Challenges, Strengths and Opportunities Related to Implementing Comprehensive Evidence-Based Guidelines on Breast Cancer Survivorship Care by Primary Care Physicians and Nurse Practitioners in Southeastern Ontario

Background Many breast cancer survivors continue to have a broad range of physical and psychosocial problems after breast cancer treatment. As cancer centres move forward with earlier discharge of stable breast cancer survivors to primary care follow-up it is important that comprehensive evidence-based breast cancer survivorship care is implemented to effectively address these needs. Research suggests primary care providers are willing to provide breast cancer survivorship care but many lack the knowledge and confidence to provide evidence-based care. Purpose The overall purpose of this thesis was to determine the challenges, strengths and opportunities related to implementing comprehensive evidence-based breast cancer survivorship guidelines by primary care physicians and nurse practitioners in southeastern Ontario. Methods This mixed-methods research was conducted in three phases: (1) synthesis and appraisal of clinical practice guidelines relevant to provision of breast cancer survivorship care within the primary care practice setting; (2) a brief quantitative survey of primary care providers to determine actual practices related to provision of evidence-based breast cancer survivorship care; and (3) individual interviews with primary care providers about the challenges, strengths and opportunities related to provision of comprehensive evidence-based breast cancer survivorship care. Results and Conclusions In the first phase, a comprehensive clinical practice framework was created to guide provision of breast cancer survivorship care and consisted of a one-page checklist outlining breast cancer survivorship issues relevant to primary care, a three-page summary of key recommendations, and a one-page list of guideline sources. The second phase identified several knowledge and practice gaps, and it was determined that guideline implementation rates were higher for recommendations related to prevention and surveillance aspects of survivorship care and lowest related to screening for and management of long-term effects. The third phase identified three major challenges to providing breast cancer survivorship care: inconsistent educational preparation, provider anxieties, and primary care burden; and three major strengths or opportunities to facilitate implementation of survivorship care guidelines: tools and technology, empowering survivors, and optimizing nursing roles. A better understanding of these challenges, strengths and opportunities will inform development of targeted knowledge translation interventions to provide support and education to primary care providers.

The Impact of Cultural Factors on Post-Acquisition Integration: Domestic and Foreign Acquisitions of Finnish Companies in 1993-2004

Acquisitions are a central component of corporate strategy. They contribute to competitive advantage by offering possibilities for both cost reductions and for revenue enhancements. However, many acquisition benefits cannot be realized without a successful integration of the acquiring and the acquired firms. Previous research shows that national and organizational culture can play a major role in determining the integration outcomes. Therefore, the overall aim of the thesis is to map out and illustrate the impact mechanisms of cultural factors in post-acquisition integration in order to explain the cultural aspects of acquisitions. This study has three main contributions. First, the study shows that international and domestic acquisitions differ concerning both strategic and cultural fit. Second, the findings highlight the importance of acculturation and cultural integration in determining post-acquisition outcomes. Finally, the study uncovers several impact mechanisms that shed light to the contradictory results related to cultural differences in previous research.

A Mixed-Method Study of Educator Knowledge and Practice Related to Student Socio-moral Development

The purpose of this study was to explore elementary educators’ knowledge of moral development, how this knowledge relates to their beliefs and sense of efficacy pertaining to character education practices and the socio-moral reasoning of their students. It was hypothesized that educators’ beliefs and practices related to character education would reflect their pedagogy rather than knowledge of moral development theory. It was further hypothesized that there would be differences in student socio-moral reasoning specifically the beliefs and desires that guide actions would differ based on grade and gender. This mixed-method study employing self-report questionnaires, open response vignettes, and semi-structured educator interviews yielded quantitative and qualitative data. Findings indicated socio-moral reasoning of students differed according to grade (age) and gender. Knowledge of moral development theory was found to vary among participants however some practices employed by educators did align with a social cognitive approach to moral development. Significant variables identified consistently among educator and student participants included, autonomy, social competence, sense of school community, and supportiveness. These variables, in conjunction with a sense of fairness, have been identified elsewhere as foundational to moral development (Nucci, 2009), and intrinsic motivation (Ryan & Deci, 2000) and are relevant to educators working to develop student socio-moral reasoning as an aspect of character.

