Challenges Faced by Refugee New Parents from Africa in Canada.

This study examines challenges faced by refugee new parents from Africa in Canada. Refugee new parents from Zimbabwe (n = 36) and Sudan (n = 36) were interviewed individually about challenges of coping concurrently with migration and new parenthood and completed loneliness and trauma/stress measures. Four group interviews with refugee new parents (n = 30) were subsequently conducted. Participants reported isolation, loneliness, and stress linked to migration and new parenthood. New gender roles evoked marital discord. Barriers to health-related services included language. Compounding challenges included discrimination, time restrictions for financial support, prolonged immigration and family reunification processes, uncoordinated government services, and culturally insensitive policies. The results reinforce the need for research on influences of refugees' stressful experiences on parenting and potential role of social support in mitigating effects of stress among refugee new parents. Language services should be integrated within health systems to facilitate provision of information, affirmation, and emotional support to refugee new parents. Our study reinforces the need for culturally appropriate services that mobilize and sustain support in health and health related (e.g., education, employment, immigration) policies.

In-home nursing care for women with high-risk pregnancies: outcomes and cost.

OBJECTIVE: To evaluate a program that provides in-home care to women with pregnancies threatened by preterm delivery (including preterm labor, preterm premature rupture of membranes, and multiple gestation) and women with pregnancy-related hypertension. METHODS: Data from hospital discharge summaries were used to compare birth outcomes and cost of care for women in the in-home program and a cohort of women who received in-hospital antenatal care before the new program. Birth outcomes included data for mothers and infants. The sample included 437 women with threatened preterm delivery (n = 228 in-home, n = 209 in-hospital) and 308 with hypertension (n = 155 in-home, n = 153 in-hospital). The cost per woman included all costs of services for mothers and infants. RESULTS: Women at risk of preterm delivery who received in-home care were half as likely to have their infants in the neonatal intensive care unit more than 48 hours (odds ratio 0.53, 95% confidence interval 0.36, 0.78). On average, their infants weighed more (2732 +/- 716 g versus 2330 +/- 749 g, P <.001) and were 2 weeks older at birth (36.1 +/- 3.1 weeks versus 34.0 +/- 4.0 weeks, P <.001). There was a wide range in the total cost per woman and no significant difference between cohorts. For women with hypertension, there were no significant differences between in-home and in-hospital cohorts in birth outcomes or costs of care per woman. CONCLUSION: The program with current admission criteria, staffing, and guidelines for antenatal hospital admission provides safe care to women at similar cost to that of hospitalization.

Primary care physicians' experience with mental health consultation.

A total of 684 primary care physicians in Wisconsin participated in a survey designed to explore their experiences of consulting with and referring patients to mental health care professionals. The respondents indicated that they had only moderate access to mental health care professionals, and even less access when a patient was covered by Medicare or Medicaid or had no insurance. Physicians in group practices that included at least one mental health professional reported having better access to care than those in practices that did not include mental health services. Perceived access to mental health care services was not related to community size or to a managed care setting.

Fine volumetric analysis of the cerebral ventricular system in schizophrenia: further evidence for multifocal mild to moderate enlargement.

We used traditional volumetric regional analysis and a finer anterior-posterior (AP) profile volumetric analysis to examine the cerebral ventricular system in an all-male, demographically matched sample of schizophrenia patients (n = 73) and normal controls (n = 29) using 2.8-mm-thin coronal T1-weighted magnetic resonance images from a 1.5 tesla scanner. Traditional regional analysis was performed on various regions using absolute volumes after adjusting for intracranial volume (ICV) and age. The fine AP profile analysis was done by intrasubject "stacking" of contiguous coronal cross-sectional volumes (adjusted for ICV and age) across the AP plane, intersubject AP alignment of all slices relative to the mammillary bodies, and plotting of slice volumes along the AP plane with 95 percent t-test-based confidence intervals. Schizophrenia subjects had mild to moderate multifocal ventricular enlargement (overall effect size d = 0.48), which was especially prominent in the right posterior temporal horn and, more generally, in the central to posterior portions of the lateral and third ventricles. Schizophrenia subjects also had milder enlargement in the left frontal horn, but no significant differences were found in the anterior temporal horns and the right frontal horn. Post hoc analyses of demographic, clinical, and neuropsychological variables did not account for much variance in the ventriculomegaly observed in the schizophrenia group. The lack of a single locus in the observed ventricular enlargement, the nonsignificant results from schizophrenia subtypes based on regional distributions, and the strong positive correlations among the ventricular regions for the schizophrenia group suggest that the ventriculomegaly seen in this chronic population reflects a single brainwide disease process leading to a multifocal or patchy loss of integrity in brain structure.

Warrantable evidence in nursing science.

