Is cancer stage data missing completely at random? A report from a large population-based cohort of non-small cell lung cancer.

Introduction: Population-based datasets are often used to estimate changes in utilization or outcomes of novel therapies. Inclusion or exclusion of unstaged patients may impact on interpretation of these studies. Methods: A large population-based dataset in Ontario, Canada of non-small cell lung cancer patients was examined to evaluate the characteristics and outcomes of unstaged patients compared to staged patients. Multivariable Poisson regression was used to evaluate differences in patient-level characteristics between groups. Kaplan-Meier estimates of survival and log-rank statistics were utilized. Results: In our Ontario cohort of 51,152 patients with NSCLC, 11.2% (n=5,707) were unstaged, and there was evidence that stage data was not missing completely at random. Those without assigned stage were more likely than staged patients to be older (RR [95%CI]), (70-79 vs. 20-59: 1.51 [1.38-1.66]; 80+ vs. 20-59: 2.87 [2.62-3.15]), have a higher comorbidity index (Score 1-2 vs 0: 1.19 [1.12-1.27]; 3 vs. 0: 1.49 [1.38-1.60]), and have a lower socioeconomic class (4 vs. 1 (lowest): 0.91 [0.84-0.98]; 5 vs. 1 (lowest): 0.89 [0.83-0.97]). Overall survival of unstaged patients suggested a mixture of early and advanced stage, but with a large proportion that are probably stage IV patients with more rapid death than those with reported stage IV disease. Conclusion: In this case study, evaluation of stage-specific health care utilization and outcomes for staged patients with stage IV disease at the population level may have a bias as a distinct subset of stage IV patients with rapid death are likely among those without a documented stage in administrative data.

Investigating Specialized Chronic Pain Care Among Emerging Adults.

BACKGROUND: AIMS: To investigate characteristics of emerging adults accessing a specialized chronic non-cancer pain clinic and describe interventions offered and utilized by this group. DESIGN: A retrospective chart review was conducted of emerging adults and middle-aged adults with chronic pain receiving care over a six-month period. SETTING: A chronic pain clinic in Southeastern Ontario. PARTICIPANTS: 82 participants comprised of 41 emerging adults (aged 18-29) and 41 middle-aged adults (aged 30-64) METHODS: Groups were matched on sex and number of pain sites. Demographic and pain characteristics, interventions, referrals, and clinic utilization were examined using bivariate and multivariate analysis. RESULTS: Emerging adults reported lower pain severity scores (t(80) = -2.15, p = .035), were more likely to receive referrals for additional consultation and/or diagnostic investigations (X2(1, n = 82) = 4.97, p = .026) and to have at least one psychology visit (X2 = 7.29, p = .007). Moreover, emerging adults with higher depression scores were more likely to see a psychologist (OR 1.23, 95% CI 1.014-1.492). CONCLUSIONS: Pain presentation and care patterns differed between emerging adults and middle-aged adults. Increased use of non-pharmacologic interventions in emerging adults may reflect differences in pain presentations as well as clinician's sensitivity to emerging adult's particular developmental needs but further research is needed. Further research is needed to contribute to nurses' understanding of the quality and efficacy of pain management approaches.

Quality of End-of-Life Care for People with Advanced Non-Small Cell Lung Cancer in Ontario: A Population-Based Study.

