Search

The present literature is conflicting regarding the management of microinvasive ductal carcinoma in situ (miDCIS) as to following recommendations for DCIS (margin status, surgical axillary staging, and possible observation) versus invasive breast cancer. We hypothesize that miDCIS represents more aggressive disease than pure DCIS.We performed a retrospective review of female miDCIS patients compared with age-matched cohorts of DCIS and T1b/c patients with invasive breast cancer. We collected demographic, clinicopathologic, treatment, and outcome information. Analysis of variance or Kruskal-Wallis tests were used to analyze continuous variables and chi-square or Fisher's exact tests for categorical variables. Survival outcomes were analyzed using Kaplan-Meier curves.We included 375 patients (125 in each group) with median age 59 y (range 33-91 y). miDCIS tumors were more likely to be hormone receptor negative and human epidermal growth factor receptor 2 positive compared with DCIS or invasive ductal carcinoma (IDC; all P 0.001). Subgroup analysis by miDCIS focality demonstrated no significant differences. The number of involved lymph nodes was not significantly different from DCIS patients but was significantly fewer than invasive cancer patients. Of 115 miDCIS patients (88%) staged with sentinel lymph node biopsy, eight (7%) had nodal metastases. Six miDCIS patients (5%) were treated with adjuvant chemotherapy. Over a median follow-up of 23.3 mo, there were no significant differences in local or distant recurrence.Based on our results, miDCIS has more aggressive pathologic features compared with DCIS and warrants surgical treatment and nodal staging similar to the management of IDC. In addition, similar to IDC, nodal and receptor status may influence medical management.

We used ethnographic methods in the tradition of Spradley (1979) and constant comparative analysis to explore case manager resource allocation decision making. We interviewed, observed, and shadowed 11 case managers within a children's home care program in a regional health authority in western Canada as they went about their daily work over a 5-month period. Our findings provide knowledge about the little-understood set of processes at the micro level of resource allocation. Although the case manager considers many factors, reported elsewhere (Fraser, Estabrooks, Allen, & Strang, 2009), they balance and weigh these factors within a relational context. The purpose of this article is to use Jenna's story as a case example to illustrate how the case manager balances and weighs the factors that influence their resource allocation decisions within this context. Jenna's story demonstrates the complex and multidimensional processes that are embedded in the relational nature of resource allocation decisions. We discuss home care case manager resource allocation decisions as viewed through the lens of relational ethics. Keywords: home care; service authorization; relational ethics; care planning Everything affects everything else. The case manager keeps the wheels turning. They are all wheels that work together and all the little cogs need to be in order for everything to function. (case manager) It takes a lot of work to maintain a healthy family life. That work is exponentially increased in families living with chronically ill and medically fragile children who have complex care needs. Families provide much of the sophisticated and heavy care to these children (Peter et al., 2007). Home care programs provide care that supports these families in keeping their children at home within the family unit. Case managers working within home care programs are charged with making resource allocation decisions regarding the type and amount of services to be provided for these chronically ill children. To many people, decisions are choices between competing alternatives, but to home care case managers, their decisions are much more complex and are embedded within relationships in a multidimensional decision-making context. Case managers work closely with clients and their families as they intricately balance and weigh various influencing factors within system constraints so that children with complex medical needs can be cared for at home. The factors that case managers use are reported in detail elsewhere (Fraser, Estabrooks, Allen, & Strang, 2008). In this article, we share a case that resonated with us as we conducted the previously mentioned ethnographic study. Our purpose in telling Jenna's story, as told to us primarily through Rosie, her case manager, is to illustrate how case managers balance and weigh the factors that influence them in making resource allocation decisions through the lens of relational ethics. We use Jenna's case to highlight the relational nature of the process that surround case manager resource allocation decisions in the midst of complexity. METHODS Our research study was approved by the Health Ethics Review Board at the University of Alberta. We received administrative approval from the health region in which it was conducted. We used ethnographic methods, specifically ethnoscience (Spradley, 1979), to uncover the factors that influence case managers in making resource allocation decisions for home care clients in the main study. Ethnoscience is used to study language and, in particular, how people use language to categorize their world. Specific data collection and analysis procedures for the main ethnographic study are fully described elsewhere (Fraser et al., 2008). In addition to ethnoscience, we used constant comparative analysis to analyze the process date that arose in the study. This case arose out of the constant comparative analysis. An overview of the research context, participants, and methods is provided here to help situate this case in the overall study. …

