Experiences of and responses to HIV among African and Caribbean communities in Toronto, Canada.

African and Caribbean communities in Canada and other developed countries are disproportionately affected by HIV/AIDS. This qualitative study of African and Caribbean communities in Toronto sought to understand HIV-related stigma, discrimination, denial and fear, and the effects of multiple intersecting factors that influence responses to the disease, prevention practices and access to treatment and support services. Semi-structured interviews were conducted with 30 HIV-positive men and women and focus groups were conducted with 74 men and women whose HIV status was negative or unknown. We identified a range of issues faced by African and Caribbean people that may increase the risk for HIV infection, create obstacles to testing and treatment and lead to isolation of HIV-positive people. Our findings suggest the need for greater sensitivity and knowledge on the part of healthcare providers; more culturally specific support services; community development; greater community awareness; and expanded efforts to tackle housing, poverty, racism and settlement issues.

Acute respiratory distress syndrome in pregnancy and the puerperium: causes, courses, and outcomes.

OBJECTIVE: To describe causes, courses, complications, and outcomes of patients with pregnancy-associated acute respiratory distress syndrome (RDS). METHODS: Twenty-eight women with ARDS during pregnancy or within a week postpartum formed the study population. Eight cases had been reported previously. Charts were abstracted for maternal demographics, etiology, and treatment of acute RDS, and maternal outcomes. For antepartum acute RDS, newborn charts were also reviewed. RESULTS: The incidence of acute RDS, excluding maternal transports, was one per 6277 deliveries or 0.016% (95% confidence interval [CI] 0, 0.027%). Leading causes were infection (12 cases), preeclampsia or eclampsia (seven cases), and aspiration (three cases). Eleven mothers died, a maternal mortality rate of 39.3% (CI 21.5%, 59.4%). Six of eight women who were ventilated for over 14 days survived. Nine of the acute RDS cases might have been preventable. Ten mothers with living fetuses were ventilated during the third trimester; nine delivered within 4 days. Among six infants delivered because of fetal heart rate abnormalities, one died and at least three had evidence of asphyxia. CONCLUSIONS: Acute RDS occurs more frequently in pregnancy than the 1.5 cases per 100,000 per year reported for the general population. Prolonged ventilator support is warranted. The high rate of perinatal asphyxia in infants who have fetal heart rate abnormalities supports a strategy of expeditious delivery during the third trimester.

A qualitative study of the transition to adulthood for youth with physical disabilities.

The purpose of this qualitative study was to explore the experiences, perceptions, and needs of youth with physical disabilities in transition from adolescence to adulthood. Purposeful sampling strategies were used to select 34 study participants who lived in three regions of south-central Ontario, Canada. Data collection methods were individual and focus group interviews, and were guided by a set of open-ended questions. An editing style of analysis sorted the text into codes for description and interpretation. Themes emerged about context, the transition process, needs, and services. Participants identified a poor fit between young persons with disabilities and the adult world they were entering. They recommended that services be focused on environmental supports to enable them to "build their own bridges" to the adult world. Community-based transition services need to be planned in collaboration with youth with disabilities and their parents. Concepts of person-environment fit and health promotion can be incorporated into services to enable young persons with disabilities to experience a smooth transition from adolescence to adulthood.

Towards a "good" death: end-of-life narratives constructed in an intensive care unit.

End-of-life decisions regarding the withdrawal and withholding of life supporting technology have become commonplace within intensive care units (ICUs). In this paper, we examine the dialogue between ICU team members and families regarding limitation of treatment as a therapeutic narrative--that is, as a story which frames therapeutic events as well as the critically ill patient's experience in a meaningful and psychologically comforting way for families and health care providers alike. The key themes of these end-of-life narratives are discussed, as well as the qualities that the stories share with other narratives of the same genre.

Gay and lesbian physicians in training: a qualitative study.

