Learning to Fail Better: Reflections on the Challenges and Risks of Community-Based Participatory Mental Health Research With Inuit Youth in Nunavut.

Community-based participatory research (CBPR) is a mine field of moral dilemmas. Even when carefully planned for and continuously critically reflected upon, conflicts are likely to occur as part of the process. This paper illustrates the lessons learned from "Building on Strengths in Naujaat", a resiliency initiative with the objective of promoting sense of belonging, collective efficacy, and well-being in Inuit youth. Naujaat community members over time established strong meaningful relationships with academic researchers. Youth took on the challenge of organizing community events, trips out on the land, and fundraisers. While their creativity and resourcefulness are at the heart of the initiative, this paper explores conflicts and pitfalls that accompanied it. Based on three themes - struggles in coming together as academic and community partners, the danger of perpetuating colonial power structures, and the challenges of navigating complex layers of relations within the community - we examine the dilemmas unearthed by these conflicts, including an exploration of how much we as CBPR researchers are at risk of reproducing colonial power structures. Acknowledging and addressing power imbalances, while striving for transparency, accountability, and trust, are compelling guiding principles needed to support Indigenous communities on the road toward health equity.

Building on strengths in Naujaat: the process of engaging Inuit youth in suicide prevention.

Death by suicide and attempted suicide among Inuit youth is now considered a public health emergency of epidemic proportion, with rates among the highest worldwide. A strong sense of cultural identity and pride, as well as social capital, has been identified as being protective against suicide. The Canadian Institute for Health Research (CIHR) Guidelines for Health Research Involving Aboriginal People call for communities to be included in the conception, planning and implementation of research. The authors took first steps towards sharing the responsibility of designing a community initiative with the youth of Naujaat, Nunavut, a community located directly on the Arctic Circle. With the objectives of promoting open listening and exploration of community needs and enhancing self-determination and sustainability, we postulated a youth resiliency project that will be co-authored by the community. This paper describes the joint work process. We recount how Inuit youth take ownership of the project with the guidance of Ms. Elizabeth Haqpi, a Naujaat Elder. The article will particularly reflect on the process of balancing the different perspectives and expectations while enjoying the richness of mutual learning through keeping each other accountable.

The Value of Detecting Asymptomatic Signs of Myocardial Ischemia in Patients With Coronary Artery Disease in Outpatient Cardiac Rehabilitation.

BACKGROUND: Electrocardiographic (ECG) monitored outpatient cardiac rehabilitation (OP-CR) is routinely performed following a variety of cardiovascular procedures and conditions. OBJECTIVE: The aim of this study is to determine if diagnostic-quality ECG monitoring in patients with coronary artery disease (CAD) during OP-CR is useful in identifying asymptomatic myocardial ischemia, resulting in change(s) in care or medical management. METHODS: A retrospective analysis of ECG monitoring was done on all OP-CR patients diagnosed with CAD (n = 1213) from January 2000 through June 2013. RESULTS: Nearly a quarter of the patients (24%; n = 288) displayed at least 1 mm of asymptomatic ST-segment depression at 80 milliseconds after the J-point during at least 1 session of OP-CR. Of these patients, 57% had medical management change(s) compared with 24% for those who did not show ECG changes suggesting ischemia (P < .0001). In patients with asymptomatic ischemia having medical management change(s), 84% resulted directly from OP-CR staff detection. Fewer patients diagnosed with myocardial infarction and coronary artery bypass graft surgery demonstrated ECG signs of ischemia, whereas more patients diagnosed with stable angina and percutaneous coronary interventions demonstrated ECG signs of ischemia. CONCLUSION: This study demonstrates that most patients with CAD showing asymptomatic ECG signs suggesting ischemia undergo medical management change(s) as a result of the finding. Diagnostic-quality ECG monitoring during OP-CR appears warranted in this population.

Text-messaging program improves outcomes in outpatient cardiovascular rehabilitation.