Social networks and social support are recognized as important determinants of health. Relocation is a common transition in older adults’ lives that can disrupt existing social networks and challenge seniors to reconstitute these networks. Social engagement is a required component of the process of reconstituting social relationships and of feeling connected. The purpose of this focused ethnographic study was to develop an understanding of the experience of social engagement in relocated residents of a senior-designated apartment building. Data generation included interviews with 19 older adults. Transcribed interviews were analyzed using thematic analysis. Seniors developed four types of relationships for provision of feelings of security, casual interactions, opportunity to be supportive, and friendship. The findings of this research provide a better understanding of the relationships seniors developed in a new community as a result of the process of social engagement.

This study’s purpose was to explore family caregivers’ experiences while they waited placement of family members with dementia in long-term care and how they coped during this period of waiting and transition. In this exploratory descriptive qualitative study, interviews were conducted with 29 caregivers at entry to the placement wait-list and at 3 to 4-month intervals thereafter. Final interviews, with 15 caregivers, were conducted shortly after admission to long-term care. When “the waiting begins,” the themes of crisis as initiator, synchronicity, control, and reciprocity emerged. “After placement” included the themes of deeply bonded relationships, attempting continuity, and sorting out the change. The findings provide new insight into family caregiver experiences during and after placement of a family member with dementia in long-term care. Clinicians must recognize that wherever services are provided, at home before placement or in institutions after placement, family caregivers must be incorporated as full partners in care.

Demographic trends indicate a growth in the older adult population, and in turn, are affecting the availability and use of health services. Although placement of an older adult charge into nursing home care is often described as a logical progression through the continuum of available services, informal caregivers often view placement as a last resort or as an indication of failure. This qualitative study used grounded theory methods to explore the experiences of caregivers actively involved in the process ofplacing an older adult in a long-term carefacility upon discharge from acute care. Four themes (uncertainty, surrendering to the system, urgency, and validating) were interwoven throughout caregivers'perspectives of the conflictive decision to use nursing home care after hospitalization.

Evaluation of health care programs is a complex process which presents many challenges. A case study of a small-scale adult day care program evaluation is presented to illustrate these issues. The rationale for developing the program and the findings from the evaluation study are discussed. Several evaluation issues including the use of multiple methods, levels of analysis, characteristics of the sponsoring agency, political influences, methodological issues and influences on utilization of findings are addressed.

Shortened hospital stays have necessitated examination of alternative approaches for pre and postoperative teaching. An investigation of one alternative became a study in which a home care preoperative teaching programme for older adults undergoing cataract extractions with lens implants was implemented and evaluated. The findings indicated that the teaching programme was effective and resulted in positive benefits.

The clinical application of computerized continuous-infusion pressure-monitored sialography using an aqueous contrast medium during the investigation of 296 salivary glands is described. A comparison between the pressure changes and the sialographic features revealed a significant (P less than 0.001) correlation between raised filling pressure (greater than 60 mmHg) and the presence of an obstructive lesion (stricture, mucous plug, sialolith). Occasionally a raised filling pressure was observed although the associated sialography films were normal. The sensitivity of the technique was 86.4%. It is concluded that the monitoring of pressure changes occurring during sialography can alert the clinician to the presence of high filling pressure and may also provide additional evidence of obstructive changes within salivary glands.

Respite care can be considered an illness prevention and health promotion intervention for both caregivers and the older people dependent on them. By maintaining clients' level of functioning, the process of deterioration is delayed and a degree of health promotion is achieved. Similarly, the relief of caregivers' burden, although minimal, sustains them in their role. A community-based mode of providing adult day care is supported in the literature. It seems logical to combine the services of a community-based organization and a long-term care institutional setting whenever possible.

The purpose of this qualitative interpretive study was to explore the experience of bereavement following home-based family caregiving for persons with advanced cancer. The research question addressed by this research was: How do family caregivers of patients with advanced cancer perceive the effects of home-based caregiving on their bereavement? Fifteen caregivers were retrospectively interviewed twice after the death of their family member. Caregivers reported both positive (e.g., feelings of accomplishment, improved family relationships) and negative (e.g., haunting images, feelings of failure) outcomes that they attributed to having cared for their family member. Overall, positive outcomes predominated and bereaved family members reported satisfaction with having provided care for their loved one who had died.

