Occupation and Breast Cancer: a Canadian Case-Control Study

A local collaborative process was launched in Windsor, Ontario, Canada to explore the role of occupation as a risk factor for cancer. An initial hypothesis-generating study found an increased risk for breast cancer among women aged 55 years or younger who had ever worked in farming. On the basis of this result, a 2-year case–control study was undertaken to evaluate the lifetime occupational histories of women with breast cancer. The results indicate that women with breast cancer were nearly three times more likely to have worked in agriculture when compared to the controls (OR = 2.80 [95% CI, 1.6–4.8]). The risk for those who worked in agriculture and subsequently worked in automotive-related manufacturing was further elevated (OR = 4.0 [95% CI, 1.7–9.9]). The risk for those employed in agriculture and subsequently employed in health care was also elevated (OR = 2.3 [95% CI, 1.1–4.6]). Farming tended to be among the earlier jobs worked, often during adolescence. While this article has limitations including the small sample size and the lack of information regarding specific exposures, it does provide evidence of a possible association between farming and breast cancer. The findings indicate the need for further study to determine which aspects of farming may be of biological importance and to better understand the significance of timing of exposure in terms of cancer risk.

Development of an Arcellacean (testate lobose amoebae) based transfer function for sedimentary phosphorous in lakes.

Arcellacea (testate lobose amoebae) communities were assessed from 73 sediment-water interface samples collected from 33 lakes in urban and rural settings within the Greater Toronto Area (GTA), Ontario, Canada, as well as from forested control areas in the Lake Simcoe area, Algonquin Park and eastern Ontario. The results were used to: (1) develop a statistically rigorous arcellacean-based training set for sedimentary phosphorus (Olsen P (OP)) loading; and (2) derive a transfer function to reconstruct OP levels during the post-European settlement era (AD1870s onward) using a chronologically well-constrained core from Haynes Lake on the environmentally sensitive Oak Ridges Moraine, within the GTA. Ordination analysis indicated that OP most influenced arcellacean assemblages, explaining 6.5% (p < 0.005) of total variance. An improved training set where the influence of other important environmental variables (e.g. total organic carbon, total nitrogen, Mg) was reduced, comprised 40 samples from 31 lakes, and was used to construct a transfer function for lacustrine arcellaceans for sedimentary phosphorus (Olsen P) using tolerance downweighted weighted averaging (WA-Tol) with inverse deshrinking (RMSEPjack-77pp; r2jack = 0.68). The inferred reconstruction indicates that OP levels remained near pre-settlement background levels from settlement in the late AD 1970s through to the early AD 1970s. Since OP runoff from both forests and pasture is minimal, early agricultural land use within the lake catchment was as most likely pasture and/or was used to grow perennial crops such as Timothy-grass for hay. A significant increase in inferred OP concentration beginning ~ AD 1972 may have been related to a change in crops (e.g. corn production) in the catchment resulting in more runoff, and the introduction of chemical fertilizers. A dramatic decline in OP after ~ AD 1985 probably corresponds to a reduction in chemical fertilizer use related to advances in agronomy, which permitted a more precise control over required fertilizer application. Another significant increase in OP levels after ~ AD 1995 may have been related to the construction of a large golf course upslope and immediately to the north of Haynes Lake in AD 1993, where significant fertilizer use is required to maintain the fairways. These results demonstrate that arcellaceans have great potential for reconstructing lake water geochemistry and will complement other proxies (e.g. diatoms) in paleolimnological research.