Consumer attitudes, knowledge, and behavior related to salt consumption in sentinel countries of the Americas

Objective. To describe individual attitudes, knowledge, and behavior regarding salt intake, its dietary sources, and current food-labeling practices related to salt and sodium in five sentinel countries of the Americas. Methods. A convenience sample of 1 992 adults (>= 18 years old) from Argentina, Canada, Chile, Costa Rica, and Ecuador (approximately 400 from each country) was obtained between September 2010 and February 2011. Data collection was conducted in shopping malls or major commercial areas using a questionnaire containing 33 questions. Descriptive estimates are presented for the total sample and stratified by country and sociodemographic characteristics of the studied population. Results. Almost 90% of participants associated excess intake of salt with the occurrence of adverse health conditions, more than 60% indicated they were trying to reduce their current intake of salt, and more than 30% believed reducing dietary salt to be of high importance. Only 26% of participants claimed to know the existence of a recommended maximum value of salt or sodium intake and 47% of them stated they knew the content of salt in food items. More than 80% of participants said that they would like food labeling to indicate high, medium, and low levels of salt or sodium and would like to see a clear warning label on packages of foods high in salt. Conclusions. Additional effort is required to increase consumers' knowledge about the existence of a maximum limit for intake and to improve their capacity to accurately monitor and reduce their personal salt consumption.

Report of the Illinois Commission on Atomic Energy to the ... General Assembly.

Title from cover.

A study of the effects of orally administered female hormones on the volume and composition of lacrimal fluid related to the toleration of corneal contact lenses

This study was designed to evaluate the effects of certain orally active contraceptive steroids on the eye, related to the tolerance of a corneal contact lens. An oestrogen, ethinyloestradiol BP. 0.05 mg, a progestogen, norethisterone acetate BP. 2.50 mg and a control tablet (vitamin C, 50 mg) were utilised. The effect of these preparations on corneal curvature, lacrimal fluid volume and protein composition and directly on corneal lens tolerance was monitored in a group of 23 volunteer patients. The progestogen was found to produce a significant (P≥ 0.05) decrease in tear volume as measured by a 3 minute Schirmer test. A smaller volume reduction was observed with ethinyloestradiol. A normal cornea appears unaffected, within the measurement limits available, by the use of either hormone. However, in the presence of a corneal lens, oestrogen was found to induce substantial corneal steepening, indicative of tissue oedema, during the initial 2-3 weeks of medication. Progestogen occasionally produced a similar effect, which could recur with either hormone shortly after the end of the treatment period. A new method of acrylamide gel electrophoresis was developed for examination of the protein concentration and composition of lacrimal fluid. This allowed much greater resolution of microquantities of unconcentrated fluid than anything previously reported. Quantitation by densitometry has permitted the recording of medication and lens-induced changes in the protein pattern. Tear albumin has been shown to differ from serum albumin and to consist of up to 3 subfractions, 7 further protein fractions may also be resolved. The concentration and probable origin of these proteins have been established and the overall effects of hormone administration described. Individual idiosyncratic responses are also discussed. The study has established tbenature of some effects of contraceptive steroids on the anterior eye, and the probable reasons for resultant corneal lens intolerance.

The contribution of psychosocial factors to socioeconomic differences in food purchasing

