The use of pharmacogenetic testing in psychiatry.

ABSTRACT: Psychiatric pharmacogenetic testing is commonly used by providers in primary care and mental health settings. The purpose of this article is to describe the extent to which psychiatric pharmacogenetic testing supports clinical practice. human leukocyte antigen (HLA)-A and HLA-B should be tested before initiating carbamazepine and oxcarbazepine due to risk of serious skin reactions. For psychotropic medications metabolized through the liver, limited evidence suggests testing for variation in metabolism through CYP2D6 and CYP2D19. For specific medication and genotype-phenotype variations, guidance through the Clinical Pharmacogenetics Implementation Consortium (CPIC) or the International Society of Psychiatric Genetics (ISPG) should be reviewed. Commercial tests interpret this information differently and should not be used for broad guidance. Clinicians should follow current guidelines from professional bodies such as CPIC or ISPG and test for HLA-A or HLA-B before initiating carbamazepine or oxcarbazepine. Evidence is limited for psychiatric pharmacogenetic testing. Clinicians should continue to follow best practice and clinical practice guidelines.

A Review and Comparative Analysis of Information Targeted to the General Public on the Websites of Breast Screening Programs in Canada.

Organized breast screening programs in Canada recommend that women, usually 50-74 years of age, are screened regularly with mammography to reduce their risk of breast cancer death. There is increasing evidence that estimates of mortality reduction are overestimated and harms under-reported. This article will report on a review of the websites of 12 breast screening programs in Canada. The primary goal is to determine what information is provided to enable women to make an informed decision about mammography and whether choice is emphasized. All publicly available English language information was extracted from the 12 websites by two independent reviewers, using a data extraction sheet. Information extracted included eligible age, screening interval and potential benefits and harms. This review is relevant to policy makers and breast screening program staff so they can determine what additional or alternative information is required on their websites to enable women to make informed decisions.

Survey of Managers Regarding Nurses' Performance of Nonnursing Duties.

BACKGROUND: The performance of nonnursing duties by nursing staff contributes to an already busy workload while taking time away from patient care. OBJECTIVE: This article reports on a process implemented by a large regional health authority in Canada to measure and address nurses' performance of nonnursing duties through a newly created tool. METHODS: Process improvement methodology was used to conduct this project. A measurement tool, the "Non-Nursing Duties Tracking Tool," was designed for frontline nursing staff and patient care attendants to document the performance of tasks classified as clerical, housekeeping, food services, clinical support, and transportation. This article reports on a survey of managers regarding information collected from frontline nurses and patient care attendants regarding their performance of nonnursing duties and actions taken or planned to address this. RESULTS: Tasks were identified that could be delegated to housekeeping, transport, and clerical staff. Both frontline nurses and managers expressed the need for administrative support to realign nonnursing tasks to more appropriate personnel. Although most managers of nurses expressed concern about the support of managers in other departments to make these changes, little resistance was encountered when adequate resources were in place. CONCLUSIONS: The "Non-Nursing Duties Tracking Tool" is a valid instrument to support the assessment of nonnursing direct care duties.

Impact of the Relocation of a Long-term Residential Care Facility on Staff.

This article describes the relocation of residents and staff of a long-term residential care facility into a new state-of-the-art building in a Canadian province. All staff were surveyed about their perceptions of the moving process 2 months after the move occurred using a newly created 51-item questionnaire containing both open-ended and closed questions (5-point Likert scale). The results were positive for the 3 subscales of the survey, with average scores for premove, midmove, and postmove items of 3.67, 3.94, and 3.66, respectively. There was no significant difference in the means when comparing staff position, years of employment, or assignment to 1 or more units. Staff were very positive about the move itself, the orientation provided and overall planning, and support from coworkers and management. Some concerns were raised about staffing shortages, involvement of residents, and preparedness of the units and building. In addition, it is evident that relocation is an ongoing process, with many supports required in the months after the move. This article describes a very well planned and executed relocation of a long-term residential care facility and can provide guidance and lessons learned to assist other administrators who are planning a similar endeavor.

Viewpoint: It is time to reconsider policy for population-based mammography screening.