BACKGROUND: Gay and lesbian physicians in training face considerable challenges as they become professionalized. Qualitative research is necessary to understand the social and cultural factors that influence their medical training. In this study we explored the significance of gay or lesbian identity on the experiences of medical training using naturalistic methods of inquiry. METHODS: Semi-structured interviews, focus groups and an e-mail listserv were used to explore professional and personal issues of importance to 29 gay and lesbian medical students and residents in 4 Canadian cities. Data, time, method and investigator triangulation were used to identify and corroborate emerging themes. The domains explored included career choice, "coming out," becoming a doctor, the environment and career implications. RESULTS: Gay or lesbian medical students and residents experienced significant challenges. For all participants, sexual orientation had an effect on their decisions to enter and remain in medicine. Once in training, the safety of a variety of learning environments was of paramount importance, and it affected subsequent decisions about identity disclosure, residency and career path. Respondents' assessment of professional and personal risk was influenced by the presence of identifiable supports, curricula inclusive of gay and lesbian sexuality and health issues and effective policies censuring discrimination based on sexual orientation. The need for training programs to be proactive in acknowledging and supporting diversity was identified. INTERPRETATION: Considerable energy and emotion are spent by gay and lesbian medical students and residents navigating training programs, which may be, at best, indifferent and, at worst, hostile.

Long-term survival with use of percutaneous extracorporeal life support in patients presenting with acute myocardial infarction and cardiovascular collapse.

Up to 10% of patients who arrive at the hospital with acute myocardial infarction (AMI) present with or develop cardiogenic shock. Some patients, despite inotropes and intra-aortic balloon pump (IABP) placement, are not hemodynamically stable enough to undergo emergent revascularization. The use of percutaneous extracorporeal life support (ECLS) can stabilize patients to allow effective therapy. In a retrospective review of the first 100 patients emergently placed on ECLS by a nurse-supported physician insertion technique at Sharp Memorial Hospital, 10 patients underwent placement of ECLS after out-of hospital AMI. All AMI patients required intubation for respiratory failure and temporary CPR for cardiovascular collapse before initiation of ECLS. Of the 10 AMI patients placed on ECLS, four (40%) are currently long-term survivors (5.1 +/- 4.2 years; range, 6 months to 11 years). All survivors underwent successful revascularization after placement on ECLS. The cause of death in the other six patients was neurologic insufficiency in two, ineffective ECLS in two, and recurrent cardiovascular collapse after weaning from bypass in two. Total CPR time before initiation of cardiopulmonary bypass was 17 +/- 10.3 minutes for the survivors and 54.2 +/-11.1 minutes for the nonsurvivors (p < 0.001). The average time on ECLS was 29 +/- 26 hours for the survivors and 30 +/-67 hours for the nonsurvivors (p = NS). Leg complications were common among long-term survivors, associated with the use of ECLS (three ischemia, one infection). After AMI and cardiovascular collapse, insertion of ECLS may permit long-term patient survival.

Life support in the intensive care unit: a qualitative investigation of technological purposes. Canadian Critical Care Trials Group.

BACKGROUND: The ability of many intensive care unit (ICU) technologies to prolong life has led to an outcomes-oriented approach to technology assessment, focusing on morbidity and mortality as clinically important end points. With advanced life support, however, the therapeutic goals sometimes shift from extending life to allowing life to end. The objective of this study was to understand the purposes for which advanced life support is withheld, provided, continued or withdrawn in the ICU. METHODS: In a 15-bed ICU in a university-affiliated hospital, the authors observed 25 rounds and 11 family meetings in which withdrawal or withholding of advanced life support was addressed. Semi-structured interviews were conducted with 7 intensivists, 5 consultants, 9 ICU nurses, the ICU nutritionist, the hospital ethicist and 3 pastoral services representatives, to discuss patients about whom life support decisions were made and to discuss life-support practices in general. Interview transcripts and field notes were analysed inductively to identify and corroborate emerging themes; data were coded following modified grounded theory techniques. Triangulation methods included corroboration among multiple sources of data, multidisciplinary team consensus, sharing of results with participants and theory triangulation. RESULTS: Although life-support technologies are traditionally deployed to treat morbidity and delay mortality in ICU patients, they are also used to orchestrate dying. Advanced life support can be withheld or withdrawn to help determine prognosis. The tempo of withdrawal influences the method and timing of death. Decisions to withhold, provide, continue or withdraw life support are socially negotiated to synchronize understanding and expectations among family members and clinicians. In discussions, one discrete life support technology is sometimes used as an archetype for the more general concept of technology. At other times, life-support technologies are discussed collectively to clarify the pursuit of appropriate goals of care. CONCLUSIONS: The orchestration of death involves process-oriented as well as outcome-oriented uses of technology. These uses should be considered in the assessment of life-support technologies and directives for their appropriate use in the ICU.

