Evaluating the WISE (Women in the South-East) Telehealth Network: A Model of Healthcare and Health Promotion at Rural Libraries

PURPOSE

The purpose of this study was to evaluate the effectiveness of the WISE (Women in the South-East) Telehealth Network.

DESIGN

A follow-up survey design was used to determine the impact of the program on access to healthcare.

SETTING

WISE provided preventive care to women and gender expansive people at local libraries and the Mobile Library in the rural South Carolina Lowcountry.

SUBJECTS

In 1 year (February 2021-2022), WISE reached 523 individuals with 151 agreeing to participate in the study. Most participants identified as white (66%) or Black (22%).

INTERVENTION

A Community Health Worker provided health education, connection to telehealth services, referrals, and connected individuals with community and social services.

MEASURES

The Telehealth Usability Questionnaire (TUQ), changes in knowledge, satisfaction with WISE, Acceptability of Intervention measure (AIM), and sociodemographic characteristics.

RESULTS

Participants with a high telehealth usability score were significantly more likely to be under the age of 35 (OR 4.60 [95% CI 1.21-17.52]), married (OR 10.00 [95% CI 2.19-45.64]), or white (OR 4.00 [95% CI 1.06-15.08]). The intervention earned a high acceptability score 4.46 (± .61)/5.0 by helping participants obtain necessary medical care and resources, as well as meeting their educational needs.

CONCLUSION

This study offers practical suggestions to expand the use of telehealth initiatives to improve health outcomes by engaging libraries in rural communities.

Liminality: A major category of the experience of cancer illness

Narrative analysis is well established as a means of examining the subjective experience of those who suffer chronic illness and cancer. In a study of perceptions of the outcomes of treatment of cancer of the colon, we have been struck by the consistency with which patients record three particular observations of their subjective experience: (1) the immediate impact of the cancer diagnosis and a persisting identification as a cancer patient, regardless of the time since treatment and of the presence or absence of persistent or recurrent disease; (2) a state of variable alienation from social familiars, expressed as an inability to communicate the nature of the experience of the illness, its diagnosis and treatment; and (3) a persistent sense of boundedness, an awareness of limits to space, empowerment and available time. These subjectivities were experienced in varying degree by all patients in our study. Individual responses to these experiences were complex and variable. The experiences are best understood under the rubric of a category we call "liminality". We believe that all cancer patients enter and experience liminality as a process which begins with the first manifestations of their malignancy. An initial acute phase of liminality is marked by disorientation, a sense of loss and of loss of control, and a sense of uncertainty. An adaptive, enduring phase of suspended liminality supervenes, in which each patient constructs and reconstructs meaning for their experience by means of narrative. This phase persists, probably for the rest of the cancer patient's life. The experience of liminality is firmly grounded in the changing and experiencing body that houses both the disease and the self. Insights into the nature of the experience can be gained from the Existentialist philosophers and from the history of attitudes to death. Understanding liminality helps us to understand what it is that patients with cancer (and other serious illnesses) seek from the system to which they turn for help. Its explication should therefore be important for those who provide health care, those who educate health care workers and those concerned to study and use outcomes as administrative and policy making instruments.

Pragmatic pluralism: Mutual tolerance of contested understandings between orthodox and alternative practitioners in autologous stem cell transplantation

High-dose chemotherapy and autologous stem cell transplantation (ASCT) is used to treat some advanced malignancies. It is a traumatic procedure, with a high complication rate and significant mortality. ASCT patients and their carers draw on many sources of information as they seek to understand the procedure and its consequences. Some seek information from beyond orthodox medicine. Alternative beliefs and practices may conflict with conventional understanding of the theory and practice of ASCT, and 'contested understandings' might interfere with patient adherence to the strict and demanding protocols required for successful ASCT.The present study, conducted in Sydney, Australia, examines narrative-style interviews with 10 sequentially recruited ASCT patients and nine of their carers conducted at the time of transplant and three months later. Transcripts were read for instances of mention of alternative advice, and for instances of contested understanding of information relevant to the transplant.Patients and carer pairs expressed closely concordant views about alternative advice. Five pairs were consulting alternative practitioners. Contested understanding was expressed in four domains-understandings of the transplant itself and its underlying theory, of the relationship between the components of the 'transplant', of the nature and role of stem cells, and of beliefs about bodily function and life-style. Contested understandings of the transplant treatment were expressed as predominantly personal interpretations of orthodox informationPatients and carers seemed to recognise that alternative and conventional systems were discordant, yet they were able to separate the two, and adhere to each practice without prejudicing their medical treatment. A single case of late, post-transplant repudiation of Western medicine is discussed to emphasise some of the possible determinants of dissonance when it does occur.