Consensus among nurse scholars has not been reached regarding suitable qualities for accepting or rejecting the evidence arising from various world views. The authors' purpose in writing the paper is to describe the qualities or warrants for evaluating scientific findings (the 'evidence') of different research perspectives. The warrantable evidence pertinent to post-positivist, interpretivist, critical social theorist, and feminist perspectives are described and common warrants are suggested. Three warrants common to these scientific perspectives are proposed: (a) scrutiny and critique of methodological rigor and findings by the scientific community; (b) corroboration and intersubjectivity; and (c) scope of the evidence. The identification of common warrantable evidence will assist nurses in developing some core values regarding the constituents of good science or good scholarship even in the face of pluralism in nursing science approaches.

The use of magnetic resonance angiography prior to pharyngeal flap surgery in patients with velocardiofacial syndrome.

Twenty consecutive patients with velocardiofacial syndrome underwent magnetic resonance angiography (MRA) to determine if abnormalities of the neck arteries would contraindicate pharyngeal flap surgery. All 20 patients were found to have anomalies to the carotid arteries, vertebral arteries, medially placed internal carotids, low carotid bifurcations, and tortuous or kinked internal carotids. The internal carotids were found to be almost directly under the mucous membrane of the pharynx in two patients. In these two patients, the arteries were close to the pharyngeal midline at the base of the first cervical vertebra and might easily be severed during the raising of a pharyngeal flap. Hypoplastic vertebral arteries also were found. One patient had an extra neck vessel. The anomalies of the internal carotids did not have a strong correlation with endoscopically observed pulsations in the position affected the location of the internal carotids did not have a strong posterior pharyngeal wall. It also was found that head position affected the location of the internal carotid arteries when they were located close to the pharyngeal mucous membrane. The information provided in the MRA studies allowed assessment of the arterial anomalies in relation to the flap donor site so that the patients in the sample who underwent pharyngeal flap surgery using a short superiorly based flap had no major bleeding complications.

Women in transition: access and barriers to social support.

As little is known about how support assists individuals during a normative life transition, this qualitative, prospective study explored how women chose sources of informal support. Women having their first child, returning to work after an extended absence or recently retired from full-time employment were interviewed. Support during a life transition was described as having someone who would listen while the woman problem-solved. Women preferred to get their support from close family members or others experiencing a similar life transition. A number of barriers to the use of support were identified: perception that the use of support would be a burden on others, lack of reciprocity, reluctance to ask for support, and nonsupportive messages included within supportive actions. The transition often took more than 2 years to complete and, for a subgroup of women, involved major changes in their self-expectations and ability to access support. The findings identify areas that nurses should consider in health promotion activities with women who are experiencing these life transitions.

Treatment of asymmetric velopharyngeal insufficiency with skewed pharyngeal flap.

Twenty-two patients, with hypernasal speech and asymmetric velopharyngeal insufficiency (VPI) identified preoperatively by multi-view video-fluoroscopy and nasopharyngoscopy, were managed with superiorly based pharyngeal flaps skewed to the side with reduced lateral pharyngeal wall movement. Patient age ranged from 5 to 58 years. The etiology of the VPI included cleft palate with or without cleft lip, neurogenic VPI, velocardiofacial syndrome, tumor resection or iatrogenic causes, submucous cleft palate, neurofibromatosis, and hemifacial microsomia. Follow-up, at 1 year and thereafter, showed resolution of VPI in all but two patients. An auxiliary flap to augment the primary flap was added on the side of diminished lateral pharyngeal wall motion which corrected the residual VPI. Three patients developed hyponasality. One was a child whose symptoms improved with time and growth. Two were adults, but the hyponasal resonance was mild and required no further intervention. The advantage of skewing flaps is that at least one port functions adequately for ease in respiration and for drainage of secretions, thus reducing the risk of nasal obstruction. One open port also allows access for nasoendotracheal intubation should anesthetic be required for future operations.

Effect of glossopexy on speech sound production in Robin sequence.

The management of Robin sequence may include glossopexy, in which the tongue is attached to the lower lip and mandible for anterior lingual positioning to resolve upper airway obstruction. The procedure is performed early in infancy and reversed at the time of palatal repair near 1 year of age. This period is critical to prespeech vocalization. The effect of glossopexy on speech sound production was investigated in 17 children with Robin sequence who had glossopexies. Analysis suggested that glossopexy may temporarily affect the development of prespeech skills and sound production. The onset of babbling and initiation of first words was often delayed in the subjects in comparison with syndrome-matched children who had not undergone glossopexy. Tongue-tip sounds were often produced with the tongue blade, but production was perceptually normal. The early delays were temporary and the only long-term effect of glossopexy was a tendency to produce tongue-tip sounds with the tongue blade.

Pharyngeal flap surgery in adults.