Bronchopulmonary segmental lavage with Surfaxin (KL(4)-surfactant) for acute respiratory distress syndrome.

We performed a trial to assess the safety and tolerability of sequential bronchopulmonary segmental lavage with a dilute synthetic surfactant (Surfaxin) in 12 adults with ARDS. Patients received one of three dosing regimens in which aliquots of Surfaxin were administered via a wedged bronchoscope to each of the 19 bronchopulmonary segments. Suctioning was performed 10-30 s after instillation of individual aliquots. Group 1 patients (n = 3) received one 30-ml aliquot of a 2.5-mg/ml concentration of Surfaxin in each segment, followed by a second 30-ml aliquot with a 10-mg/ml concentration. Group 2 patients (n = 4) received two 30-ml aliquots of the 2.5-mg/ml concentration followed by a third lavage with the 10-mg/ml concentration. Group 3 patients (n = 5) received therapy identical to that received by patients in Group 2 and were eligible for repeat dosing 6 to 24 h later. All patients tolerated the procedure. There were no serious adverse experiences ascribed to either the procedure or the surfactant. In the 96 h after treatment initiation, FI(O(2)) decreased from 0.80 to 0.52 and PEEP decreased from 10.3 to 7.6 cm H(2)O. Bronchoscopic "cleansing" of the lungs with dilute Surfaxin may offer a safe and feasible approach to improving outcomes in patients with ARDS. Wiswell TE, Smith RM, Katz LB, Mastroianni L, Wong DY, Willms D, Heard S, Wilson M, Hite RD, Anzueto A, Revak SD, Cochrane CG. Bronchopulmonary segmental lavage with Surfaxin (KL(4)-surfactant) for acute respiratory distress syndrome.

Brain death during pregnancy: tocolytic therapy and aggressive maternal support on behalf of the fetus.

We report a case of maternal brain death at 25 weeks gestation in which aggressive maternal hemodynamic, respiratory, and metabolic support and tocolytic drug therapy resulted in prolongation of pregnancy for 25 days. The indication for delivery was torulopsis giabrata amnionitis, which may have occurred due to transmembrane or transplacental route. The baby was treated for fungal sepsis, and did well. Premature labor may occur spontaneously after maternal brain death, and may be precipitated by infection or by maternal drug therapy. The myriad of hemodynamic and endocrine issues associated with maternal brain death complicate the choice of tocolytic drugs, but this case illustrates that uterine activity can be successfully blocked, potentially diminishing risks to the newborn, following the tragedy of maternal brain death during pregnancy.

Adult respiratory distress syndrome in pregnancy: report of three cases and review of the literature.

Adult respiratory distress syndrome (ARDS) is rarely encountered in association with pregnancy, but with the decline in other causes of maternal death, is an increasingly important cause of mortality in obstetric patients. ARDS may result from a variety of different types of pulmonary injury; uniquely obstetric causes include preeclampsia, amnionitis-endometritis, obstetric hemorrhage, and tocolytic therapy. Crucial management issues include support of maternal oxygenation and cardiac output, myriad interactions between the pulmonary process and its treatment, with maternal and fetal physiology, and decision making regarding delivery. Our review of the literature suggests that, for the patient requiring antepartum intubation for ARDS, except at a very early gestational age or when pyelonephritis or varicella pneumonia is a cause of respiratory compromise, delivery will likely be required for maternal and/or fetal indications, and an early decision for delivery may be beneficial. Postpartum management is similar to treatment of the nonpregnant patient with ARDS, with aggressive attention to potential surgically correctable causes for infection. Maternal mortality rates are affected little by duration of intubation, and therefore prolonged mechanical ventilation is justified and appropriate for mothers with ARDS.