Response-Corruption, Trust, and Professional Regulation

In their 2018 article in the Cambridge Quarterly of Healthcare Ethics, Little, Lipworth, and Kerridge unpack the concept of corruption and clarify the mechanisms that foster corruption and allow it to persist, noting that organizations are "corruptogenic." To address the "so-what" question, I draw on research about trust and trustworthiness, emphasizing that a person's well-being and sense of security require trust to be present at both the individual and organizational levels-which is not possible in an environment where corruption and misconduct prevail. I highlight similarities in Little et al.'s framing of corruption to the persistent problem of scientific misconduct in research and publishing. I acknowledge the challenges in stemming corruption in science and medicine and conclude with a discussion about the need to reinvigorate a web of stakeholders to actively engage in professional regulation.

Guideline-Recommended Symptom Management Strategies That Cross Over Two or More Cancer Symptoms

PROBLEM IDENTIFICATION

Patients with cancer experience multiple symptoms, but current practice is driven by guidelines that address single symptoms. Identifying symptom management strategies recommended across two or more symptoms could relieve multiple symptoms and reduce patient burden.

LITERATURE SEARCH

The Oncology Nursing Society, National Comprehensive Cancer Network, and American Society of Clinical Oncology websites were searched to identify management guidelines for 15 symptoms.

DATA EVALUATION

The authors extracted symptom management strategies and recommendations. Recommendations were synthesized by symptom across the guidelines, and recommended strategies were compared across symptoms.

SYNTHESIS

Among 32 guidelines reviewed, a total of 88 symptom management strategies (41 pharmacologic, 47 nonpharmacologic) were recommended across two or more symptoms.

IMPLICATIONS FOR PRACTICE

Findings support the potential for coordinated selection of symptom management strategies that cross over multiple symptoms in a patient. Investigators should test these symptom management strategies in the context of co-occurring symptoms and develop guidelines that address multiple symptoms.

P–206 Does oocyte vitrifcation affect morphokinetics of subsequent embryo development?

Study question

Are the morphokinetic profiles, as assessed using time-lapse technology, of human embryos developed from vitrified oocytes different to those from fresh oocytes.

Summary answer

Vitrification of oocytes does have an effect on early developmental morphokinetic profiles, but this is normalized by the time the embryo has reached blastocyst.

What is known already

Vitrification of oocytes is now commonplace, but little is known about the effect this may have on subsequent embryo development.

Study design, size, duration

This was a retrospective data analysis, from 8 fertility clinics in the UK between 2012 and 2019. Embryos from patients in the vitrified group (n = 557) were matched to fresh patient controls (n = 539). The matching was performed based on the following criteria: type of treatment, patient age, cause of infertility and number of embryos.

Participants/materials, setting, methods

The embryos in each group were compared for mean morphokinetics of key developmental stages in hours post insemination (hpi). Parameters compared included early cleavage divisions (t2-t8), time to start of compaction (tSC), time to morula (tM), time to start blastulation (tSB), time to full blastocyst (tB) and duration of compaction (tB-tSC). Treatment outcomes were compared between the two groups, including percentage of blastocyst formation, clinical pregnancy rate, implantation rate and live birth rate.

Main results and the role of chance

The results showed a significant delay across all early cleavage divisions as follows for vitrified and fresh oocytes respectively: 2-cell (28.14 vs 26.10 (p < 0.001)), 3 cell (37.56 vs 35.37 (p < 0.001)), 4 cell (40.58 vs 37.54 (p < 0.001)), 5 cell (50.31 vs 47.14 (p < 0.001)), 6 cell (53.99 vs 50.87 (p < 0.001)), 7 cell (57.08 vs 54.48 (p < 0.001)) and 8 cell (61.26 vs 58.91 (p < 0.01)). In addition, tSC was also significantly delayed in the vitrified group (80.65 vs 76.36 (p < 0.001)). However, the compaction stage was significantly shorter in the vitrified oocytes (19.02 vs 22.45 (p < 0.001)). Therefore, there was no difference in the time that embryos derived from fresh and vitrified oocytes reached the blastocyst stage (108.03 vs 107.78 (p > 0.05)). No difference was found in clinical pregnancy, implantation or live birth rates but significantly fewer blastocyst developed from vitrified oocytes compared to fresh (36.09% vs 42.4% (p < 0.05)).