The elimination of hypernasal speech in patients with cleft palate following pharyngeal flap surgery in childhood is well established. However, pharyngeal flaps in adults have been considered to yield more modest results. This study reports on 20 adult patients with cleft palate-related hypernasality who underwent pharyngeal flap surgery. Normal nasal resonance was achieved in 15 cases, hyponasality occurred in 3 cases, and hypernasality persisted in 2 cases. However, speech intelligibility was not always dramatically improved. Indications and outcome were found to be highly dependent on preoperative articulation.

Standardization for the reporting of nasopharyngoscopy and multiview videofluoroscopy: a report from an International Working Group.

A multidisciplinary International Working Group of scientists was assembled to address the question of standardizing reporting techniques for multiview videofluoroscopy and nasopharyngoscopy, the generally accepted standards for direct observation of the velopharyngeal valve. This report is a first attempt to propose standards while seeking feedback from the readership in order to further develop a common methodology.

Evaluation of velopharyngeal insufficiency.

To summarize briefly, in our opinion, the combined use of end-viewing flexible fiber optic nasopharyngoscopy and multiview videofluoroscopy (which must include lateral and frontal views) and a behavioral assessment of the patient's speech provides the examiner with all of the information necessary to select the appropriate treatment for VPI. Indirect assessment procedures, such as airflow studies, do not enhance the decision making process even though they may provide what would appear to be objective data. Treatment decisions depend on the ability to confirm the type of speech abnormality present (by behavioral assessment) followed by a direct view of the defect (by endoscopy and fluoroscopy).

Family physicians' perceptions of the family conference.

Ninety-one of 127 graduates (72 percent) of one family practice residency returned a questionnaire in which they estimated the likelihood that their patients would want a physician-family conference for each of 21 clinical situations. For each situation the physicians also rated their own preferences regarding patients' interest in family conferences. Serious medical illnesses received the highest ratings for both sets of ratings. For all 21 situations, physicians' estimates of patients' responses were significantly lower than physicians' preferred response ratings. The physicians' estimates and preferences regarding patients' interest in family conferences were compared with actual patients' ratings obtained in a previous study. The patient ratings were significantly greater than the physicians' estimates of patient ratings for 14 of 21 situations; the physicians' preferences ratings were significantly higher than the actual patient ratings for 11 situations and lower for three situations. The mean number of actual family conferences conducted in the previous month was 2.6, and 66 percent of respondents had conducted at least one such conference during this time. These data indicate that physicians may be more interested in family conferences than their patients are, but that they may underestimate the degree to which patients do, in fact, want them. The implications of these data for teaching, practice, and research are discussed.

Patients' attitudes toward physician involvement in family conferences.

Patients' interest in family conferences was investigated using Doherty and Baird's concept of level of physician involvement with families. Patients entering two primary care clinics (N = 239) completed a questionnaire assessing their interest in physician level of involvement for each of six representative clinical situations: hospitalization for serious illness, new diagnosis of serious illness, depression, marital or relationship problems, stress-related symptoms, and frequent visits without improvement. Most patients indicated that they would want family conferences with their primary physician if a family member experienced hospitalization, new diagnosis of a serious illness, or depression. Slightly less than one half of the patients indicated that they would want family conferences for the remaining situations. Among those patients desiring family conferences, majorities responded that they would want their primary physician to provide all of Doherty and Baird's levels 2 through 5 (ongoing medical information and advice, feelings and support, systematic assessment and planned intervention, and family therapy), especially for hospitalization for serious illness and for depression. Most patients who indicated that they would want their physician to provide family therapy in the family conference also responded that they would want referral to a mental health professional for family therapy. The implications of these findings for clinical practice, residency training, and future research are discussed.

Treat or refer: patients' interest in family physician involvement in their psychosocial problems.

Seven hundred fifteen patients entering three family practice clinics (rural private practice, urban private practice, urban residency) completed a questionnaire assessing their interest in their family physicians' involvement in four representative psychosocial problems: spouse abuse or neglect, lack of exercise, a dying family member, and a sexual problem. A majority of the patients (57 to 78 percent) wanted help for the four problems from their family physicians either independently or in conjunction with a specialist, whereas only 4 to 21 percent wanted referral to specialists exclusively. Desired level of family physician involvement was predicted (R2 = .291) by a series of reason for involvement variables representing the following conceptual areas: perception of value in talking about personal problems; perception of family physician background, time, and interest; and the Health Belief Model. This study supports the conclusion that family physicians need skills in managing psychosocial problems so they can provide the type of care that most patients want.

The family conference: what do patients want?

This study investigated patients' desire for family conferences in a variety of clinical situations encountered in family practice. Two hundred seventy-six family practice center patients were given a questionnaire in which they indicated the likelihood that they would want a family conference in 21 clinical situations. Patients' past experiences with family conferences as well as demographic information were obtained. For serious medical problems and some behavioral problems, patients indicated a high likelihood of wanting a family conference. They showed moderate to low interest in such conferences for guidance for family developmental stages, health promotion, and minor acute problems. Demographic factors and previous experiences with family conferences did not predict patients' interest in future conferences.