Breast cancer in women is an important cause of morbidity and mortality. Many countries in the Western world have widely promoted early detection through mammography screening and established population-based screening programs. Over the past 15 years, there has been growing debate about the benefits and harms of universal mammography screening. This article presents findings from the latest systematic review conducted by the Cochrane Collaboration and from the Canadian National Breast Screening Study 25-year follow up. The authors of both reports conclude there is no reliable evidence that population-based mammography screening reduces mortality, but there is good evidence of harm in the form of false positive findings, over-diagnosis and unnecessary treatment, and associated psychological distress. It is time for policymakers to discontinue universal population-based mammography screening and shift to a more selective approach to early detection.

Emotional and informational needs of women experiencing outpatient surgery for breast cancer.

This article reports a qualitative study about informational and emotional needs of women who had surgery for breast cancer on an outpatient basis. Nineteen women volunteered for the study. The interviews, lasting approximately 60 minutes, were audio taped and transcribed verbatim. Data were analyzed using content analysis outlined by Hsieh and Shannon (2005). Findings are organized according to: 1) emotional and informational needs prior to and immediately after surgery; 2) emotional and informational supports while recovering at home; and 3) emotional responses to the outpatient surgery experience. Overall, women were satisfied with the experience of surgery for breast cancer on an outpatient basis, but there were several aspects that warrant closer attention, such as the amount and timing of information delivery, discharge care, and the need for consistent community nursing support and follow-up.

Primary care closed claims experience of Massachusetts malpractice insurers.

IMPORTANCE: Despite prior focus on high-impact inpatient cases, there are increasing data and awareness that malpractice in the outpatient setting, particularly in primary care, is a leading contributor to malpractice risk and claims. OBJECTIVE: To study patterns of primary care malpractice types, causes, and outcomes as part of a Massachusetts ambulatory malpractice risk and safety improvement project. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of pooled closed claims data of 2 malpractice carriers covering most Massachusetts physicians during a 5-year period (January 1, 2005, through December 31, 2009). Data were harmonized between the 2 insurers using a standardized taxonomy. Primary care practices in Massachusetts. All malpractice claims that involved primary care practices insured by the 2 largest insurers in the state were screened. A total of 551 claims from primary care practices were identified for the analysis. MAIN OUTCOMES AND MEASURES: Numbers and types of claims, including whether claims involved primary care physicians or practices; classification of alleged malpractice (eg, misdiagnosis or medication error); patient diagnosis; breakdown in care process; and claim outcome (dismissed, settled, verdict for plaintiff, or verdict for defendant). RESULTS: During a 5-year period there were 7224 malpractice claims of which 551 (7.7%) were from primary care practices. Allegations were related to diagnosis in 397 (72.1%), medications in 68 (12.3%), other medical treatment in 41 (7.4%), communication in 15 (2.7%), patient rights in 11 (2.0%), and patient safety or security in 8 (1.5%). Leading diagnoses were cancer (n = 190), heart diseases (n = 43), blood vessel diseases (n = 27), infections (n = 22), and stroke (n = 16). Primary care cases were significantly more likely to be settled (35.2% vs 20.5%) or result in a verdict for the plaintiff (1.6% vs 0.9%) compared with non-general medical malpractice claims (P < .001). CONCLUSIONS AND RELEVANCE: In Massachusetts, most primary care claims filed are related to alleged misdiagnosis. Compared with malpractice allegations in other settings, primary care ambulatory claims appear to be more difficult to defend, with more cases settled or resulting in a verdict for the plaintiff.

Quality of work life of novice nurses: a qualitative exploration.

This qualitative research study examines factors influencing the quality of work life of novice nurses (less than 2 years' experience) in the Eastern Regional Health Authority in St. John's, Newfoundland and Labrador, Canada. Although novice nurses are highly motivated to provide quality patient care, they encounter many sources of stress, including "difficult personalities," inadequate orientation and mentoring, and horizontal violence from nursing and medical colleagues. These stressors are compounded by staffing shortages and heavy workloads. Supportive mentoring and adequate orientation are key factors to successful transition.

The path to self-management: a qualitative study involving older people with multiple sclerosis.