Limitations, reasons for caution

Although this was a matched analysis, it was a retrospective in nature therefore is subject to confounders. However, it would be problematic to perform a prospective randomized controlled trial to address this study question given the need to randomize patients to elective freezing of oocytes prior to embryo creation.

Wider implications of the findings: Vitrification of oocytes may affect early developmental morphokinetic profiles, but any effect is normalized by the time the embryo has reached blastocyst. However, fewer blastocysts may develop following oocyte vitrification. This may have implications for oocyte donation banks and those patients choosing to cryopreserve oocytes.

Trial registration number

NA

Characteristics of Cancer Symptom Clusters Reported through a Patient-Centered Symptom Cluster Assessment

In the scope of symptom cluster research, few investigators have obtained patients' perceptions of their symptom clusters, even though this information is central to designing effective interventions. In this cross-sectional study, 38 adults with cancer completed measures of demographics, health outcomes (functional status, well-being, quality of life) and a symptom cluster assessment that captured symptom occurrence, severity, distress, clustering, a priority cluster, causal attributions, duration, directional relationships, and cluster interference with daily life. Participants described 72 distinct symptom clusters. Symptoms were most frequently attributed to the cancer diagnosis. Participants' priority symptom cluster typically included two symptoms of continuous duration and one intermittent symptom. Temporal order and direction of symptom relationships varied, with 75 different relationships described among symptom pairs. Greater symptom cluster burden and interference were related to poorer health outcomes. This patient-centered view of symptom clusters revealed substantial variability in symptom cluster characteristics with important implications for symptom management.

Promoting ethics across the healthcare sector: what can codes achieve?

Over the course of the twentieth century, numerous national and international ethics 'codes' have been developed. While such codes serve important substantive and symbolic functions, they can also pose challenges. In this article, we discuss these challenges, noting that they fall into four main categories relating to conceptual tensions, power imbalances, organisational barriers, and threats of exploitation. We illustrate these challenges using examples provided from the United Nations Educational Scientific and Cultural Organization (UNESCO) Universal Declaration on Bioethics and Human Rights. We emphasise the importance of accountability in the development and maintenance of national and international codes and argue that, despite all their challenges, codes provide an important common language among otherwise disparate and sometimes adversarial groups, and provide visible and explicit sets of standards that may be invoked by community members to criticise and hold powerful bodies to account. This is particularly important for practitioners and researchers who belong to organisations that are signatories to codes, who can use these codes to both guide and justify ethical behaviour in the face of competing organisational, professional and political imperatives.

A Quality Initiative to Decrease Time to Antibiotics in Children with Sickle Cell Disease and Fever

Children with sickle cell disease (SCD) are at increased risk for sepsis secondary to functional asplenia. Timely administration of antibiotics, within 60 minutes of triage, is a national indicator of quality SCD care in the United States. However, there are no reports demonstrating the feasibility of doing so in the outpatient hematology-oncology clinic setting.

Local Problem

At baseline, in our pediatric hematology-oncology outpatient center, just 10% of children with SCD and fever received timely antibiotics.

Methods

We implemented a process improvement initiative for children with SCD and fever with the aim of ≥90% receiving timely antibiotics. We enacted interventions focused on general clinic processes from check-in to antibiotics and population-specific interventions, including an intravenous access protocol, notification/communication among staff members, and design of an electronic order set.

Results

The percentage of children receiving timely antibiotics improved from 10% to 77% with successful maintenance following the interventions. Residual delays are due to nonexpeditious order placement and difficult intravenous access.

Conclusion

Improving the timely administration of antibiotics in the outpatient hematology-oncology clinic setting for children with SCD and fever is possible. Achieving at least 90% timely antibiotics for children with SCD and fever in the outpatient clinic setting will require ongoing efforts at expeditious order placement and intravenous access.

CVAD Homecare Management: Investigating the Use of a Digital Education Tool During Nurse-Delivered Instruction to Parents for New Central Lines in Children With Cancer

BACKGROUND

Research on parent understanding of homecare management of external central venous access devices (CVADs) for children with cancer is limited.

OBJECTIVES

The goal was to investigate whether the use of a DVD education intervention reduced adverse complications and improved parent education for homecare management of CVADs for pediatric patients with cancer.

METHODS

Participants were randomized to an experimental group (DVD and nurse teaching) or a control group (nurse teaching). Postintervention evaluation included parent satisfaction and CVAD knowledge proficiency, blood infection rates, use of alteplase, and CVAD replacement.

FINDINGS

Fifty-four enrolled caregiver-patient dyads completed the study measures, with 21 dyads assigned to the control group and 33 assigned to the experimental group. Alteplase was ordered significantly less often in the experimental group. No other findings were significant.