The purpose of this study was to examine the relationship between knowledge and practice of lifestyle behaviors in healthy older adults related to the prevention of vascular dementia. Data were derived from a convenience sample of 281 Canadian participants 55 years of age and older. Lifestyle was measured using the health-promoting lifestyle profile (HPLP). Seven knowledge sub-scales were developed consistent to the HPLP. Multivariate analysis found that four independent variables accounted for 26% of the variance of a healthy lifestyle score and included those who reported a lower level of stress, indicated a higher knowledge of interpersonal relations, had a better general health self-assessment and higher medical knowledge. These Canadian results were compared with those from a study conducted in Australia and found to be similar. The study argues that health professionals and health education programs can better promote and increase awareness of healthy lifestyle behaviors by assisting older adults to apply this knowledge in their daily lives. Specifically, the study discusses policy and practice implications with regards to lifestyle issues relating to health responsibility, physical activity, spirituality, stress management, interpersonal relationships and nutrition.

Respite services are seen as one key formal support intervention mitigating the negative consequences of family caregiving. The purpose of this paper is to examine how the caregivers' respite experience influenced their return to the responsibilities of caring for their family members. The discussion is based on a qualitative interpretative study with 20 caregivers exploring the meaning of respite to family caregivers of persons with dementia. Although the beneficial effect of the emotional and physical refreshment and renewal was evident throughout, there were notable variations in how caregivers experienced their return to caregiver responsibilities. Some experienced short-term despondency and feelings of 'let-down' while others felt guilty and emotionally devastated when they returned. Three factors emerged which related to the differential caregiver experiences: the amount of time and quality of the respite interval; the nature and quality of the respite help that was used for the dependent family member; and the condition of their dementia family member when the caregiver resumed the caregiver role. Clinicians must recognize that these factors strongly influence how the responsibilities of caregiving are resumed. Researchers must explore for additional factors which detract from the anticipated positive effects of the caregiver respite experience. Clarification of these factors can provide guidance to service providers to develop respite services that are more attuned to the caregivers' perceptions of benefit for themselves and for their dependent family members.

The caregiver respite experience is seen as one way to moderate the negative consequences of caregiving. From an interpretivist research orientation, this study explored how 10 family care-givers of persons with dementia experienced respite. From a coping theoretical perspective, the caregiver respite experience is discussed as a process of “getting out” of the caregiver world, and is linked to avoidance strategies of emotion-focused coping. The following three phases within the coping dimension of the respite experience were found: caregivers recognizing their need to get out of the caregiver world, giving themselves permission to actually get out from it temporarily, and having the appropriate social support resources available to facilitate the getting out. The critical practice and research implications linked to caregivers’ability to acknowledge their need for respite are described.

A retrospective descriptive study of patients who had had coronary artery bypass surgery was carried out to assess the completeness of recording of risk factors in case notes in hospital and in general practice, and to determine the prevalence of documented risk factors in patients who have had coronary artery bypass surgery. Data from reviews of hospital case notes and questionnaires to general practitioners were used to describe the frequency of documenting coronary risk factors and preventative advice in case notes and in correspondence between general practitioners and hospital doctors. Documentation of risk in hospital records revealed that all 102 patients had been assessed for family history, hypertension and current smoking, but 9 (9%) had no record of serum cholesterol, 35 (34%) patients did not have a record of their blood glucose, and in 83 (81%) patients there was no evidence that obesity had been assessed. Documentation of risk factors in general practice records identified that out of 77 patients, all had their blood pressure and smoking status recorded but 29 (38%) had not been assessed for hypercholesterolaemia. From the hospital records, the prevalence of risk factors in the sample population was 41% for hypertension or raised blood pressure, 49% for hypercholesterolaemia, 12% for current smoking and 8% for diabetes mellitus. In conclusion, patients who have had coronary artery bypass surgery have substantial needs for secondary prevention. A more structured approach to risk factor assessment and preventative care should begin as soon as the diagnosis of coronary heart disease is made, and should not be postponed until the patient has deteriorated to the point of needing bypass surgery.