PURPOSE: This qualitative study sought to explore older people's experience of ageing with multiple sclerosis (MS) and to describe the natural history of self-management from their points of view. METHODS: Eighteen people over age 55 and living with MS for at least 20 years were recruited from an MS clinic and rehabilitation outpatient records. Interviews (60-80 min), using open-ended questions, explored participants' lifelong experiences of MS. Following interview transcription, data were coded and analyzed; themes, subthemes, and their relationships were described based on consensus. RESULTS: Participants recounted their diagnosis process, their life experience with MS, and how they eventually accepted their disease, adapted, and moved toward self-management. The findings included vivid descriptions of social relationships, health care interactions, overcoming barriers, and the emotions associated with living with MS. A conceptual model of phases of self-management, from diagnosis to integration of MS into a sense of self, was developed. CONCLUSIONS: Study participants valued self-management and described its phases, facilitators, and inhibitors from their points of view. Over years and decades, learning from life experiences, trial and error, and interactions with health care professionals, participants seemed to consolidate MS into their sense of self. Self-determination, social support, strong problem-solving abilities, and collaborative relationships with health professionals aided adaptation and coping. Findings from this study make initial steps toward understanding how MS self-management evolves over the life course and how self-management programmes can help people with MS begin to manage wellness earlier in their lives.

Differential responses of ammonia-oxidizing archaea and bacteria to long-term fertilization in a New England salt marsh.

Since the discovery of ammonia-oxidizing archaea (AOA), new questions have arisen about population and community dynamics and potential interactions between AOA and ammonia-oxidizing bacteria (AOB). We investigated the effects of long-term fertilization on AOA and AOB in the Great Sippewissett Marsh, Falmouth, MA, USA to address some of these questions. Sediment samples were collected from low and high marsh habitats in July 2009 from replicate plots that received low (LF), high (HF), and extra high (XF) levels of a mixed NPK fertilizer biweekly during the growing season since 1974. Additional untreated plots were included as controls (C). Terminal restriction fragment length polymorphism analysis of the amoA genes revealed distinct shifts in AOB communities related to fertilization treatment, but the response patterns of AOA were less consistent. Four AOB operational taxonomic units (OTUs) predictably and significantly responded to fertilization, but only one AOA OTU showed a significant pattern. Betaproteobacterial amoA gene sequences within the Nitrosospira-like cluster dominated at C and LF sites, while sequences related to Nitrosomonas spp. dominated at HF and XF sites. We identified some clusters of AOA sequences recovered primarily from high fertilization regimes, but other clusters consisted of sequences recovered from all fertilization treatments, suggesting greater physiological diversity. Surprisingly, fertilization appeared to have little impact on abundance of AOA or AOB. In summary, our data reveal striking patterns for AOA and AOB in response to long-term fertilization, and also suggest a missing link between community composition and abundance and nitrogen processing in the marsh.

Factors influencing healthy aging with multiple sclerosis: a qualitative study.

PURPOSE: The purpose of this study was to describe the factors influencing healthy aging from the perspective of the older person with multiple sclerosis (MS) in order to build curricula for MS self-management programs. METHOD: We sourced participants, older than 55 years with MS for more than 20 years, from a database of MS clinic and outpatient rehabilitation visits. Recruitment continued until data saturation was reached (n = 18). Semi-structured interviews explored perspectives on aging and health and lifestyle habits. Demographic, lifestyle and perceived health status information was also gathered. We analyzed the transcribed text for themes and theme relationships. RESULTS: Work and social engagement, effective and accessible health care, healthy lifestyle habits, and maintaining independence at home were found to be critical proximal factors for healthy aging. The presence of financial flexibility, social support, cognitive and mental health, and resilience provided a supporting foundation to these critical proximal factors. These factors comprised a two-tiered model of healthy aging with MS. CONCLUSIONS: This two-tiered conceptual model of health aging, based on the perspectives of older persons with MS, provides a potential framework for the development of MS self-management program curricula aimed at optimizing quality of life. Further empirical testing may validate its utility in predicting healthy aging with MS.

Validation of the normalized difference vegetation index as a measure of neighborhood greenness.

PURPOSE: To assess the validity of a Geographic Information Systems (GIS) measure, the Normalized Difference Vegetation Index (NDVI), as a measure of neighborhood greenness for epidemiologic research. METHODS: Using remote-sensing spectral data, NDVI was calculated for a 100-m radial distance around 124 residences in greater Seattle. The criterion standard was rating of greenness for corresponding residential areas by 3 environmental psychologists. Pearson correlations and regression models were used to assess the association between the psychologists' ratings of greenness and NDVI. Analyses were also stratified by residential density to assess whether the correlations differed between low and high density. RESULTS: The mean NDVI among this sample of residences was 0.27 (standard deviation [SD], 0.11; range, -0.04 to 0.54), and the mean psychologist rating of greenness was 2.84 (SD, 0.98; range, 1-5). The correlation between NDVI and expert ratings of greenness was high (r = 0.69). The correlation was equivalently strong within each strata of residential density. CONCLUSIONS: NDVI is a useful measure of neighborhood greenness. In addition to showing a strong correlation with expert ratings, this measure has practical advantages, including availability of data and ease of application to various boundaries, which would aid in replication and comparability across studies.