The Benefits and Burdens of Pediatric Palliative Care and End-of-Life Research: A Systematic Review

Objective: The aim of this study is to report the benefits and burdens of palliative research participation on children, siblings, parents, clinicians, and researchers. Background: Pediatric palliative care requires research to mature the science and improve interventions. A tension exists between the desire to enhance palliative and end-of-life care for children and their families and the need to protect these potentially vulnerable populations from untoward burdens. Methods: Systematic review followed PRISMA guidelines with prepared protocol registered as PROSPERO #CRD42018087304. MEDLINE, CINAHL, PsycINFO, EMBASE, Scopus, and The Cochrane Library were searched (2000-2017). English-language studies depicting the benefits or burdens of palliative care or end-of-life research participation on either pediatric patients and/or their family members, clinicians, or study teams were eligible for inclusion. Study quality was appraised using the Mixed Methods Appraisal Tool (MMAT). Results: Twenty-four studies met final inclusion criteria. The benefit or burden of palliative care research participation was reported for the child in 6 papers; siblings in 2; parents in 19; clinicians in 3; and researchers in 5 papers. Benefits were more heavily emphasized by patients and family members, whereas burdens were more prominently emphasized by researchers and clinicians. No paper utilized a validated benefit/burden scale. Discussion: The lack of published exploration into the benefits and burdens of those asked to take part in pediatric palliative care research and those conducting the research is striking. There is a need for implementation of a validated benefit/burden instrument or interview measure as part of pediatric palliative and end-of-life research design and reporting.

Students Tend to Overestimate Their Course Performance

Students in 84 courses estimated their grades as part of a confidential evaluation at the end of the course. Class average predictions were compared with average grades for those classes. A high portion of classes overestimate their actual performance.

The importance of mindfulness in psychosocial distress and quality of life in dermatology patients

BACKGROUND

Mindfulness, defined as purposively and nonjudgementally paying attention in the present moment, could be used within psychosocial interventions to reduce the distress associated with social anxiety and avoidance found in many skin conditions. However, little is known about the relationship between naturally occurring levels of mindfulness and distress in dermatology patients.

OBJECTIVES

To examine the relationship between mindfulness and psychosocial distress in a dermatological population. It was hypothesized that higher levels of mindfulness would be associated with lower levels of social anxiety, anxiety, depression and skin shame, and with better quality of life.

METHODS

Adult dermatology outpatients (n = 120) from one hospital completed items assessing subjective severity, skin shame, fear of negative evaluation, anxiety and depression, quality of life, and levels of mindfulness.

RESULTS

Considering depression, 14% reported mild, 5% moderate and 2·5% severe symptoms. For anxiety, 22% reported mild, 23% moderate and 6% severe symptoms. In addition, 33·4% reported clinically significant social anxiety. After controlling for subjective severity, mindfulness explained an additional 19% of the variance in depression, 39% in anxiety, 41% in social anxiety, 13% in skin shame and 6% in dermatological quality of life. One specific facet of mindfulness (acting with awareness) was found to be the most consistent predictor of distress.

CONCLUSIONS

The findings indicate that higher levels of mindfulness are associated with lower distress. This suggests that facilitating mindfulness may be helpful in reducing distress in dermatology patients, and the use of mindfulness techniques warrants further investigation.

Accounting for Differences in Norms of Respect

Incivility, an often ignored but potentially destructive workplace behavior, represents violations in norms of respect. The authors propose that norms of respect may not be shared within a work place and that variations in norms are reflected in the way individuals assess uncivil behavior toward others. Tests are carried out for variations in personal norms of respect with data from observers of the behavior by professional men toward a professional woman. Results from this study suggest that males and females may have different thresholds at which they perceive a vio lation of their norms of respect. Furthermore, perceptions may be affected by observers’ social identification (by race and sex) with either the perpetrators or the targets of incivility. The authors discuss implications from the study for perpetuating workplace inequalities.

Responses by Professional Organizations to Multiple and Ambiguous Institutional Environments: The Case of AIDS

In this paper we examine responses to multiple and ambiguous pressures gener ated by the environmental threat of AIDS. Using an institutional theory frame work and insights from professional dominance theory, we develop a two- dimensional typology, incorporating the belief systems of important constituents and the degree of institutional rules, to explain the patterns of organizational adoption of AIDS-related policies and related professional prac tices. Hypotheses are tested with data from a national survey of hospitals ( n= 506), with interviews from administrators and chiefs of medicine. Results sup port the usefulness of the explanatory schema for patterns of organizational policy adoption; the schema also provides a stronger explanation of pro fessional behaviour patterns than does the existence of policies requiring such behaviour. Theoretical and practical implications of the findings for professional organizations in the context of environmental threats are discussed.