Analysis of clinical trends in a program of emergent ECLS for cardiovascular collapse.

Between June 1986 and October 1995, 81 patients were emergently resuscitated with a portable extracorporeal life support (ECLS) system. Venoarterial perfusion was achieved using a centrifugal pump (BioMedicus; Medtronic, Anaheim, CA) and a hollow fiber oxygenator (BARD in 56 patients; Medtronic heparin-bonded MAXIMA, [MAXIMA, Medtronic, Minneapolis, MN] in the last 25 patients. The ECLS system was used at various locations in the hospital with the setup, priming, and initiation of perfusion done by ECLS trained intensive care unit nurses. Clinical data in these patients were reviewed to analyze variables influencing survival and trends that develop as the authors' experience accumulated and the technology evolved. The indication for ECLS was cardiac arrest in 68 patients and refractory cardiogenic shock in 13 patients. Thirty-five patients (43.2%) survived > 24 hrs after termination of ECLS, whereas 20 patients (24.7%) are long-term survivors (> 30 days). The ECLS system permitted an additional therapeutic surgical intervention in 45 cases. Patients who had a surgically remediable problem were more likely to survive. Prolongation of cardiopulmonary resuscitation beyond 30 mins before initiation of ECLS correlated with a decreased likelihood of survival.

HIV/AIDS in the context of culture: selection of ethnocultural communities for study in Canada.

This article reports on the methodology used to select six ethnocultural communities invited to participate in subsequent phases of the project on HIV/AIDS in the context of culture in Canada. Selection was based on quantitative data on demography, qualitative assessment of ethnocultural cohesion; and quantitative data and qualitative data of exposure to risk for sexually transmitted disease. A principle of partnership insured that the final selection was completed by interaction between the investigators and the National Advisory Committee representing ethnocultural communities in Canada. The six communities asked to participate in Phase II of the study were: in Montreal, the Latin American and the Arabic-speaking communities; in Toronto, the English-speaking Caribbean communities and communities from the Horn of Africa; in Vancouver, the Chinese and the South Asian communities. The results are significant for the future both of research on ethnicity in Canada and of control of HIV and AIDS.

Participatory aspects in the qualitative research design of phase II of the ethnocultural communities facing AIDS study.

This paper describes the steps taken in generating and implementing a qualitative research design for Phase II of the Ethnocultural Communities Facing AIDS Study. Theoretically framed by the macro-level, sociocultural model of health behaviour developed by Kleinman, the methodological procedures are an adaptation of Scrimshaw's Rapid Assessment Procedures (RAP) and a participatory approach involving stakeholders from each ethnocultural community. Qualitative data-on behaviours conducive to HIV transmission in six ethnocultural communities in Canada-were elicited using a combination of key communicator interviews, focus groups, and participant observation techniques. Data were analyzed using systematic content analysis techniques. Inter-rater reliability checks and procedures of triangulation demonstrated the validity of evidence generated. A commitment to research partnership with community persons, and an accountability loop that provided assurances of how the data would be scientifically represented, were critical elements in the process of design construction.

Overview of the Canadian study on the determinants of ethnoculturally specific behaviours related to HIV/AIDS.

Canada's population is composed of heterogenous ethnocultural communities. There is a need for information and educational initiatives on HIV and AIDS directed specifically at these communities. For such interventions to be effective we must determine the existing personal and sociocultural factors related to HIV transmission. There has been little such research in Canada. In this supplement we report on various aspects of a study conducted between May 1992 and December 1994 to determine the factors related to HIV transmission in several ethnocultural communities. This paper describes some innovative aspects of the project: the conceptual framework, the community participatory model, the use of a multi-method research design, and the ongoing communication strategy. The combination of these elements makes the study unique. The value of the study lies not only in the information obtained but also in the model it provides for future research in other settings.

