les soins habituels) a été déterminé en fonction des dossiers du PODCS et du lieu de biopsie ou d’intervention chirurgicale. Nous avons cartographié l’intervalle diagnostique et de la couverture des UED en fonction du lieu de résidence des femmes. Résultats. En 2011, 36 % des cas de cancer du sein en Ontario ont été détectés par dépistage, dont 48 % chez des femmes de 50 à 69 ans. L’intervalle diagnostique provincial médian était de 32 jours, les médianes par comté variant entre 15 et 65 jours. À l’échelle provinciale, 48,4 % des cas ont été diagnostiqués dans une UED, ce pourcentage variant entre 0 et 100 % selon les comtés. Conclusion. Le taux de détection au dépistage correspondant aux patientes admissibles du fait de leur âge s'est révélé inférieur au taux de dépistage officiel du cancer du sein pour l’ensemble de la population. La répartition géographique de l’intervalle diagnostique et du recours aux UED révèle des variations régionales dans les soins diagnostiques en oncologie qu'il est nécessaire de corriger.

ABSTRACT Objectives Early diagnosis leads to better cancer survival and short diagnostic intervals reduce patient anxiety. We are studying factors that prolong the breast cancer diagnostic process in Ontario, Canada. Approach This is a retrospective study of all patients diagnosed 2007-2011 (n=33,752). We linked data from Cancer Care Ontario and the Institute for Clinical Evaluative Sciences including: Ontario Cancer Registry, physician claims, ambulatory, ER visits, and hospital discharges. Detection method (screening versus symptomatic) was determined using Screening Program and claims data. The diagnostic interval is the time from first relevant health care encounter to the definitive diagnosis. Elements of the diagnostic interval include: use of imaging, biopsy, and the number of encounters and providers. Results Overall, 30.6% were screen-diagnosed and the median diagnostic interval was 40 days (IQR 21-80). The median interval was shorter in the screened group at 32 days versus symptomatic at 45 days. The diagnostic interval was longer for stage I patients at 47 days compared to stage II (37 days), stage III (33 days) or stage IV (22 days). Stage IV patients were less likely to be diagnosed via biopsy (44% vs 61%) and the symptomatic stage IV subgroup less likely to have breast imaging (61% vs 96%). 26% of stage IV patients saw 0 or 1 providers while 8% of stage I patients saw 6 or more. 19% of stage I patients had 10 or more encounters overall versus 15% and 28% had >1 mammogram versus 14%. Effects are largely similar in screened and symptomatic groups. Conclusion Shorter diagnostic intervals in stage IV are associated with a more direct diagnostic path. We will present results quantifying the number of days attributable to the diagnostic elements. Understanding the impact of elements of the diagnostic process provide targets for improvement of its length.

In Ontario, Diagnostic Assessment Programs (DAPs) have been implemented to improve the quality of care patients receive during the diagnostic phase of the cancer journey. Patient navigators play a critical role in this model by coordinating care and providing information and support to patients and their families. The objectives of this study were 1) to determine whether patient navigation in DAPs is associated with a better patient experience and 2) to examine whether patient navigation in DAPs modifies the effect of wait times and patient volumes on patient experience. Data reflecting patients’ experience within the DAP were collected via survey and an average experience score was calculated for each region. To ascertain the relationship between patient experience, wait times and volumes, correlation coefficients were computed between regional patient experience scores and total regional patient volumes and between regional patient experience score and regional diagnostic wait times. To understand the impact of navigators on the patient experience, the sample was subdivided according to whether or not the respondent reported knowing their navigator. Patients who knew their navigator rated their experience significantly better than those who did not. For those who did not know their navigator, there was an inverse and significant correlation between patient experience scores and wait times; patients in regions with long waits had poorer experience scores overall. Patients who knew their navigator reported consistently good experience regardless of their diagnostic wait. The navigator appears to mitigate the negative impact of longer wait times on experience.

Seeking ways to develop information literacy skills among first year college students, librarians at our institution developed a pilot program to measure the effects of a multiple library instruction session module on students' research skills in the first semester. The pilot program incorporates a substantial assessment model consisting of a pretest, posttest, and a citation analysis of final papers. Results demonstrate that students who had multiple library instruction sessions during the first semester report higher levels of confidence and greater use of library resources than students who had only a single instruction session.

