Organizational guidance for the care of patients with head-and-neck cancer in Ontario.

Background: At the request of the Head and Neck Cancers Advisory Committee of Ontario Health (Cancer Care Ontario), a working group and expert panel of clinicians with expertise in the management of head-and-neck cancer developed the present guideline. The purpose of the guideline is to provide advice about the organization and delivery of health care services for adult patients with head-and-neck cancer. Methods: This document updates the recommendations published in the Ontario Health (Cancer Care Ontario) 2009 organizational guideline The Management of Head and Neck Cancer in Ontario. The guideline development methods included an updated literature search, internal review by content and methodology experts, and external review by relevant health care providers and potential users. Results: To ensure that all patients have access to the highest standard of care available in Ontario, the guideline establishes the minimum requirements to maintain a head-and-neck disease site program. Recommendations are made about the membership of core and extended provider teams, minimum skill sets and experience of practitioners, cancer centre-specific and practitioner-specific volumes, multidisciplinary care requirements, and unique infrastructure demands. Conclusions: The recommendations contained in this document offer guidance for clinicians and institutions providing care for patients with head-and-neck cancer in Ontario, and for policymakers and other stakeholders involved in the delivery of health care services for head-and-neck cancer.

Engaging cancer patients in clinical practice guideline development: a pilot study.

Background: Patient engagement is a key quality component of cancer guideline development; however, the optimal strategy for engaging patients in guideline development remains unclear. The feasibility and efficacy of two patient engagement models was tested by Cancer Care Ontario's cancer guideline development program, the Program in Evidence-Based Care (pebc). Methods: In model 1, patients participated in the guideline development process as active members of a working group. In model 2, patients formed a separate consultation group to review project plans and recommendations generated by multiple working groups. Training included online resources (model 1) and an in-person orientation (model 2). The pebc's standard patient engagement process acted as a control. The study was conducted for 1 year. Surveys measured the satisfaction of patients and members of the guideline working groups with the process and the outcome of each model. Results: Three guideline projects used model 1 to engage patients, six projects used model 2 to receive feedback, and one project was used as a control group (14 patients total). Most participants, whatever the model, reported satisfaction with their experience. Key challenges to implementation included patient recruitment and long wait times between meetings (model 1), and difficulty focusing on the discussion topic and poor meeting attendance on the part of patients (model 2). Conclusions: The pilot study demonstrated that, although both models are feasible and effective for the engagement of patients in cancer guideline development, modifications are required to optimize their continued interest. The pebc will use the study results to inform the implementation of a patient engagement strategy for its program.

Cancer diagnostic assessment programs: standards for the organization of care in Ontario.

BACKGROUND: Improving access to better, more efficient, and rapid cancer diagnosis is a necessary component of a high-quality cancer system. How diagnostic services ought to be organized, structured, and evaluated is less understood and studied. Our objective was to address this gap. METHODS: As a quality initiative of Cancer Care Ontario's Program in Evidence-Based Care, the Diagnostic Assessment Standards Panel, with representation from clinical oncology experts, institutional and clinical administrative leaders, health service researchers, and methodologists, conducted a systematic review and a targeted environmental scan of the unpublished literature. Standards were developed based on expert consensus opinion informed by the identified evidence. Through external review, clinicians and administrators across Ontario were given the opportunity to provide feedback. RESULTS: The body of evidence consists of thirty-five published studies and fifteen unpublished guidance documents. The evidence and consensus opinion consistently favoured an organized, centralized system with multidisciplinary team membership as the optimal approach for the delivery of diagnostic cancer assessment services. Independent external stakeholders agreed (with higher mean values, maximum 5, indicating stronger agreement) that DAP standards are needed (mean: 4.6), that standards should be formally approved (mean: 4.3), and importantly, that standards reflect an effective approach that will lead to quality improvements in the cancer system (mean: 4.5) and in patient care (mean: 4.3). INTERPRETATION: Based on the best available evidence, standards for the organization of DAPS are offered. There is clear need to integrate formal and comprehensive evaluation strategies with the implementation of the standards to advance this field.

Membrane-induced secondary structures of neuropeptides: a comparison of the solution conformations adopted by agonists and antagonists of the mammalian tachykinin NK1 receptor.

We present what we believe to be the first documented example of an inducement of distinctly different secondary structure types onto agonists and antagonists selective for the same G-coupled protein receptor using the same membrane-model matrix wherein the induced structures are consistent with those suggested to be biologically active by extensive analogue studies and conventional binding assays. 1H NMR chemical shift assignments for the mammalian NK1 receptor-selective agonists alpha-neurokinin (NKA) and beta-neurokinin (NKB) as well as the mammalian NK1 receptor-selective antagonists [d-Pro2,d-Phe7,d-Trp9]SP and [d-Arg1, d-Pro2,d-Phe7,d-His9]SP have been determined at 600 MHz in sodium dodecyl sulfate (SDS) micelles. The SDS micelle system simulates the membrane-interface environment the peptide experiences when in the proximity of the membrane-embedded receptor, allowing for conformational studies that are a rough approximation of in vivo conditions. Two-dimensional NMR techniques were used to assign proton resonances, and interproton distances were estimated from the observed nuclear Overhauser effects (NOEs). The experimental distances were used as constraints in a molecular dynamics and simulated annealing protocol using the modeling package DISCOVER to generate three-dimensional structures of the two agonists and two antagonists when present in a membrane-model environment to determine possible prebinding ligand conformations. It was determined that (1) NKA is helical from residues 6 to 9, with an extended N-terminus; (2) NKB is helical from residues 4 to 10, with an extended N-terminus; (3) [d-Pro2,d-Phe7,d-Trp9]SP has poorly defined helical properties in the midregion and a beta-turn structure in the C-terminus (residues 6-9); and (4) [d-Arg1,d-Pro2, d-Phe7,d-His9]SP has a helical structure in the midregion (residues 4-6) and a well-defined beta-turn structure in the C-terminus (residues 6-10). Attempts have been made to correlate the observed conformational differences between the agonists and antagonists to their binding potencies and biological activity.