BACKGROUND: Outpatient cardiac rehabilitation (OP-CR) is a highly beneficial program but vastly under utilized. METHODS: The efficacy of a text-messaging program was analyzed to determine if implementation could improve number of OP-CR sessions completed. All patients enrolled in OP-CR from July 2011 through December 2012 were invited to join a text-messaging program on their first visit. The program required that the patient possesses a cell phone with texting capabilities. Participants received three to five text-messages per week offering heart-healthy tips and requests for body weight, minutes of exercise, blood pressure, and medication adherence. Patients enrolled (n = 52) in the texting program (Tx) were compared with those who were not (n = 185) (NTx) in several clinical indices and were compared using matched pairs (same subjects), comparison of means and frequencies, chi-square statistics, t-tests, and the Wilcoxon Rank Sum test. RESULTS: Significantly more patients in the Tx group completed the OP-CR program (61.5% versus 50%, p = 0.01). For those completing OP-CR, subjects in the Tx group completed significantly more sessions (31.4) than the NTx group (25.3) (p = 0.01). Additionally, significantly more in the Tx group were younger than those in the Ntx group. CONCLUSIONS: Patients enrolled in OP-CR who participated in a text-messaging program were younger, attended significantly more sessions and were significantly more likely to complete the program.

Gender disparities in common sense models of illness among myocardial infarction victims.

Symptom attributions were contrasted between male and female myocardial infarction victims (N = 157) who were comparable on age, cardiac risk status, medical history, symptom presentation, and other variables. Women were less likely than men to attribute their prehospital symptoms to cardiac causes. In the context of hearing symptom attributions or advice from support persons, women were less likely than men to report receiving a cardiac attribution or advice to seek medical attention. Results have implications for how victim gender influences the lay interpretation of cardiac symptoms.

Dermatofibrosarcoma protuberans: a report on 29 patients treated by Mohs micrographic surgery with long-term follow-up and review of the literature.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is an uncommon tumor of the skin. Clinically, it often masquerades as a benign, indolent tumor on the trunk and extremities. Microscopically, it extends far beyond assessed clinical margins, spreading locally in the dermis, subcutaneous tissue, and muscle. The local recurrence rate in patients with DFSP who undergo wide local excision ranges from 0% to 21%. Recent preliminary reports indicate more consistently favorable cure rates with Mohs micrographic surgery (MMS). However, to date only a few scattered reports have documented long-term 5-year follow-up. The authors present data on 29 patients with DFSP who underwent MMS. In addition, they reviewed the medical literature to summarize the accumulated experience of MMS treatment in the management of DFSP. METHODS: The authors conducted a retrospective review of a series of 40 consecutive patients with DFSP who underwent MMS over the last 20 years. Of these, there were 29 patients with > 5 years of follow-up who formed the basis of the current review. The literature also was searched for patients with DFSP who underwent MMS with > 5 years of follow-up RESULTS: At the University of Wisconsin Mohs Surgery Clinic, 29 patients with > 5 years of follow-up were treated. There were 16 women and 13 men. Eight patients developed recurrent disease after previous non-Mohs treatment. Site distribution was 45% head and neck and 55% trunk and extremities. In the current series, there were no local recurrences, with a local 5-year cure rate of 100%. In the literature review, which included the current series, there were 136 patients with DFSP who underwent Mohs surgery with > 5 years of follow-up. Nine patients in the current series developed local recurrences, including five patients who underwent a second Mohs procedure. The local cure rates after the first and second Mohs surgeries were 93.4% and 98.5%, respectively. The rate (percent) and time to local recurrence was 50% at 3 years and 75% at 5 years. However, 25% of local recurrences appeared late, after the usual 5-year recommendation. CONCLUSIONS: In a series of 29 patients with of DFSP and in an accompanying update of the medical literature, 136 patients with DFSP underwent MMS with > 5 years of follow-up. There were no regional and/or distant metastases. However, late recurrences beyond the usual recommended 5-year follow-up may occur. Therefore, all patients with DFSP, especially those with recurrent tumors, should be followed for an extended period. The accumulated data continue to confirm that, when DFSP is discovered early and is accessible readily to excision by MMS, a favorable outcome can be expected with minimal trauma or sacrifice of adjacent normal structures and with a low recurrence rate.

How do female and male cardiac patients and their spouses share responsibilities after discharge from the hospital?

This study explored sex differences in household and employment responsibilities among cardiac patients (N = 63; 46 men) and spouses during the 5 months following discharge from the hospital. Results showed that both patients and partners maintained traditional sex-typed activities. As patients or spouses, women tended to assume greater responsibility for domestic tasks such as laundry, cleaning, and cooking than their husbands. Men as patients or spouses tended to assume greater responsibility for household repair and maintenance tasks. Husbands also worked more for pay outside the home than did wives, except in couples where the male patient was high risk. Correlations for male patients indicated that reports of more cardiac symptoms were associated with assuming fewer responsibilities. In contrast, among women, the correlations between symptoms and activities were more complex and suggested that female patients might not be heeding signs of overexertion.