Breast cancer screening among Asian immigrant women in Canada.

OBJECTIVE: The objective of this study was to examine the pattern of breast cancer screening among Asian immigrant women aged 50-69 years and compare it with corresponding non-immigrant women in Canada. METHODS: Data from the Canadian Community Health Survey cycle 2.1 (2003) were utilized. Self-reported screening histories were used as outcome variables: socioeconomic status and medical histories were used as predictive variables. Analyses were weighted to represent the target population. Multivariate logistic regression analyses were performed to compare the screening pattern among Asian immigrant women and corresponding non-immigrant Canadians. RESULTS: In total, 508 Asian immigrant women were included in this study. The results suggest that 71% and 60% of Asian immigrant women reported ever having had and recent mammogram use, respectively, while the corresponding figures for non-immigrant women were 89% and 72%. The observed differences were statistically significant and could not be explained by confounding factors. The ability to speak one of the two official languages is an important barrier to mammography screening among Asian immigrant women. CONCLUSION: The findings show lower rates of mammography screening among Asian immigrant women in Canada. If breast screening is to remain a health policy objective in Canada, targeted efforts to increase the recruitment of Asian immigrant women need to be developed or strengthened.

Breast cancer screening recommendations: is mammography the only answer?

Early detection of breast cancer is important to reduce mortality and morbidity. Traditionally, three methods of breast screening were recommended: mammography, clinical breast examination (CBE), and breast self-examination (BSE). At present, BSE and CBE are no longer widely recommended, while mammography is still broadly promoted in the Western world. The primary intent of this article is to examine whether current health policy recommendations related to breast cancer screening are informed by evidence. The issue of whether women are adequately aware of the potential benefits and risks of breast screening methods to make informed decisions is also discussed. It is argued that it is premature to caution women against BSE and CBE because the current evidence is inconclusive or incomplete. Moreover, women should be better informed about the potential harms associated with mammography screening. Recommendations for research and health policy are also discussed.

Facilitating interprofessional education and practice.

Collaborative patient-centred care has the potential to address serious issues in the Canadian health-care system such as those related to increasing complexity of care; patient safety and access; and recruitment and retention of health human resources. This approach involves teams of health professionals working together to provide more coordinated and comprehensive care to clients. It places priority on the preferences of the patient and fosters respect for the skills and perspectives of all health-care providers. Interprofessional education at the undergraduate, graduate and practice levels is essential for facilitating the transition to team-based care. The author presents the rationale for collaborative care and describes an interprofessional education project at Memorial University of Newfoundland that is preparing students and health professionals for this groundbreaking change in practice.

University collaboration in delivering applied health and nursing services research training.

In 2001-2002, the Canadian Health Services Research Foundation (CHSRF) and the Canadian Institutes of Health Research (CIHR) committed 10 years of funding for the creation and implementation of three Regional Training Centres to build capacity in health services and policy research in the Atlantic, Ontario and Western regions of Canada and one training centre in Quebec to focus on the development of nursing services researchers. Each RTC comprises several universities that collaborate to deliver the graduate training. The authors of this paper describe the consortium-related features of the RTCs, including approval processes, formal agreements, governance, communication, students, curriculum, administration and use of educational technology. The discussion outlines the benefits and challenges of university collaboration for participating students, faculty and universities and summarizes lessons learned.

Evidence against breast self examination is not conclusive: what policymakers and health professionals need to know.

Breast cancer is a serious health concern and a disease that is not well understood. Early detection remains the best way to prevent debilitation and death. Traditionally, mammography, clinical breast examination (CBE), and breast self examination (BSE) have been accepted as legitimate breast screening modalities. Over the past 5 years, academics, health professionals, and policymakers have seriously questioned the usefulness of BSE after influential organizations such as the Canadian Task Force on Preventive Health Care downgraded their BSE recommendation citing fair evidence of no benefit and good evidence of harm. We briefly review the three large BSE trials, highlighting methodological weaknesses limiting their ability to evaluate its effectiveness, as well as critique the 2001 Canadian Task Force on Preventive Health Care report on BSE. We argue that it is premature to conclude that BSE is ineffective. Given that most women find their own breast cancer, this article cautions policymakers and health professionals that a prudent approach to BSE promotion should be taken.