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Peter Tsasis,1 Jenna M Evans,2 David Forrest,3 Richard Keith Jones4 1School of Health Policy and Management, Faculty of Health, York University, Toronto, Canada; 2Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Canada; 3Global Vision Consulting Ltd, Victoria, Canada; 4R Keith Jones and Associates, Victoria, Canada Abstract: Health systems around the world are implementing integrated care strategies to improve quality, reduce or maintain costs, and improve the patient experience. Yet few practical tools exist to aid leaders and managers in building the prerequisites to integrated care, namely a shared vision, clear roles and responsibilities, and a common understanding of how the vision will be realized. Outcome mapping may facilitate stakeholder alignment on the vision, roles, and processes of integrated care delivery via participative and focused dialogue among diverse stakeholders on desired outcomes and enabling actions. In this paper, we describe an outcome-mapping exercise we conducted at a Local Health Integration Network in Ontario, Canada, using consensus development conferences. Our preliminary findings suggest that outcome mapping may help stakeholders make sense of a complex system and foster collaborative capital, a resource that can support information sharing, trust, and coordinated change toward integration across organizational and professional boundaries. Drawing from the theoretical perspectives of complex adaptive systems and collaborative capital, we also outline recommendations for future outcome-mapping exercises. In particular, we emphasize the potential for outcome mapping to be used as a tool not only for identifying and linking strategic outcomes and actions, but also for studying the boundaries, gaps, and ties that characterize social networks across the continuum of care. Keywords: integrated care, integrated delivery systems, complex adaptive systems, social capital, collaborative capital

Objective: To estimate abortion rates among subpopulations of women in 2008, assess changes in subpopulation abortion rates since 2000, and estimate the lifetime incidence of abortion.Methods: We combined secondary data from several sources, including the 2008 Abortion Patient Survey, the Current Population Surveys for 2008 and 2009, and the 2006-2008 National Survey of Family Growth, to estimate abortion rates by subgroup and lifetime incidence of abortion for U.S. women of reproductive age.Results: The abortion rate declined 8.0% between 2000 and 2008, from 21.3 abortions per 1,000 women aged 15-44 to 19.6 per 1,000. Decreases in abortion were experienced by most subgroups of women. One notable exception was poor women; this group accounted for 42.4% of abortions in 2008, and their abortion rate increased 17.5% between 2000 and 2008 from 44.4 to 52.2 abortions per 1,000. In addition to poor women, abortion rates were highest for women who were cohabiting (52.0 per 1,000), aged 20-24 (39.9 per 1,000), or non-Hispanic African American (40.2 per 1,000). If the 2008 abortion rate prevails, 30.0% of women will have an abortion by age 45.Conclusion: Abortion is becoming increasingly concentrated among poor women, and restrictions on abortion disproportionately affect this population. [ABSTRACT FROM AUTHOR]

Background: Traditionally, reversal of nondepolarizing neuromuscular blocking agents was achieved using acetylcholinesterase inhibitors, but these are unable to adequately reverse profound blockade. Sugammadex is a novel reversal agent, reversing the effects of rocuronium by encapsulation. This study assessed the efficacy and safety of sugammadex versus neostigmine for reversal of profound rocuronium-induced neuromuscular blockade.Methods: This phase III, randomized study enrolled surgical patients, aged 18 yr or older with American Society of Anesthesiologists physical status I-IV. Patients were randomized to receive sugammadex (4.0 mg/kg) or neostigmine (70 microg/kg) plus glycopyrrolate (14 microg/kg). Anesthetized patients received an intubating dose of rocuronium (0.6 mg/kg), with maintenance doses (0.15 mg/kg) as required. Neuromuscular monitoring was performed by acceleromyography. Sugammadex or neostigmine was administered at reappearance of 1-2 posttetanic counts (profound neuromuscular blockade). The primary efficacy parameter was the time from sugammadex or neostigmine-glycopyrrolate administration to return of the train-of-four ratio to 0.9.Results: In the intent-to-treat population (n = 37 in each group), geometric mean time to recovery to a train-of-four ratio of 0.9 with sugammadex was 2.9 min versus 50.4 min with neostigmine-glycopyrrolate (P < 0.0001) (median, 2.7 min vs. 49.0 min). Most sugammadex patients (97%) recovered to a train-of-four ratio of 0.9 within 5 min after administration. In contrast, most neostigmine patients (73%) recovered between 30 and 60 min after administration, with 23% requiring more than 60 min to recover to a train-of-four ratio of 0.9.Conclusions: Recovery from profound rocuronium-induced neuromuscular blockade was significantly faster with sugammadex versus with neostigmine, suggesting that sugammadex has a unique ability to rapidly reverse profound rocuronium neuromuscular blockade. [ABSTRACT FROM AUTHOR]