Effect of a multifaceted intervention on adherence to hand hygiene among healthcare workers:A cluster-randomized trial

OBJECTIVES. Adherence to hand hygiene among healthcare workers (HCWs) is widely believed to be a key factor in reducing the spread of healthcare-associated infection. The objective of this study was to evaluate the impact of a multifaceted intervention to increase rates of adherence to hand hygiene among HCWs and to assess the effect on the incidence of hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) colonization. DESIGN. Cluster-randomized controlled trial. SETTING. Thirty hospital units in 3 tertiary care hospitals in Hamilton, Ontario, Canada. INTERVENTION. After a 3-month baseline period of data collection, 15 units were randomly assigned to the intervention arm (with performance feedback, small-group teaching seminars, and posters) and 15 units to usual practice. Hand hygiene was observed during randomly selected 15-minute periods on each unit, and the incidence of MRSA colonization was measured using weekly surveillance specimens from June 2007 through May 2008. RESULTS. We found that 3,812 (48.2%) of 7,901 opportunities for hand hygiene in the intervention group resulted in adherence, compared with 3,205 (42.6%) of 7,526 opportunities in the control group (P <.001; independent t test). There was no reduction in the incidence of hospital-acquired MRSA colonization in the intervention group. CONCLUSION. Among HCWs in Ontario tertiary care hospitals, the rate of adherence to hand hygiene had a statistically significant increase of 6% with a multifaceted intervention, but the incidence of MRSA colonization was not reduced.

The Evaluation of an Interdisciplinary Pain Protocol in Long Term Care

Objectives: To evaluate the effectiveness of (1) dissemination strategies to improve clinical practice behaviors (eg, frequency and documentation of pain assessments, use of pain medication) among health care team members, and (2) the implementation of the pain protocol in reducing pain in long term care (LTC) residents. Design: A controlled before-after design was used to evaluate the effectiveness of the pain protocol, whereas qualitative interviews and focus groups were used to obtain additional context-driven data. Setting: Four LTC facilities in southern Ontario, Canada; 2 for the intervention group and 2 for the control group. Participants: Data were collected from 200 LTC residents; 99 for the intervention and 101 for the control group. Intervention: Implementation of a pain protocol using a multifaceted approach, including a site working group or Pain Team, pain education and skills training, and other quality improvement activities. Measurements: Resident pain was measured using 3 assessment tools: the Pain Assessment Checklist for Seniors with Limited Ability to Communicate, the Pain Assessment in the Communicatively Impaired Elderly, and the Present Pain Intensity Scale. Clinical practice behaviors were measured using a number of process indicators; for example, use of pain assessment tools, documentation about pain management, and use of pain medications. A semistructured interview guide was used to collect qualitative data via focus groups and interviews. Results: Pain increased significantly more for the control group than the intervention group over the 1-year intervention period. There were significantly more positive changes over the intervention period in the intervention group compared with the control group for the following indicators: the use of a standardized pain assessment tool and completed admission/initial pain assessment. Qualitative findings highlight the importance of reminding staff to think about pain as a priority in caring for residents and to be mindful of it during daily activities. Using onsite champions, in this case advanced practice nurses and a Pain Team, were key to successfully implementing the pain protocol. Conclusions: These study findings indicate that the implementation of a pain protocol intervention improved the way pain was managed and provided pain relief for LTC residents.

Effect of preventive primary care outreach on health related quality of life among older adults at risk of functional decline: Randomised controlled trial

Objective: To evaluate the impact of a provider initiated primary care outreach intervention compared with usual care among older adults at risk of functional decline. Design: Randomised controlled trial. Setting: Patients enrolled with 35 family physicians in five primary care networks in Hamilton, Ontario, Canada. Participants Patients: were eligible if they were 75 years of age or older and were not receiving home care services. Of 3166 potentially eligible patients, 2662 (84%) completed the validated postal questionnaire used to determine risk of functional decline. Of 1724 patients who met the risk criteria, 769 (45%) agreed to participate and 719 were randomised. Intervention: The 12 month intervention, provided by experienced home care nurses in 2004-6, consisted of a comprehensive initial assessment using the resident assessment instrument for home care; collaborative care planning with patients, their families, and family physicians; health promotion; and referral to community health and social support services. Main outcome measures: Quality adjusted life years (QALYs), use and costs of health and social services, functional status, self rated health, and mortality. Results: The mean difference in QALYs between intervention and control patients during the study period was not statistically significant (0.017, 95% confidence interval -0.022 to 0.056; P=0.388). The mean difference in overall cost of prescription drugs and services between the intervention and control groups was not statistically significant, (-$C165 (£107; €118; $162), 95% confidence interval -$C16 545 to $C16 214; P=0.984). Changes over 12 months in functional status and self rated health were not significantly different between the intervention and control groups. Ten patients died in each group. Conclusions: The results of this study do not support adoption of this preventive primary care intervention for this target population of high risk older adults. Trial registration: Clinical trials NCT00134836.