Ensuring high quality end of life (EOL) care is necessary for people with advanced non-small-cell lung cancer (NSCLC), given its high incidence, mortality and symptom burden. Aggressive EOL care can adversely affect the quality of life of NSCLC patients without providing meaningful oncologic benefit. OBJECTIVES: (1) To describe EOL health services quality indicators and timing of palliative care consultation provided to patients dying of NSCLC. (2) To examine associations between aggressive and supportive care and patient, disease and treatment characteristics. METHODS: This retrospective population-based cohort study describes those who died of NSCLC in Ontario, Canada from 2009-2017. Socio-demographic, patient, disease and treatment characteristics as well as EOL health service quality and use of palliative care consultation were investigated. Multivariable logistic regression models examined factors associated with receiving aggressive or supportive care. RESULTS: Aggressive care quality indicators were present in 50.3% and supportive care indicators in 60.3% of the cohort (N = 37,203). Aggressive care indicators decreased between 2009 and 2017 (57.4% to 45.3%) and increased for supportive care (54.2% to 67.5%). Benchmarks were not met by 2017 in 3 of 4 cases. Male sex and greater comorbidity were associated with more aggressive EOL care and less supportive care. Older age was negatively associated and rurality positively associated with aggressive care. No palliative care consultation occurred in 56.0%. CONCLUSIONS: While improvements in the use of supportive rather than aggressive care were noted, established Canadian benchmarks were not met. Moreover, there is variation in EOL quality between groups and use of earlier palliative care must improve.

Evaluating student perceptions of a multi-platform classroom response system in undergraduate nursing.

BACKGROUND: Classroom response systems (CRSs) support interactive learning in undergraduate nursing education. Simple "clicker" hardware has evolved into more sophisticated multi-platform software allowing multiple operating systems and devices including smartphones, tablets and laptops to enhance in-class, proximate student engagement. However, student perspectives of multi-platform mobile CRSs have not been assessed among undergraduate nursing students. OBJECTIVES: To evaluate undergraduate nursing student perceptions of usability, engagement, and learning associated with Top Hat™ CRS software. METHODS: This descriptive study utilized a cross sectional survey of undergraduate Bachelor of Nursing Science (BNSc) students enrolled in a four-year (n = 160) and a two-year (n = 75) accelerated program. Descriptive statistics were used to evaluate learner perceptions of usability, engagement, and learning, measured using the Classroom Response System Perceptions (CRiSP) questionnaire. Thematic analysis was used to examine data from open-ended questions designed to capture qualitative feedback related to the perceived benefits, limitations and the technology's impact on learning. RESULTS: Students perceived the use of the CRS, TopHat™, as a positive influence on classroom learning. The mean CRiSP scores for all subscales [usability 16.51 (SD 2.7), engagement 40.97 (SD 7.2), learning 43.96 (SD 6.8)] correlated with "agree" or "strongly agree". There was no statistical difference among CRiSP scores between the two programs. Students reported that CRS in the classroom improved learning, enhanced formative assessment and increased participation. Perceived limitations include practical drawbacks such as redundant features, technical difficulties, limited access and cost. Moreover, some students felt that it did not add value to teaching as it was disruptive to classroom time. CONCLUSIONS: This study addresses a gap in the nursing education literature and contributes to the growing body of scientific knowledge related to using technology in proximal classroom teaching. One multi-platform CRS, TopHat™, did enhance learning but important recommendations and limitations should be considered before implementing this technology.

Enhancing metabolic monitoring for children and adolescents using second-generation antipsychotics.

The prevalence of children and adolescents using second-generation antipsychotics (SGAs) has increased significantly in recent years. In this population, SGAs are used to treat mood and behavioural disorders although considered 'off-label' or not approved for these indications. Metabolic monitoring is the systematic physical health assessment of antipsychotic users utilized to detect cardiovascular and endocrine side effects and prevent adverse events such as weight gain, hyperglycaemia, hyperlipidemia, and arrhythmias. This practice ensures safe and efficacious SGA use among children and adolescents. Despite widely available, evidence-based metabolic monitoring guidelines, rates of monitoring continue to be suboptimal; this exposes children to the unnecessary risk of developing poor cardiovascular health and long-term disease. In this discursive paper, existing approaches to metabolic monitoring as well as challenges to implementing monitoring guidelines in practice are explored. The strengths and weaknesses of providing metabolic monitoring across outpatient psychiatry, primary care, and collaborative community settings are discussed. We suggest that there is no one-size-fits-all solution to improving metabolic monitoring care for children and adolescents using SGA in all settings. However, we advocate for a pragmatic global approach to enhance safety of children and adolescents taking SGAs through collaboration among healthcare disciplines with a focus on integrating nurses as champions of metabolic monitoring.