A Fresh Look at How Professions Take Shape: Dual-directed Networking Dynamics and Social Boundaries

Understanding boundary-spanning activities such as interorganizational alliances and professional/organizational integration requires clarity about what boundaries are being spanned and how they were constructed. We approach this goal by drawing on social identity theory and institutional theory to develop a process model, whereby inward- and outward-directed networking activities combine to build the social boundaries marking exclusive membership and proprietary domain. Four stages in the process are demonstrated, using two longitudinal case studies of emerging professions: the Jewish legal profession in Israel and physician executives in the USA. Despite the cases' contextual differences, analysis of networking activities supports propositions based on the model.

Acquired vulvar lymphangioma circumscriptum after cervical cancer treatment: Case report

Vulvar lymphangioma circumscriptum (LC) is a rare entity which may present as a painful, warty lesion. In contrast to the congenital form, which occurs in children, the acquired form arises in older adults and may be associated with infection, Crohn's disease, or prior pelvic/regional surgery. We present a case of acquired LC of the vulva in a 55-year-old woman who presented with a 3-4 year history of vulvar pain following chemotherapy, radiation, and brachytherapy for cervical cancer. Vulvar shave biopsies followed by excision revealed a thickened dermis with epidermal hyperkeratosis, parakeratosis, elongated rete ridges and dilated lymphatic channels containing eosinophilic material and scattered thrombi. The differential diagnosis for this unusual lesion includes more common conditions such as condyloma acuminatum, fungating squamous cell carcinoma and molluscum contagiosum. It is important to recognize the clinical presentation as well as the distinct histological appearance of this rare benign entity.

Experiences of Pediatric Oncology Patients and Their Parents at End of Life

Improvement in pediatric palliative and end-of-life care has been identified as an ongoing research priority. The child and parent experience provides valuable information to guide how health care professionals can improve the transition to end of life and the care provided to children and families during the vulnerable period. The purpose of this systematic review was to describe the experience of pediatric oncology patients and their parents during end of life, and identify gaps to be addressed with interventions. A literature search was completed using multiple databases, including CINAHL, PubMed, and PsycInfo. A total of 43 articles were included in the review. The analysis of the evidence revealed 5 themes: symptom prevalence and symptom management, parent and child perspectives of care, patterns of care, decision making, and parent and child outcomes of care. Guidelines for quality end-of-life care are needed. More research is needed to address methodological gaps that include the pediatric patient and their sibling’s experience.

Stroke rehabilitation: availability of a family member as caregiver and discharge destination

BACKGROUND

In today's health care environment where resources are scarce discharge planning is an important component of resource allocation. Knowledge of the factors that influence discharge disposition is fundamental to such planning. Further, return to home is an important outcome metric related to the effectiveness of a stroke rehabilitation program.

AIM

To test the hypothesis that the patients who have a caregiver at home willing to participate in the care of the patient discharged from a stroke rehabilitation unit are more likely to be discharged home given other predictive factors being the same.

DESIGN

Retrospective cohort study using binary logistic regression analysis with outcome as discharge home vs. discharge not home after in-patient stroke rehabilitation.

SETTING

Hamilton Health Sciences multidisciplinary integrated stroke program unit.

POPULATION

During this period, 276 patients were admitted to the integrated stroke unit, of which 268 patients were living in the community prior to hospitalization. The remaining eight patients were admitted from a care facility, such as a nursing home or assisted living facility. Since a sample size of eight is too small, these patients were excluded from the analysis. As such, the analysis is based on the 268 patients who were living at home prior to the onset of stroke.

METHODS

The data points collected during the study period were age, gender, days from stroke onset to rehabilitation unit admission, pre-stroke living arrangement (lived alone vs. lived with spouse, partner, or another family member), FIMTM at admission, type of stroke, laterality of impairment, and discharge destination (i.e., private dwelling vs. nursing home, assisted living facility, or back to acute care).

RESULTS

As established by a number of previous studies, the most significant predictors of home as discharge destination was admission FIMTM. However, the second most important predictive factor for home discharge was prestroke living arrangement (lived alone vs lived with spouse/partner/other family member) as hypothesized by the authors.

CONCLUSION

Literature is rich with studies showing functional independence to be the most important predictor of home as discharge disposition but our analysis shows that pre-stroke living arrangement, i.e., lived alone vs lived not alone is also an important predictor for patients to be discharged home after stroke rehabilitation.