Moral distress experienced by health care professionals who provide home-based palliative care

Health care providers regularly encounter situations of moral conflict and distress in their practice. Moral distress may result in unfavorable outcomes for both health care providers and those in their care. The purpose of this study was to examine the experience of moral distress from a broad range of health care occupations that provide home-based palliative care as the initial step of addressing the issue. A critical incident approach was used in qualitative interviews to elicit the experiences on moral distress from 18 health care providers drawn from five home visiting organizations in south central Ontario, Canada. Most participants described at least two critical incidents in their interview generating a total of 47 critical incidents. Analyses of the critical incidents revealed 11 issues that triggered moral distress which clustered into three themes, (a) the role of informal caregivers, b) challenging clinical situations and (c) service delivery issues. The findings suggest that the training and practice environments for health care providers need to be designed to recognize the moral challenges related to day-to-day practice.

Romanticism and Blackwood's Magazine:'An Unprecedented Phenomenon'

Romanticism and Blackwood's Magazine is inspired by the ongoing critical fascination with Blackwood's Edinburgh Magazine, and the burgeoning recognition of its centrality to the Romantic age. Though the magazine itself was published continuously for well over a century and a half, this volume concentrates specifically on those years when William Blackwood was at the helm, beginning with his founding of the magazine in 1817 and closing with his death in 1834. These were the years when, as Samuel Taylor Coleridge put it in 1832, Blackwood's reigned as 'an unprecedented Phenomenon in the world of letters.' The magazine placed itself at the centre of the emerging mass media, commented decisively on all the major political and cultural issues that shaped the Romantic movement, and published some of the leading writers of the day, including Coleridge, Thomas De Quincey, John Galt, Felicia Hemans, James Hogg, Walter Scott, and Mary Shelley.

'This much-needed volume reminds us not only why Blackwood's was the most influential periodical publication of the time, but also how its writers, writings, and critical agendas continue to shape so many of the scholarly concerns of Romantic studies in the twenty-first century.' - Charles Mahoney, Associate Professor, University of Connecticut, USA

List of Illustrations
Acknowledgements
Abbreviations
Notes on Contributors
'A character so various, and yet so indisputably its own': A Passage to Blackwood's Edinburgh Magazine; R.Morrison & D.S.Roberts
PART I: BLACKWOOD'S AND THE PERIODICAL PRESS
Beginning Blackwood's: The Right Mix of Dulce and Ùtile; P.Flynn
John Gibson Lockhart and Blackwood's: Shaping the Romantic Periodical Press; T.Richardson
From Gluttony to Justified Sinning: Confessional Writing in Blackwood's and the London Magazine; D.Higgins
Camaraderie and Conflict: De Quincey and Wilson on Enemy Lines; R.Morrison
Selling Blackwood's Magazine, 1817-1834; D.Finkelstein
PART II: BLACKWOOD'S CULTURE AND CRITICISM
Blackwood's 'Personalities'; T.Mole
Communal Reception, Mary Shelley, and the 'Blackwood's School' of Criticism; N.Mason
Blackwoodian Allusion and the Culture of Miscellaneity; D.Stewart
Blackwood's Edinburgh Magazine in the Scientific Culture of Early Nineteenth-Century Edinburgh; W.Christie
The Art and Science of Politics in Blackwood's Edinburgh Magazine, c. 1817-1841; D.Kelly
Prosing Poetry: Blackwood's and Generic Transposition, 1820-1840; J.Camlot
PART III: BLACKWOOD'S FICTIONS
Blackwood's and the Boundaries of the Short Story; T.Killick
The Edinburgh of Blackwood's Edinburgh Magazine and James Hogg's Fiction; G.Hughes
'The Taste for Violence in Blackwood's Magazine'; M.Schoenfield
PART IV: BLACKWOOD'S AT HOME
John Wilson and Regency Authorship; R.Cronin
John Wilson and Sport; J.Strachan
William Maginn and the Blackwood's 'Preface' of 1826; D.E.Latané, Jr.
All Work and All Play: Felicia Hemans's Edinburgh Noctes; N.Sweet
PART V: BLACKWOOD'S ABROAD
Imagining India in Early Blackwood's; D.S.Roberts
Tales of the Colonies: Blackwood's, Provincialism, and British Interests Abroad; A.Jarrells
Selected Bibliography
Index

