Three philosophical approaches to the study of spirituality.

Since the turn of the century, there has been an expanded interest in the place that spirituality has in nursing practice, education, and research. The purpose of this article is to examine the study of spirituality from the perspective of 3 philosophical paradigms: empiricism, interpretivism, and poststructuralism. The strengths and weaknesses of the paradigms are identified through a review of an exemplar article for each. Each paradigm provides a unique approach to the development of knowledge, and thus makes its own contribution to the understanding of spirituality. It is the researcher's responsibility to identify the appropriate paradigm for the question.

Challenging pedigrees seen in a hereditary cancer consultation center.

The clinical translation of the significance of cancer "running in families" has become a source of major contention as a result of the explosion of knowledge about cancer causality at the molecular level. At the clinical level, the increasing awareness of the familial and hereditary burden of cancer has contributed heavily to both physician and lay concern about cancer risk. Problems in interpretation of the significance of a cancer family history may arise due to a variety of factors, and even if the physician correctly diagnoses a hereditary cancer-predisposing syndrome there may still be barriers to patient compliance with surveillance and management recommendations. Our purpose is to discuss a variety of potential barriers in the diagnosis and management of patients at increased hereditary cancer risk, drawing on examples from a cohort of approximately 300 families evaluated at Creighton University's Hereditary Cancer Consultation Center over 8 years. Each case was selected because of the presence of one or more clinical, pathologic, molecular genetic, psychosocial, economic, confidentiality, or insurance or employment discrimination factors that had the potential to pose an obstacle in diagnosis or in patient compliance with screening and management recommendations.

Screening adherence in BRCA1/2 families is associated with primary physicians' behavior.

This study provides an assessment of long-term breast and ovarian cancer screening behaviors and the variables associated with adherence with screening among women with or at 50% for having a BRCA1/2 mutation. Participants in the study included 112 women (33 mutation carriers and 79 at 50% risk). Data was collected through a mailed questionnaire, which included items to assess screening behaviors in the last 2 years, risk perception, cancer specific distress, adherence determinants, specific barriers, and cancer history. Statistical analysis included descriptive statistics and non-parametric tests to describe bivariate associations and regression analysis. Adherence rates were 72% for annual mammography, 21% for semi-annual clinical breast exam (CBE), 29% for monthly breast self-exam (BSE), and 19% for annual transvaginal ultrasound (US). Only one participant was adherent with semi-annual CA125. Variables that had a significant association (P < 0.05) with at least one screening modality included: a lack of time, marital status, education, cancer history, provider concern, perceived screening utility, confidence in ability to overcome barriers, cancer specific distress, and risk perception. Primary physician behavior, either in terms of screening recommendations or screening performance in the case of CBE, had significant independent association with adherence to mammography, CBE, and US screening recommendations. The results of this study highlight the essential role that primary physicians play in supporting their very high-risk patients' adherence.

Challenging colonic polyposis pedigrees: differential diagnosis, surveillance, and management concerns.

Hereditary polyposis syndromes show extensive phenotypic and genotypic heterogeneity within and among families, a situation that may hinder diagnosis. In these settings, germline mutation testing may be the sine qua non for diagnosis if such a mutation is identified in a patient or family. We provide examples of phenotypically differing polyposis pedigrees depicting various challenges in hereditary polyposis syndrome diagnosis. Our purpose is to augment physician understanding of phenotypic variation and thus help identify high-risk presymptomatic family members who could benefit from highly targeted surveillance and management strategies. We describe nine familial polyposis pedigrees displaying anecdotal clinical problems that can confound the differential diagnosis. Emphasis was given to a multidisciplinary approach focusing on pathological confirmation with respect to number, histology, and location of polyps in the gastrointestinal tract; a detailed family history of cancer at all anatomic sites; noncancer phenotypic features of hereditary polyposis syndromes; and appropriate molecular genetic testing in concert with genetic counseling. Improved physician understanding of the clinical natural history features, genetic transmission patterns, and appropriate gene testing will help in diagnosis and, ultimately, surveillance and management for the various hereditary polyposis syndromes.