In developed countries the relationship between socioeconomic position (SEP) and health is unequivocal. Those who are socioeconomically disadvantaged are known to experience higher morbidity and mortality from a range of chronic diet-related conditions compared to those of higher SEP. Socioeconomic inequalities in diet are well established. Compared to their more advantaged counterparts, those of low SEP are consistently found to consume diets less consistent with dietary guidelines (i.e. higher in fat, salt and sugar and lower in fibre, fruit and vegetables). Although the reasons for dietary inequalities remain unclear, understanding how such differences arise is important for the development of strategies to reduce health inequalities. Both environmental (e.g. proximity of supermarkets, price, and availability of foods) and psychosocial (e.g. taste preference, nutrition knowledge) influences are proposed to account for inequalities in food choices. Although in the United States (US), United Kingdom (UK), and parts of Australia, environmental factors are associated with socioeconomic differences in food choices, these factors do not completely account for the observed inequalities. Internationally, this context has prompted calls for further exploration of the role of psychological and social factors in relation to inequalities in food choices. It is this task that forms the primary goal of this PhD research. In the small body of research examining the contribution of psychosocial factors to inequalities in food choices, studies have focussed on food cost concerns, nutrition knowledge or health concerns. These factors are generally found to be influential. However, since a range of psychosocial factors are known determinants of food choices in the general population, it is likely that a range of factors also contribute to inequalities in food choices. Identification of additional psychosocial factors of relevance to inequalities in food choices would provide new opportunities for health promotion, including the adaption of existing strategies. The methodological features of previous research have also hindered the advancement of knowledge in this area and a lack of qualitative studies has resulted in a dearth of descriptive information on this topic. This PhD investigation extends previous research by assessing a range of psychosocial factors in relation to inequalities in food choices using both quantitative and qualitative techniques. Secondary data analyses were undertaken using data obtained from two Brisbane-based studies, the Brisbane Food Study (N=1003, conducted in 2000), and the Sixty Families Study (N=60, conducted in 1998). Both studies involved main household food purchasers completing an interviewer-administered survey within their own home. Data pertaining to food-purchasing, and psychosocial, socioeconomic and demographic characteristics were collected in each study. The mutual goals of both the qualitative and quantitative phases of this investigation were to assess socioeconomic differences in food purchasing and to identify psychosocial factors relevant to any observed differences. The quantitative methods then additionally considered whether the associations examined differed according to the socioeconomic indicator used (i.e. income or education). The qualitative analyses made a unique contribution to this project by generating detailed descriptions of socioeconomic differences in psychosocial factors. Those with lower levels of income and education were found to make food purchasing choices less consistent with dietary guidelines compared to those of high SEP. The psychosocial factors identified as relevant to food-purchasing inequalities were: taste preferences, health concerns, health beliefs, nutrition knowledge, nutrition concerns, weight concerns, nutrition label use, and several other values and beliefs unique to particular socioeconomic groups. Factors more tenuously or inconsistently related to socioeconomic differences in food purchasing were cost concerns, and perceived adequacy of the family diet. Evidence was displayed in both the quantitative and qualitative analyses to suggest that psychosocial factors contribute to inequalities in food purchasing in a collective manner. The quantitative analyses revealed that considerable overlap in the socioeconomic variation in food purchasing was accounted for by key psychosocial factors of importance, including taste preference, nutrition concerns, nutrition knowledge, and health concerns. Consistent with these findings, the qualitative transcripts demonstrated the interplay between such influential psychosocial factors in determining food-purchasing choices. The qualitative analyses found socioeconomic differences in the prioritisation of psychosocial factors in relation to food choices. This is suggestive of complex cultural factors that distinguish advantaged and disadvantaged groups and result in socioeconomically distinct schemas related to health and food choices. Compared to those of high SEP, those of lower SEP were less likely to indicate that health concerns, nutrition concerns, or food labels influenced food choices, and exhibited lower levels of nutrition knowledge. In the absence of health or nutrition-related concerns, taste preferences tended to dominate the food purchasing choices of those of low SEP. Overall, while cost concerns did not appear to be a main determinant of socioeconomic differences in food purchasing, this factor had a dominant influence on the food choices of some of the most disadvantaged respondents included in this research. The findings of this study have several implications for health promotion. The integrated operation of psychosocial factors on food purchasing inequalities indicates that multiple psychosocial factors may be appropriate to target in health promotion. It also seems possible that the inter-relatedness of psychosocial factors would allow health promotion targeting a single psychosocial factor to have a flow-on affect in terms of altering other influential psychosocial factors. This research also suggests that current mass marketing approaches to health promotion may not be effective across all socioeconomic groups due to differences in the priorities and main factors of influence in food purchasing decisions across groups. In addition to the practical recommendations for health promotion, this investigation, through the critique of previous research, and through the substantive study findings, has highlighted important methodological considerations for future research. Of particular note are the recommendations pertaining to the selection of socioeconomic indicators, measurement of relevant constructs, consideration of confounders, and development of an analytical approach. Addressing inequalities in health has been noted as a main objective by many health authorities and governments internationally. It is envisaged that the substantive and methodological findings of this thesis will make a useful contribution towards this important goal.