ROBERT MORRISON is Queen's National Scholar at Queen's University, Kingston, Ontario, Canada. His book, The English Opium-Eater: A Biography of Thomas De Quincey was a finalist for the James Tait Black Prize. He has edited writings by Jane Austen, Leigh Hunt, Thomas De Quincey, and John Polidori.
DANIEL SANJIV ROBERTS is Reader in English at Queen's University Belfast, UK. His publications include a monograph, Revisionary Gleam: De Quincey, Coleridge, and the High Romantic Argument (2000), and major critical editions of Thomas De Quincey's Autobiographic Sketches and Robert Southey's The Curse of Kehama; the latter was cited as a Distinguished Scholarly Edition by the MLA. He is currently working on an edition of Charles Johnstone's novel The History of Arsaces, Prince of Betlis for the Early Irish Fiction series.

Gender differences among Canadian spousal caregivers at the end of life

The purpose of this study was to examine gender differences in spousal caregiving at the end of life. The primary research question was to determine gender differences in caregiver strain among spousal caregivers. Secondary research questions investigated included (i) the presence of gender differences among spousal caregivers in the duration of care provided; (ii) gender differences among spousal caregivers in formal service use and unmet service needs; and (iii) whether support to care recipients in activities of daily living varied according to the gender of the spousal caregiver. The study was conducted over a 2-year period (2000-2002) in south-central Ontario, Canada. The study sample included 283 informal spousal caregivers (198 females, 85 males) each of whom were caring for a terminally ill spouse at the time they participated in a cross-sectional telephone survey. The analysis showed that females reported a significantly greater level of caregiving strain than males (t = -2.12, d.f. = 281, P = 0.035). When considering source of support in activities of daily living for the care recipient, differential assistance was noted on the basis of caregiver gender. Female caregivers had almost twice the odds of providing support in toileting-related tasks than male caregivers (odds ratio (OR) = 1.98, 95% confidence interval (CI) = 1.01-3.85, P = 0.044), while male caregivers had approximately twice the odds of providing support in mobility-related tasks (OR = 0.41, 95% CI = 0.21-0.81, P = 0.011). Care recipients who had a female caregiver had lower odds of receiving support from family and friends in tasks associated with personal care (OR = 0.17, 95% CI = 0.05-0.53, P = 0.002). To address gender differences in caregiving, a realistic home-based palliative care approach must take into account the importance of informal caregivers. © 2008 Blackwell Publishing Ltd.

Family caregiver views on patient-centred care at the end of life

Aim: The purpose of this study was to evaluate the patient-centredness of community palliative care from the perspective of family members who were responsible for the care of a terminally ill family member. Method: A survey questionnaire was mailed to families of a deceased family member who had been designated as palliative and had received formal home care services in the central west region of the Province of Ontario, Canada. Respondents reported on service use in the last four weeks of life; the Client-Centred Care Questionnaire (CCCQ) was used to evaluate the extent to which care was patient-centred. The accessibility instrument was used to assess respondent perception of access to care. Descriptive and inferential statistics were used for data analyses. Results: Of the 243 potential participants, 111 (46.0%) family caregivers completed the survey questionnaire. On average, respondents reported that they used five different services during the last four weeks of the care recipient's life. When asked about programme accessibility, care was also perceived as largely accessible and responsive to patients' changing needs (M=4.3 (SD=1.04)]. Most respondents also reported that they knew what service provider to contact if they experienced any problems concerning the care of their family member. However, this service provider was not consistent among respondents. Most respondents were relatively positive about the patient-centred care they received. There were however considerable differences between some items on the CCCQ. Respondents tended to provide more negative ratings concerning practical arrangement and the organization of care: who was coming, how often and when. They also rated more negatively the observation that service providers were quick to say something was possible when it was not the case. Bivariate analyses found no significant differences in CCCQ or accessibility domain scores by caregiver age, care recipient age, income, education and caregiver sex. Conclusions: Patient-centred care represents a service attribute that should be recognized as an important outcome to assess the quality of service delivery. This study demonstrates how this attribute can be evaluated in the provision of care. © 2011 The Authors. Scandinavian Journal of Caring Sciences © 2011 Nordic College of Caring Science.