CLINICAL REHABILITATION IMPACT

If current discharge planning relies on the availability of a caregiver at home after discharge from in-patient stroke rehabilitation then it may be worthwhile to include these caregivers in the inpatient rehabilitation process, to prepare them for their loved one's return home. Additionally, once the patient is discharged home more resources should be made available to support caregivers in the community. This may include more home healthcare personnel training and availability along with respite care.

How pharmaceutical industry employees manage competing commitments in the face of public criticism

The pharmaceutical industry has been criticised for pervasive misconduct. These concerns have generally resulted in increasing regulation. While such regulation is no doubt necessary, it tends to assume that everyone working for pharmaceutical companies is equally motivated by commerce, without much understanding of the specific views and experiences of those who work in different parts of the industry. In order to gain a more nuanced picture of the work that goes on in the "medical affairs" departments of pharmaceutical companies, we conducted 15 semi-structured interviews with professionals working in medical departments of companies in Sydney, Australia. We show that this group of pharmaceutical professionals are committed to their responsibilities both to patients, research participants, and the public and to their companies. Despite the discrepancies between these commitments, our participants did not express much cognitive dissonance, and this appeared to stem from their use of two dialectically related strategies, one of which embraces commerce and the other of which resists the commercial imperative. We interpret these findings through the lens of institutional theory and consider their implications for pharmaceutical ethics and governance.

Trouble in the gap: a bioethical and sociological analysis of informed consent for high-risk medical procedures

Concerns are frequently raised about the extent to which formal consent procedures actually lead to "informed" consent. As part of a study of consent to high-risk medical procedures, we analyzed in-depth interviews with 16 health care professionals working in bone-marrow transplantation in Sydney, Australia. We find that these professionals recognize and act on their responsibility to inform and educate patients and that they expect patients to reciprocate these efforts by demonstrably engaging in the education process. This expectation is largely implicit, however, and when it is not met, this can give rise to trouble that can have adverse consequences for patients, physicians, and relationships within the clinic. We revisit the concept of the sick role to formalize this new role expectation, and we argue that "informed" consent is a process that is usually incomplete, despite trappings and assumptions that help to create the illusion of completeness.

Perceptions of Nutrition Support in Pediatric Oncology Patients and Parents

An estimated 60% of pediatric oncology patients experience malnutrition during cancer therapy. Initiation of enteral nutrition (EN) and parenteral nutrition (PN) are interventions aimed at maintaining and promoting growth. Limited literature addressing perceptions of nutrition support methods exists. To develop effective guidelines on nutrition education, it is important to understand perceptions regarding nutrition support. The purpose of this pilot study was to describe perceptions of pediatric oncology patients and parents regarding the use of EN and PN and identify influencing variables. A convenience sample of pediatric oncology patients and parents were surveyed at a large Midwestern children’s hospital. The majority of those surveyed chose PN over EN if they or their child were unable to eat or maintain their nutritional status. Perceptions may be influenced by comfort, ease of nutrition or medication administration, experience, health care team’s recommendation, choice, and image. This study provides health care professionals an initial opportunity to understand perceptions of EN and PN, which may provide a foundation for a multi-institutional study and enhance patient and family education.

P2-06-04: Phosphatidylinositol-3-Kinase Pathway Mutations Are Common in Breast Columnar Cell Lesions

The phosphatidylinositol-3-kinase pathway is one of the most commonly mutated in invasive breast carcinoma, with PIK3CA mutations present in ∼25% of invasive carcinomas, and AKT1 mutations identified in up to 5%. Several studies have demonstrated the same complement of mutations in ductal carcinoma in-situ (DCIS), as well as benign papillomas. We sought to investigate whether PIK3CA mutations occur in breast columnar cell lesions (CCL).