The majority of U.S. women who have abortions (61%) have children. This exploratory study analyzes qualitative information from 38 women obtaining abortions to examine how issues of motherhood influenced their decisions to terminate their pregnancies. Women in the sample had abortions because of the material responsibilities of motherhood, such as the care for their existing children, as well as the more abstract expectations of parenting, such as the desire to provide children with a good home. The women believed that children were entitled to a stable and loving family, financial security, and a high level of care and attention. One fourth of the women had considered adoption but regarded it as being emotionally distressing. The findings demonstrate reasons why women have abortions throughout their reproductive life spans and that their decisions to terminate pregnancies are often influenced by the desire to be a good parent. [ABSTRACT FROM AUTHOR]

Context: Legislation has been proposed that would mandate parental notification for adolescents younger than 18 years (minors) obtaining prescription contraception from federally funded family planning clinics.Objective: To determine the extent to which parents are currently aware that their teenage daughters are accessing reproductive health services and how minors would react in the face of mandated parental involvement laws for prescription birth control.Design, Setting, and Participants: A total of 1526 female adolescents younger than 18 years seeking reproductive health services at a national sample of 79 family planning clinics were surveyed between May 2003 and February 2004.Main Outcome Measures: Proportions of minor females who reported that a parent or guardian was aware that they were at the family planning clinic and, under conditions of mandated parental involvement, proportions of minors who would access prescription contraceptives at family planning clinics or engage in unsafe sex.Results: Sixty percent of minors reported that a parent or guardian knew they were accessing sexual health services at the clinic. Fifty-nine percent of all adolescents would use the clinic for prescription contraception even if parental notification were mandated. This response was less common (29.5%) among adolescents whose parents were unaware of their clinic visits and more common (79%) among those whose parents were aware. Many adolescents gave more than 1 response to mandated parental involvement. Forty-six percent would use an over-the-counter method, and 18% would go to a private physician. Seven percent said that they would stop having sex as one response, but only 1% indicated this would be their only reaction. One in 5 adolescents would use no contraception or rely on withdrawal as one response to mandated notification.Conclusions: Most minor adolescent females seeking family planning services report that their parents are aware of their use of services. Most would continue to use clinic services if parental notification were mandated. However, mandated parental notification laws would likely increase risky or unsafe sexual behavior and, in turn, the incidence of adolescent pregnancy and sexually transmitted diseases. [ABSTRACT FROM AUTHOR]

An assessment of women's knowledge of cervical screening and cervical cancer was considered important as up to 92% of those dying from this form of cancer had never been tested. What were the reasons which determined their non-attendance? Issues to be addressed were reactions to invitation, women's knowledge of screening, and the possible factors which they envisaged as being associated with cervical cancer. Other issues to be considered were practical problems associated with attendance, and preference for the sex and professional status of the health professionals involved; 187 women in a general practitioner practice in Lothian, Scotland were targeted by questionnaire. As with other studies in this field 50% of those contacted were ineligible for a variety of reasons. Seventy-two women completed the questionnaire, providing a mix of qualitative and quantitative data. Although the majority of women felt the invitation to attend screening was clear and easy to understand, there was a lack of knowledge with regard to both the screening itself and the possible causes of cervical cancer. The main 'causes' were seen as higher sexual activity among those aged under 37 and smoking and a virus by those over 37. The majority of women showed preference for a female professional to take the smear. Practical problems of time and venue were not considered insurmountable. The main reasons cited for non-compliance were the fear and dislike of the test itself. [ABSTRACT FROM AUTHOR]