Coordination of palliative cancer care in the community: "unfinished business"

Goal: This study assessed the degree to which services in south-central Ontario, Canada, were coordinated to meet the supportive care needs of palliative cancer patients and their families. Participants and method: Programs within the region that were identified as providing supportive care to palliative cancer patients and their families were eligible to participate in the study. Program administrators participated in a semi-structured interview and direct-care providers completed a survey instrument. Main results: Administrators from 37 (97%) of 38 eligible programs and 109 direct-care providers representing 26 (70%) programs participated in the study. Most administrator and direct-care respondents felt that existing services in the community were responsive to palliative care patients' individual needs. However, at a system level, most respondents in both groups felt that required services were not available and that resources were inadequate. The most frequently reported unmet supportive care need identified by both respondent groups was psychological/social support. Most administrator (69%) and direct-care (64%) respondents felt that palliative care services were not available when needed. The majority of administrator and direct-care respondents were satisfied with the exchange of patient information within and between programs, although direct-care staff identified a deficit in information transferred on palliative care patients' social/psychological status. Conclusions: The study demonstrated the value of a theory-based approach to evaluate the coordination of palliative cancer care services. The findings revealed that service programs faced significant challenges in their efforts to provide coordinated care. © 2009 Springer-Verlag.

Caregiving and its impact on families of the terminally ill

Changes in the health care system have meant that increasing numbers of the terminally ill receive the majority of their care at home. The purpose of this paper was to document patterns of informal and formal care provided to the terminally ill and assess the impact caregiving has on family members. One hundred and fifty-one family caregivers were recruited for interviews from two community-nursing agencies in an urban region of the province of Ontario, Canada. The majority of respondents 119 (79%) were the female spouses of the patient. The numbers of caregivers providing assistance in specific functional activities were: bathing, 133 (88%); mobility, 123 (81%); dressing and undressing, 114 (76%); toileting, 101 (67%), and assistance at night 97 (64%). Sixty-two (41%) respondents reported that they had been providing some form of caregiving for over one year. They also reported that physical demands in caregiving increased substantially during the last three months of the care recipient's life. As family caregivers provided more assistance in activities of daily living they were at greater risk of reporting high caregiver burden. The results of this paper identify the types of care provided by family caregivers of the terminally ill and the impact these demands have on the family caregiver.

Identifying educational needs in end-of-life care for staff and families of residents in care facilities.

AIM: the purpose of this article is to describe educational needs in end-of-life (EoL) care for staff and families of residents in long-term care (LTC) facilities in the province of Ontario, Canada. Barriers to providing end-of-life care education in LTC facilities are also identified. DESIGN, SETTING AND PARTICIPANTS: cross-sectional survey of directors of care in all licensed LTC facilities in the province of Ontario, Canada. RESULTS: directors of care from 426 (76.9% response rate) licensed LTC facilities completed a postal-survey questionnaire. Topics identified as very important for staff education included pain and symptom management and communication with family members about EoL care. Priorities for family education included respecting the residents' expressed wishes for care and communication about EoL care. Having sufficient institutional resources was identified as a major barrier to providing continuing education to both staff and families. CONCLUSION: through examining educational needs in EoL care this study identified an environment of inadequate staffing and over-burdened care providers. The importance of increased staffing concomitant with education is a priority for LTC facilities.