Las enfermeras deben brindar un cuidado culturalmente competente en los diferentes escenarios de la salud cada vez más multiculturales. Este artículo trata acerca de la reflexión de una investigación sobre el diálogo intercultural como un medio para incrementar el conocimiento y la conciencia de otras culturas. La metodología hermenéutica nos proporciona un camino para la exploración de ese diálogo intercultural por el compromiso de éste como un proceso de comprensión emergente y de auto-transformación mediante el diálogo. Conceptos de diálogo intercultural tales como: respeto, poder, disposición para permanecer en el proceso, responsabilidad, vulnerabilidad, expansión del propio horizonte y la auto-descubierta son incluidos en esta reflexión.

Este artículo describe la experiencia de una investigación multicéntrica en la enfermería y la salud. Comienza con un breve resumen de las metas del primer programa internacional para los enfermeros en el estudio del fenómeno de las drogas en las Américas. Este programa juntó once profesoras de enfermería de siete paises latinoamericanos junto a profesores de enfermería de Canadá, cujo enfoque fue la reducción de la demanda de las drogas. El artículo explora principalmente los beneficios y los desafíos en la planificaciòn de proyectos de investigación en un contexto fuera del pais de origen, y así desenvolver éstos en los diferentes y distantes lugares geográficos.

The Rx gene in potato confers extreme resistance against potato virus X (PVX) that is elicited by the viral coat protein (CP). Using actinomycin D to inhibit transcription of nuclear genes, we have shown that Rx is expressed prior to virus inoculation and that induction of the resistance mechanism does not require novel gene expression or continued transcription of previously expressed genes. We have also shown that transgenic plants could not be produced carrying a CP transgene from an Rx-avirulent PVX in an Rx background. These data indicate that Rx-mediated resistance involves a mechanism that suppresses viability of plant cells.

The article discusses the obstacles being faced by the U.S. government with regards the proper care and custody of unaccompanied and separated alien minors. It highlights the challenges that exist for unaccompanied minors facing the prospect of returning to their country of origin. It details some barriers to successful repatriation and safe reintegration. It highlights international legal instruments and documents that can provide guidance and direction as to how government should act to overcome barriers to non-citizen children's care.

Large and severe wildfires are an observable consequence of an increasingly arid American West. There is increasing consensus that human communities, land managers, and fire managers need to adapt and learn to live with wildfires. However, a myriad of human and ecological factors constrain adaptation, and existing science-based management strategies are not sufficient to address fire as both a problem and solution. To that end, we present a novel risk-science approach that aligns wildfire response decisions, mitigation opportunities, and land management objectives by consciously integrating social, ecological and fire management system needs. We use fire-prone landscapes of the US Pacific Northwest as our study area, and report on and describe how three complementary risk-based analytic tools—quantitative wildfire risk assessment, mapping of suppression difficulty, and atlases of potential control locations—can form the foundation for adaptive governance in fire management. Together, these tools integrate wildfire risk with fire management difficulties and opportunities, providing a more complete picture of the wildfire risk management challenge. Leveraging recent and ongoing experience integrating local experiential knowledge with these tools, we provide examples and discuss how these geospatial datasets create a risk-based planning structure that spans multiple spatial scales and uses. These uses include pre-planning strategic wildfire response, implementing safe wildfire response balancing risk with likelihood of success, and alignment of non-wildfire mitigation opportunities to support wildfire risk management more directly. We explicitly focus on multi-jurisdictional landscapes to demonstrate how these tools highlight the shared responsibility of wildfire risk mitigation. By integrating quantitative risk science, expert judgement and adaptive co-management, this process provides a much-needed pathway to transform fire-prone social ecological systems to be more responsive and adaptable to change and live with fire in an increasingly arid American West.

How wildfires are managed is a key determinant of long-term socioecological resiliency and the ability to live with fire. Safe and effective response to fire requires effective pre-fire planning, which is the main focus of this paper. We review general principles of effective federal fire management planning in the U.S., and introduce a framework for incident response planning consistent with these principles. We contextualize this framework in relation to a wildland fire management continuum based on federal fire management policy in the U.S. The framework leverages recent advancements in spatial wildfire risk assessment—notably the joint concepts of in situ risk and source risk—and integrates assessment results with additional geospatial information to develop and map strategic response zones. We operationalize this framework in a geographic information system (GIS) environment based on landscape attributes relevant to fire operations, and define Potential wildland fire Operational Delineations (PODs) as the spatial unit of analysis for strategic response. Using results from a recent risk assessment performed on several National Forests in the Southern Sierra Nevada area of California, USA, we illustrate how POD-level summaries of risk metrics can reduce uncertainty surrounding potential losses and benefits given large fire occurrence, and lend themselves naturally to design of fire and fuel management strategies. To conclude we identify gaps, limitations, and uncertainties, and prioritize future work to support safe and effective incident response.