Synergistic effects of low-intensity exercise conditioning and ß-blockade on cardiovascular and autonomic adaptation in pre- and postmenopausal women with hypertension.

The effects of a 12-week low-intensity exercise conditioning program (walking) on blood pressure (BP), heart rate (HR), rate-pressure product (RPP), and cardiac autonomic function were measured in 40 sedentary women with hypertension. Women were assigned to either an exercise group (n = 20) or a control group (n = 20), matched for ß-blockade treatment. They underwent testing at the beginning and at the end of the 12-week study period in three conditions: supine rest, standing, and low-intensity steady state exercise. The exercise group participated in a 12-week, low-intensity walking program, while the control group continued with usual sedentary activity. Compared with the control group, women in the exercise group showed reductions in systolic and diastolic BP and RPP (i.e., the estimated cardiac workload). ß-Blockers increased baroreflex sensitivity and lowered BP and HR in all participants; however, those in the exercise group showed the effects of both treatments: a greater reduction in HR and RPP. The combination of exercise training and ß-blockade produces cardiac and autonomic adaptations that are not observed with either treatment alone, suggesting that ß-blockade enhances the conditioning effects of low-intensity exercise in women with hypertension.

Nurse practitioners in postoperative cardiac surgery: are they effective?

BACKGROUND: High demand for acute care nurse practitioners (ACNPs) in Canadian postoperative cardiac surgery settings has outpaced methodologically rigorous research to support the role. PURPOSE: To compare the effectiveness of ACNP-led care to hospitalist-led care in a postoperative cardiac surgery unit in a Canadian, university-affiliated, tertiary care hospital. METHODS: Patients scheduled for urgent or elective coronary artery bypass and/or valvular surgery were randomly assigned to either ACNP-led (n=22) or hospitalist-led (n=81) postoperative care. Both ACNPs and hospitalists worked in collaboration with a cardiac surgeon. Outcome variables included length of hospital stay, hospital readmission rate, postoperative complications, adherence to follow-up appointments, attendance at cardiac rehabilitation and both patient and health care team satisfaction. RESULTS: Baseline demographic characteristics were similar between groups except more patients in the ACNP-led group had had surgery on an urgent basis (p < or = 0.01), and had undergone more complicated surgical procedures (p < or =0.01). After discharge, more patients in the hospitalist-led group had visited their family doctor within a week (p < or =0.02) and measures of satisfaction relating to teaching, answering questions, listening and pain management were higher in the ACNP-led group. CONCLUSION/IMPLICATIONS: Although challenges in recruitment yielded a lower than anticipated sample size, this study contributes to our knowledge of the ACNP role in postoperative cardiac surgery. Our findings provide support for the ACNP role in this setting as patients who received care from an ACNP had similar outcomes to hospitalist-led care and reported greater satisfaction in some measures of care.

Facilitating knowledge translation in the "real world" of community psychiatry.

BACKGROUND: Tobacco use disproportionately affects the well-being of individuals with mental illness. In community psychiatric settings, there are culturally embedded attitudes and behaviors regarding smoking that enable practitioners to remain ambivalent about their clients' tobacco use. OBJECTIVES: Given these cultural norms, the authors aimed to introduce evidence-informed smoking cessation interventions to a variety of interdisciplinary mental health care providers by using an innovative approach to knowledge translation. DESIGN: The authors used a case study design in which six community psychiatric settings were targeted. The organizational culture related to smoking was examined at each site before tailored tobacco reduction interventions were delivered. The study design was guided by the knowledge-to-action (KTA) process and two supplementary approaches to change: motivational interviewing (MI) and appreciative inquiry (AI). RESULTS/CONCLUSIONS: The principles of the KTA process, MI, and AI helped the authors to meaningfully engage with practice groups and change the organizational culture surrounding tobacco use in several community psychiatric settings.