Plaque pH was measured using a glass combination pH microelectrode of plaque deposits lining the trough of an intra-oral appliance which contained single sections of human teeth with artificial enamel lesions. Plaque exposure to a 10% sucrose solution produced significantly lower plaque pH levels than a solution of sorbitol gum extract. The subsequent flow of saliva over the plaque/pH electrode interface resulted in a significant and rapid increase in pH. Repeat experiments, using deionised water instead of saliva, demonstrated no increase in pH at the plaque/electrode interface. This system may provide a convenient method of producing plaque suitable for repeated pH analysis in intimate association with artificial enamel lesions. This may permit further study of the relationship between plaque acidogenicity, salivary buffering capacity and mineral change within the incipient enamel lesion.

The pulsed Nd: YAG laser is advocated as an alternative means of providing analgesia during routine dental procedures. Since the evidence to support this claim is mainly anecdotal, a clinical trial was carried out using an electric pulp tester (EPT) to measure the extent and duration of any analgesic effect induced by pulsed Nd: YAG laser treatment. A double-blind crossover experiment involving laser and sham treatments was used on 21 subjects. A small (3.6 arbitrary units) but statistically significant increase was observed in the mean responses measured 5 min after laser treatment with 113 mJ pulses at 15 pulses s−1 (pps) for 3 min. The pain thresholds returned to baseline values after 60 min. No statistically significant changes in threshold were found with the sham treatment. The order in which laser and sham treatment was received made no difference to the results.

Family caregivers ofpersons with dementia (N = 38) who placed their relative in a nursing home while participating in a longitudinal study were surveyed about their experiences with community services (adult day care, in-home services, and physician home visits). One third (34%) of the sample reported that at least one service issue (affordability, eligibility, access, or service quality) had a strong influence on the nursing home placement, whereas 40% reported that the availability of at least one additional service would have delayed the nursing home placement of their relative. Caregivers who were employed reported higher levels of unmet service needs. The results of this study support the existence of a group of dementia caregivers with a high need for and willingness to use community service interventions in the preinstitu-tional period.

When the costs of care for persons with AIDS are calculated, the assumption is made that the care provided by the family or other social support network members is a social and not also an economic contribution. This article challenges theflawed assumption of 'free" care, focuses on the labor and economic dimensions offamily home care, and presents a calculation of the dollar value of this care for persons with AIDS (PWAs). The sample consisted of 53 persons, each of whom identified themselves as the primary caregiver for a PWA. Studyfindings revealed caregiver estimates of 5 hours a week of housework performed specificallyfor the PWA. Caregivers spent an average of 8.5 hours a day performing personal care tasks for the PWA. The three most common activities were providing companionship, running errands, and performing food/meal-related activities. Gendercomparisons revealedthat women performed more hours of housework than men but that both provided similar types of personal care for similar numbers of hours. Using a market valuation method, the value of a day's caregiving work was estimated to be $43.78. The annual value of unpaid care, including housework, for one PWA was calculated to be $25,857.88. These data documenta significant economic contribution byfamilies and friends caringfor PWAs. This subsidy must be included as part of the policy andplanning work essential to addressing the AIDS epidemic.

No standardised method for taste threshold measurement is available and therefore comparison between clinical studies is difficult. An electrogustometer was evaluated in normal subjects. No sex difference in taste threshold was noted; however, there was a significant elevation in detection threshold with age and smoking. Electrogustometric values both in patients before and after surgery for trigeminal neuralgia and in patients with trigeminal sensory neuropathy were determined. Many patients with trigeminal nerve disorders had abnormal electrogustometric detection thresholds suggesting that there is possibly an accessory taste pathway through the trigeminal nerve, although in some individuals the site of lesion may be in the brain stem. Electrogustometry is a convenient method for clinically assessing taste.

Research was conducted to investigate postpartal women's attitudes toward their body image; these attitudes were then compared to their pre-pregnant and pregnant body image attitudes. A repeated measures design was used, with data collected at two and six weeks postpartum. Pregnant and pre-pregnant attitudes were collected retrospectively. A nonrandom, convenience sample of 63 multiparas and primiparas was used. The results indicated that the subjects had a slightly positive attitude toward their postpartum body image; multiparas felt more positive about their postpartum body image than did the primiparas; the women felt more positive about their pre-pregnant body image than about their postpartum body image; and the women felt more positive about their postpartum body image than about their pregnant body image.

The influence of sex upon short-period time estimation was investigated. In a 10-estimate session, male Ss were significantly more accurate in producing 10-sec. intervals and showed significantly less across- and intra-subject variability than female Ss.