Twenty-five breast resection specimens containing CCL (including columnar cell change, columnar cell hyperplasia, and flat epithelial atypia) were identified from the files of Stanford University Pathology; 15 of these had associated invasive carcinoma (IDC) or carcinoma in situ. DNA was prepared from punches of formalin-fixed paraffin-embedded tissue blocks using standard methods. DNA extracts were screened for a panel of point mutations using a multiplex PCR panel with a mass-spectroscopy readout (Sequenom MassARRAY). The panel covers 321 mutations in 30 genes, including ABL, AKT1/2/3, BRAF, CDK4, CTNNB1, EGFR1, ERBB2, FBX4, FBXW7, FGFR1/2/3, FLT3, GNAQ, HRAS, JAK2, KIT, KRAS, MAPK2K1/2, MET, NRAS, PDGFRA, PIK3CA, PTPN11, RET, SOS1, and TP53. The majority of mutations were confirmed by Sanger sequencing. PIK3CA mutations were identified in 12/25 CCL (48%); paired normal breast tissue was tested in 21 cases and was negative for mutations in all but one case. In associated DCIS, 4/8 (50%) harbored PIK3CA mutations, while 3/9 IDC had mutations (33%, 2 PIK3CA, 1 AKT1). The mutation status of CCL and carcinomas was frequently discordant. Of 15 cases, only 6 demonstrated the same genotype in matched samples of CCL and carcinoma (5 wildtype, 1 PIK3CA H1047R). Interestingly, 5 patients had mutations in CCL with wildtype DCIS or IDC; 2 patients had different point mutations in CCL and carcinoma, including one patient with discordant mutant DCIS and wildtype IDC. Only 3 cases had wildtype CCL and mutated carcinoma.

The nearly 50% PIK3CA mutation prevalence in CCL is greater than reported in most studies of invasive breast cancer. Further, CCL and carcinoma were frequently discordant for PIK3CA/AKT1 mutation status; most commonly the CCL harbored a PIK3CA mutation, while the associated carcinoma was wildtype. Although these findings need validation in a larger study, they raise interesting questions as to the role of PIK3CA/AKT pathway in breast carcinogenesis, and as to the biologic/precursor potential of CCL.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-06-04.

Enriching patient-centered care in serious illness: a focus on patients' experiences of agency

CONTEXT

Following models of patient-centered care, including respecting patients' preferences and enabling patients (and their families) to participate in directing their own care, is especially difficult when providing care to cancer patients undergoing complex, aggressive therapy, when their capabilities are diminished. In this context, patient-centered care can be enriched when health care providers develop a deeper awareness of and appreciation for the multiple ways in which patients experience agency-defined as the capacity to make a difference-as both the initiators and the recipients of others' agency.

METHODS

Qualitative data were collected between 2006 and 2008 in sixty-nine narrative interviews with both a panel of ten patients undergoing aggressive inpatient cancer therapy (autologous stem-cell therapy) and their lay caregivers. Data were analyzed using an interpretative approach and guided by a conceptual framework derived from recent sociological literature on agency.

FINDINGS

We examined agency experiences through three distinct lenses: (1) the nature of the actors (both human and nonhuman), (2) the nature of the actions, and (3) the nature of the domains for action. The actors were individuals and teams, drugs and technologies, and the cancer itself. Actions could be initiated or received by the patients and included fighting and violating as well as comforting and healing. Domains were the patients' bodies, the health care system, and the patients' everyday worlds. In several instances, the same phenomena can be examined through more than one lens of agency, drawing attention to different aspects of the patients' experiences. Taken together, the lenses form a comprehensive picture of patients' experiences of agency.

CONCLUSIONS

This three-lens perspective can be a valuable template for health care professionals and policymakers to use in better understanding the experiences of patients in constrained circumstances. We propose that its use is a fruitful and promising contribution to recent conceptualizations of patient-centered care that emphasize the relational and facilitative aspects of care provision.

Hip and knee implants: current trends and policy considerations

This paper constitutes an analysis of the issues, relationships, emerging hospital strategies, and policy needs surrounding hip and knee implants. Demand for hip and knee replacements is rising annually, and growth is expected to be substantial. Costs are high, reaching $11 billion for hospitals in 2004 and $5 billion for Medicare in 2006. Relationships among stakeholders add complexity. Case studies reveal emerging strategies by hospitals for management of implants. Policy considerations include development of a national council for data and technology assessment, a national joint registry, price transparency, and incentives.

Shifts in guidelines for ethical scientific conduct: how public and private organizations create and change norms of research integrity

We analyze the activities and actors involved in articulating and diffusing guidelines for ethical scientific conduct from 1975 to the present. We use a theoretical framework of institutional change at the organizational-field level to examine the co-evolution of the structure of the organizational field of 'scientific research' and its institutional logic. Public agencies have long provided funding to US universities to support faculty research, expecting that implicit norms of scientific conduct would guide behavior. Growing publicity about research fraud in the late 1960s and early 1970s triggered a shift from implicit norms to explicit behavioral proscriptions, with strong administrative oversight. As private sources of research funding exert new pressures on research behavior, public-private partnerships are emerging to articulate explicit, yet voluntary prescriptive norms of research integrity. The analysis demonstrates the co-evolution and co-dependence of changes in the identity and strength of influential actors in the field of scientific research and changes in the norms of scientific conduct. We examine how the normative guidelines have been constructed over time, illustrating the persistence of earlier norms as the foundation for current guidelines. We conclude with implications for future research conduct.