Apoptosis has been implicated in the pathogenesis of several diseases and is partly regulated by bcl-2, which blocks the apoptotic pathway and promotes cell survival. Apoptosis and bcl-2 expression were examined in paired eutopic and ectopic endometrium from women with endometriosis (n = 30 samples) or adenomyosis (n = 15 samples) and compared with control endometrium (n = 30 samples). Apoptotic cells were detected using the dUTP nick-end labelling (TUNEL) assay for DNA fragmentation; bcl-2 expression was demonstrated with a streptavidin-biotin peroxidase immunohistochemical technique. Apoptotic cells were rare in eutopic, ectopic and control endometrium; there were no significant differences between subject groups nor between eutopic and ectopic endometrium. Stromal bcl-2 expression increased in the late secretory phase in control and eutopic endometrium in endometriosis; double labelling studies revealed that most stromal bcl-2 + cells were leukocytes. Stromal bcl-2 expression in endometriotic foci was significantly increased compared with the paired eutopic endometrium, did not vary with menstrual cycle and included a significant population of non-leukocytic bcl-2 + stromal cells. In contrast, stromal bcl-2 expression in adenomyosis remained at low levels and did not show significant cyclical variation. Glandular epithelial bcl-2 expression also varied with menstrual cycle phase and peaked in the proliferative phase; in contrast, surface epithelial bcl-2 expression increased in the late secretory phase. Elevated stromal bcl-2 expression in ovarian endometriotic lesions could have implications for the growth and survival of ectopic endometrial tissue at these sites. [ABSTRACT FROM PUBLISHER]

Intraepithelial leukocytes (IEL) are recognized as an important component of most mucosal surfaces but have received scant attention in the human female reproductive tract. The aim of the present study was to characterize, quantify and compare IEL populations in normal endometrium (n = 30) and in eutopic and ectopic (endometriotic or adenomyotic lesions) endometrium from women with endometriosis (n = 30) or adenomyosis (n = 15) at different menstrual cycle phases in order to assess the role of IEL in these common but poorly understood disorders. IEL populations were examined in formalin-fixed, paraffin-embedded sections using a streptavidin-biotin-peroxidase complex technique and quantified in relation to epithelial cell numbers. IEL in control endometrium and eutopic endometrium in endometriosis and adenomyosis varied during the menstrual cycle, with CD45+, CD43+ and CD56+ cells increasing from the proliferative to the late secretory phase. IEL were elevated in surface compared with glandular epithelium in the proliferative and early secretory phases. Throughout the menstrual cycle there were no significant differences in IEL between eutopic and ectopic endometrium in adenomyosis. Endometriotic foci, however, contained elevated levels of CD45+, CD3+ and CD8+ cells and reduced numbers of CD56+ cells compared with the corresponding eutopic endometrium and these did not vary with menstrual cycle phase. In contrast, ectopic endometrium in adenomyosis showed some cyclical changes with CD56+ cells increasing significantly in the late secretory phase. It is possible these differences may play a role in the pathogenesis of endometriosis and the associated complications. [ABSTRACT FROM PUBLISHER]

The aetiology of endometriosis, a common and disabling disorder, is presently unknown, although immune dysfunction could allow ectopic endometrial fragments to survive outside the uterine cavity. These studies investigate the relationship between leukocyte populations, steroid hormone receptor expression, proliferative activity, bcl-2 expression and apoptosis in eutopic and ectopic endometrium from women with endometriosis or adenomyosis at different phases of the menstrual cycle. Significantly increased oestrogen receptor expression, bcl-2 expression and numbers of CD8+ leukocytes were found in ectopic compared with eutopic endometrium in endometriosis, and CD56+ endometrial granulated lymphocytes (eGLs) were significantly reduced in ectopic endometrium. Apoptotic cells were rarely found in control and subject endometria. In contrast with endometriosis, adenomyotic lesions showed identical steroid hormone receptor expression, proliferative activity, bcl-2 expression and leukocyte subpopulations to eutopic endometrium, indicating different aetiologies for these disorders. The unusual CD56+ CD16-eGLs present in large numbers in late secretory phase eutopic endometrium were highly purified (>98%) by immunomagnetic separation. Except for a negligible cytotoxic activity of eGLs from early proliferative samples, cytotoxic activity of eGLs from non-pregnant endometrium during the menstrual cycle was comparable with those in peripheral blood, predominantly CD56+ CD16+ natural killer cells. eGLs from non-pregnant endometrium and early pregnancy showed a variable proliferative response to 5 and 100 U/ml interleukin-2 over 48-h and 120-h time courses. eGLs are evidently functionally important in the eutopic endometrium. Their absence in endometriotic lesions together with increased CD+8 T cell numbers and increased oestrogen receptor and bcl-2 expression may have significant effects on the development and progression of endometriosis. [ABSTRACT FROM PUBLISHER]