Shared roles ensure complete care for sexual assault survivors.

Collaboration between nurse and medical practitioners is required to achieve the quality of care needed by persons experiencing sexual assault. The environment necessary to support this endeavor emerges from the larger organizational values, the program values, and from mature, confident team members. Medical and nurse practitioners understand their unique knowledge and skills as complementary and enhancing, rather than divisive; they must identify the knowledge and skill sets common to both as well as those unique to each discipline. The complex needs of the client demand a collaborative, multidisciplinary approach. This approach benefits both the client and the care provider. The atmosphere provided by this style allows individual professionals to grow and cultivates interest to learn from each other. Modeling of this behavior to clients gives unwritten and unspoken permission to rely on others in a healthy and open fashion.

The role of a forensic clinical nurse specialist in a sexual assault treatment program.

The role of a Forensic Clinical Nurse Specialist has been developed within our Regional Sexual Assault Treatment Centre in London, Ontario, to assist in meeting the short-term and long-term physical and psychological needs of victims of acute sexual assault. We report on the development and application of this most valuable role within our medical and nursing health care team.

Identifying patients with hypercholesterolemia. More than one blood sample is needed.

OBJECTIVE: To compare the use of one and two blood samples for diagnosing hypercholesterolemia DESIGN: A test-retest substudy conducted as part of a randomized control trial designed to compare the effectiveness of different counseling strategies for lowering serum cholesterol, dietary fat, and dietary cholesterol in patients with moderate hypercholesterolemia. SETTING: Thirty urban family practices. PARTICIPANTS: One hundred forty-two patients provided two blood samples for total cholesterol (TC) level determination at two different times (test results were being used as an eligibility criterion for enrollment in the main trial). MAIN OUTCOME MEASURES: Number of subjects correctly classified to cholesterol risk category (normal < 6.2 mmol/L; moderate 6.2 to 6.9 mmol/L; high > 6.9 mmol/L) on the basis of one TC value and on the average of two TC values. RESULTS: Overall misclassification rate on initial TC level was 22.5%. Overall false-positive rate was 19.0%, but false-positive rate for those initially assigned to the high category was 50%. Overall false-negative rate was 3.5%. Misclassification rates did not differ statistically on the basis of age, sex, blood pressure, smoking status, family history of coronary heart disease, presence of diabetes, obesity, the laboratory used, or whether the patient had fasted before giving blood. CONCLUSIONS: Single TC levels are too unreliable for diagnostic purposes, even if the subjects fast before testing. Family physicians should base their treatment decisions on the average of two cholesterol readings taken at different times 1 to 8 weeks apart.

Comparison of the hydrolytic activity and fluorescence of native, guanidine hydrochloride-treated and renatured cellobiohydrolase I from Trichoderma reesei.

Guanidine hydrochloride (GdnHCl) is an effective agent for the elution of cellulase protein from unhydrolyzed cellulosic residues, but once eluted the enzyme is inactive. The studies described in this paper examine the effect of GdnHCl on the hydrolytic activity and tryptophan fluorescence of cellobiohydrolase I (CBH I) from Trichoderma reesei. CBH I was found to be completely inactivated by 0.25 M GdnHCl, but higher concentrations of GdnHCl were required to partially unfold this enzyme, as determined from the measurement of a decrease in its tryptophan fluorescence. Binding of CBH I to microcrystalline cellulose was prevented by 4 M GdnHCl, suggesting that a conformational change of CBH I resulted in the loss of substrate binding. Removal of the denaturant from CBH I by dialysis or gel filtration allowed the kinetics of the reactivation of CBH I, after 4 M GdnHCl treatment, to be studied. The fluorescence and specific hydrolytic activity of native and renatured CBH I were comparable. It is concluded, therefore, that GdnHCl may be used to elute cellulase components, such as CBH I, adsorbed on undigested cellulosic substrates since this component can easily be renatured and subsequently reused.

Development of the art of medicine.

This paper reflects upon the art of family medicine experienced by one resident during an eight-month period of her two-year family medicine residency. The "science" of medicine, as experienced in medical school, is contrasted with the "art" of medicine fostered throughout the family medicine residency. Patients in all age categories, from neonates to those older than 90 years, were examined. The average number of patient-initiated encounters during the eight-month period was 2.3 per female and 2.4 per male. The five most common reasons for presenting were related to the skin, ears, throat, back, and requests for general "check-ups." According to McWhinney's taxonomy of patient behaviour, patient-initiated visits could be categorized into the following groups: 67.4% were limit of tolerance; 7.2% limit of anxiety; 8.2% underlying problems of living; 0.3% for purely administrative purposes; and 16.9% for preventive purposes. The experiences with four of the more memorable patients seen during the 12-month residency, presented here in personal vignettes, proved vital in moving the author toward her goal of becoming a well-rounded family physician.