Lifeguard--a personal physiological monitor for extreme environments

Monitoring vital signs in applications that require the subject to be mobile requires small, lightweight, and robust sensors and electronics. A body-worn system should be unobtrusive, noninvasive, and easy-to-use. It must be able to log vital signs data for several hours as well as transmit it on demand in real-time using secure wireless technologies. The NASA Ames Research Center (Astrobionics) and Stanford University (National Center for Space Biological Technologies) are currently developing a wearable physiological monitoring system for astronauts, called LifeGuard, that meets all of the above requirements and is also applicable to clinical, home-health monitoring, first responder and military applications.

Hospitals' strategies for orchestrating selection of physician preference items

This article analyzes hospitals' strategies to shape physicians' behavior and counter suppliers' power in purchasing physician preference items. Two models of standardization are limitations on the range of manufacturers or products (the "formulary" model) and price ceilings for particular item categories (the "payment-cap" model), both requiring processes to define product equivalencies often with inadequate product comparison data. The formulary model is more difficult to implement because of physicians' resistance to top-down dictates. The payment-cap model is more feasible because it preserves physicians' choice while also restraining manufacturers' power. Hospitals may influence physicians' involvement through a process of orchestration that includes committing to improve clinical facilities, scheduling, and training and fostering a culture of mutual trust and respect.

Hospitals' strategies for orchestrating selection of physician preference items

This article analyzes hospitals' strategies to shape physicians' behavior and counter suppliers' power in purchasing physician preference items. Two models of standardization are limitations on the range of manufacturers or products (the "formulary" model) and price ceilings for particular item categories (the "payment-cap" model), both requiring processes to define product equivalencies often with inadequate product comparison data. The formulary model is more difficult to implement because of physicians' resistance to top-down dictates. The payment-cap model is more feasible because it preserves physicians' choice while also restraining manufacturers' power. Hospitals may influence physicians' involvement through a process of orchestration that includes committing to improve clinical facilities, scheduling, and training and fostering a culture of mutual trust and respect.

Pragmatic pluralism: Mutual tolerance of contested understandings between orthodox and alternative practitioners in autologous stem cell transplantation

High-dose chemotherapy and autologous stem cell transplantation (ASCT) is used to treat some advanced malignancies. It is a traumatic procedure, with a high complication rate and significant mortality. ASCT patients and their carers draw on many sources of information as they seek to understand the procedure and its consequences. Some seek information from beyond orthodox medicine. Alternative beliefs and practices may conflict with conventional understanding of the theory and practice of ASCT, and 'contested understandings' might interfere with patient adherence to the strict and demanding protocols required for successful ASCT. The present study, conducted in Sydney, Australia, examines narrative-style interviews with 10 sequentially recruited ASCT patients and nine of their carers conducted at the time of transplant and three months later. Transcripts were read for instances of mention of alternative advice, and for instances of contested understanding of information relevant to the transplant. Patients and carer pairs expressed closely concordant views about alternative advice. Five pairs were consulting alternative practitioners. Contested understanding was expressed in four domains--understandings of the transplant itself and its underlying theory, of the relationship between the components of the 'transplant', of the nature and role of stem cells, and of beliefs about bodily function and life-style. Contested understandings of the transplant treatment were expressed as predominantly personal interpretations of orthodox information. Patients and carers seemed to recognise that alternative and conventional systems were discordant, yet they were able to separate the two, and adhere to each practice without prejudicing their medical treatment. A single case of late, post-transplant repudiation of Western medicine is discussed to emphasise some of the possible determinants of dissonance when it does occur.

‘Right’ way to ‘do’ illness? Thinking critically about positive thinking

Exhortations to 'be positive' accompany many situations in life, either as a general injunction or in difficult situations where people are facing pressure or adversity. It is particularly evident in health care, where positive thinking has become an aspect of the way people are expected to 'do' illness in developed society. Positive thinking is framed both as a moral injunction and as a central belief system. It is thought to help patients cope emotionally with illness and to provide a biological benefit. Yet, the meanings, expectations and outcomes of positive thinking are infrequently questioned and the risks of positive thinking are rarely examined. We outline some of the latter and suggest that health professionals should exercise caution in both 'prescribing' positive thinking and in responding to patients and carers whose belief systems and feelings of obligation rest on it.