Brain structure in healthy adults is related to serum transferrin and the H63D polymorphism in the HFE gene

Control of iron homeostasis is essential for healthy central nervous system function: iron deficiency is associated with cognitive impairment, yet iron overload is thought to promote neurodegenerative diseases. Specific genetic markers have been previously identified that influence levels of transferrin, the protein that transports iron throughout the body, in the blood and brain. Here, we discovered that transferrin levels are related to detectable differences in the macro- and microstructure of the living brain. We collected brain MRI scans from 615 healthy young adult twins and siblings, of whom 574 were also scanned with diffusion tensor imaging at 4 Tesla. Fiber integrity was assessed by using the diffusion tensor imaging-based measure of fractional anisotropy. In bivariate genetic models based on monozygotic and dizygotic twins, we discovered that partially overlapping additive genetic factors influenced transferrin levels and brain microstructure. We also examined common variants in genes associated with transferrin levels, TF and HFE, and found that a commonly carried polymorphism (H63D at rs1799945) in the hemochromatotic HFE gene was associated with white matter fiber integrity. This gene has a well documented association with iron overload. Our statistical maps reveal previously unknown influences of the same gene on brain microstructure and transferrin levels. This discovery may shed light on the neural mechanisms by which iron affects cognition, neurodevelopment, and neurodegeneration.

Effect of Genetic Variants Related to Lipid Metabolism as Risk Factors for Cholelithiasis After Bariatric Surgery in Brazilian Population

The manifestation of cholelithiasis after bariatric surgery may depend on genetic factors related to lipid metabolism, including apolipoprotein E (APOE) and cholesteryl ester transfer protein (CETP) gene polymorphisms. We investigated the association between APOE HhaI and CETP TaqIB polymorphisms [PCR-RFLP] and occurrence of cholelithiasis over up to 8 months of follow-up after gastroplasty to Roux-en-Y gastric bypass in 220 patients distributed in Group 1 (G1) 114 with cholelithiasis postoperatively and Group 2 (G2) 106 without cholelithiasis, including biochemical and anthropometric profiles analyses. In our series, the allelic and genotypic distributions of CETP TaqIB and APOE HhaI polymorphisms were similar in both groups (P > 0.05). The subgroup analysis evidenced that 54% of the patients from G1, APOE*4 allele carriers compared with APOE*3/3 carriers, presented altered low-density lipoprotein cholesterol (LDL cholesterol) serum levels (P = 0.022) before bariatric surgery. The B1 allele for CETP was associated to more quickly elevation of HDL cholesterol levels just in individuals without cholelitiasis (P < 0.0001). The multivariate logistic regression analysis demonstrates correlation between APOE*4 allele, higher total cholesterol (TC) serum levels and prediposition to cholelitiasis in preoperative period. However, the presence of postoperative cholelithiasis was not associated with altered lipid profile. The CETP TaqIB and APOE HhaI polymorphisms do not seem to have association with gallstones in the late postoperative bariatric surgery, considering that these genetic variants do not differ subgroups of patients who are eligible to routine prophylactic cholecystectomy, at least in Brazilian population.

Report of the Royal Commission on Historical Manuscripts.

First to ninth reports, 1870-1883/84, include appendices summarizing the work of inspectors appointed to examine private collections of manuscripts in Great Britain and Ireland.

Are HRM practices related with patient mortality in NHS hospitals?:A study examining the underlying reasons for such an association

This thesis will report details of two studies conducted within the National Health Service in the UK that examined the association between HRM practices related to training and appraisal with health outcomes within NHS Trusts. Study one represents the organisational analysis of 61 NHS Trusts, and will report training and appraisal practices were significantly associated with lower patient mortality. Specifically, the research will show significantly lower patient mortality within NHS Trusts that: a) had achieved Investors in People accreditation; b) had a formal strategy document relating to training; c) had tailored training policy documents across occupational groups; d) had integrated training and appraisal practices; e) had a high percentage of staff receiving either an appraisal or updated personal development plan. There was also evidence of an additive effect where NHS Trusts that displayed more of these characteristics had significantly lower patient mortality. Study one in this thesis will also report significantly lower patient mortality within the NHS Trusts where there was broad level representation for the HR function. Study two will report details of a study conducted to examine the potential reasons why HR practices may be related to hospital performance. Details are given of the results of a staff attitudinal survey within five NHS Trusts. This study examined will show that a range of developmental activity, the favourability of the immediate work environment (in relation to social support and role stressors) and motivational outcomes are important antecedents to citizenship behaviours. Furthermore, the thesis will report that principles of the demand-control model were adopted to examine the relationship between workplace support and role stressors, and workplace support, influence, and an understanding of role expectation help mitigate against the negative effects of work demands upon motivational outcomes.

Reprodução e biopolítica: infertilidades e práticas de saúde em um serviço público no Rio de Janeiro

Apesar de a reprodução assistida possibilitar transformações importantes na parentalidade e nas relações familiares, suas tecnologias têm sido mais frequentemente usadas para reiterar o modelo tradicional de reprodução biológica e social. Este estudo qualitativo, de cunho exploratório, analisou quais normas estariam presentes nas práticas de saúde relativas à dificuldade de engravidar e o que poderia ser revelado a partir destas práticas. Foram observadas interações entre profissionais e pacientes atendidos em um serviço público de reprodução humana no Rio de Janeiro. A discussão dos diagnósticos de infertilidade e de risco, duas importantes estratégias biopolíticas usadas como critério de elegibilidade para o acesso às novas tecnologias reprodutivas, revelou como algumas práticas de saúde reiteram normas de gênero e de reprodução social. Atrelados à condição socioeconômica de seus usuários, estes diagnósticos tendem a agravar exclusões e desigualdades no exercício dos direitos reprodutivos no país. A análise da atenção médica possibilitou conhecer em parte o difícil cotidiano não apenas de homens e mulheres, que por anos persistem em seus desejos por filhos, mas também de profissionais que enfrentam antigas barreiras políticas, econômicas e burocráticas do serviço público de saúde. Este estudo corrobora a visão de que o serviço representa um avanço em termos de direitos sexuais e reprodutivos, apesar de ainda ser longo o caminho para o acesso igualitário e equânime às tecnologias reprodutivas pelo sistema único de saúde brasileiro (SUS).

Mnitoramento do desenvolvimento infantil realizado no Brasil

Objective: To review scientific literature in order to check how infant development surveillance is being carried out in Brazil. Data sources: Search on databases (PubMed, Medline, SciELO and CAPES Database Thesis) for studies on medical practices related to surveillance and monitoring of child development in Brazil from 2000 to 2011. The terms used for research were: child development surveillance, early intervention, developmental screening, and developmental screening tests. There were ten texts on the subject under study. Original articles, reviews, and thesis were analyzed, as well as the reference lists of publications on the topic. Data synthesis: Studies on monitoring of child development in Brazil showed major failures from pediatrician formation to clinical practice. Conclusions: It is urgent to offer continued medical education to pediatricians in order to update their knowledge about child development monitoring, especially due to the increasing numbers of preterm infants.

School participation of students with autism spectrum disorders

This paper addresses the participation of students with autism spectrum disorders (ASD) in main- stream schools. There are different benefits for ASD students to be educated in an inclusive environment (Gena, 2006; Whitaker, 2004). They challenge the school community by presenting difficulties in essential domains for school activi- ties (Chamberlain, Kasari and Rotheram-Fuller, 2006; Eman and Farrell, 2009; Humphrey and Symes, 2010). Thus, these are students with increased difficulties participating in inclusive environments, reinforcing the need of an ade- quate inclusion process (Gena, 2006; Hall and McGregor, 2000; Hestenes and Carroll, 2000). We characterised this students ’ participation with a questionnaire to the students from mainstream classes in which ASD students were included, a questionnaire applied to each class teacher/head teacher and an interview to four of the school educational assistants. The location of the ASD student in mainstream classroom was also ana- lysed, trying to understand if it influences the quality of ASD students ’ participation, hypothesis- ing that there is an influence. Results showed a good perception of the students with ASD and their behaviour, low frequency of behaviours involving interaction with these students, good feelings about their presence at the school/class and an overall acceptance of them in the peer groups of typical development students. Results are mostly consistent across the different infor- mation sources. We found a significant effect of the location on the quality of participation. Results are mainly consistent with the literature reviewed and enlighten the need to keep making progress on inclusion practices related to ASD students in mainstream schools.