Five conversations: reflections of stakeholders on the impact of the ethnocultural communities facing AIDS study.

This paper reports on issues identified in conversations held between one of the Ethnocultural Communities Facing AIDS Study (ECFA) investigators and five stakeholders associated with this experiment in collaborative and participatory research. The stakeholders reflect on their experiences in partnering with university-based researchers, resistance in ethnocultural communities to being researched, and the next steps implicated by the research in question. The problem of HIV/AIDS in ethnocultural communities in Canada is, relative to the mainstream, also viewed as a symbol of disadvantage in these communities. The stakeholders suggest that to address these deeper concerns, there must be vital, dynamic, and enduring communication between researchers, community representatives, and government at all levels, in the process of identifying solutions and implementing them in the present.

Many voices--sociocultural results of the ethnocultural communities facing AIDS study in Canada.

This paper presents the results of Phase II of the Ethnocultural Communities Facing AIDS Study, the sociocultural investigation of factors contributing to risk behaviour associated with HIV/AIDS in six ethnocultural communities in Canada in three urban sites. In Vancouver, the South Asian and Chinese communities were studied, the Horn of Africa and English-speaking Caribbean communities in Toronto and the Latin American and Arabic-speaking communities in Montreal. Results demonstrated that there are common elements across these ethnocultural communities that increase the risk for HIV transmission. HIV/AIDS awareness and prevention in ethnocultural communities must address sociocultural differences, particularly sex role differences between men and women in terms of power within relationships to negotiate for safer sexual practices.

Understanding use of condoms among Canadian ethnocultural communities: methods and main findings of the survey.

The aim of this study was to understand the intention to use a condom for each instance of sexual intercourse with a new partner in three of Canada's non-dominant ethnocultural communities: Latin American (N = 346), English-speaking Caribbean (N = 358), and South Asian (N = 355). All respondents were recruited from multiple ethnocultural venues using predetermined sampling frames and quotas for each community. Anonymous questionnaires assessing culturally specific theoretical constructs were completed. This paper presents the methodology and the main findings. The high quality of the results of this study demonstrate the advantage of establishing strong partnerships with members of communities being studied.

PIP: During April-May 1994, in Canada, 346 members of the Latin American community aged 18-49, 358 members of the English-speaking Caribbean community aged 16-49, and 355 members of the South Asian community aged 18-45 completed a questionnaire developed by the Research Group on Psychosocial Aspects of Health Behavior at Laval University in Quebec. This study aimed to identify the variables influencing intention to use a condom for each instance of sexual intercourse with a new partner in three nondominant ethnocultural communities. 81% of Latin Americans, 75% of the Caribbeans, and 71% of the South Asians intended to use a condom for each instance of sexual intercourse with a new partner during the next 3 months. Yet, among people who had had sex with a new partner in the last year, only 30% of Latin Americans, 28% of the Caribbeans, and 47% of South Asians always used a condom. Significant predictors of intent to use a condom in each instance of sexual intercourse with a new partner were personal normative belief (a measure of the personal feelings of moral obligation or responsibility to use or refuse to use a condom), perceived behavioral control, and role beliefs (p .0001). For the Latin American community, these three constructs explained 70.7% of the variance (partial R2 = 51.1% for personal normative belief, 10% for role beliefs, and 4.1% for perceived behavioral control). For the English-speaking Caribbean community, they explained 51% of the variance (partial R2 = 35.7% for personal normative belief, 11.9% for perceived behavioral control, and 3.5% for role beliefs). For the South Asian community, they accounted for 76% of the variance (partial R2 = 63.5% for perceived behavioral control, 9.4% for personal normative belief, and 3.1% for role beliefs). These findings serve as a basis for recommendations for the prevention of HIV transmission among the participating ethnocultural communities.

Canadian ethnocultural communities facing AIDS: overview and summary of survey results from phase III.

This paper describes the survey results reporting demographic profiles, behaviours, opinions, beliefs, attitudes, and intentions related to condom use for three Canadian ethnocultural communities (Latin American, English-speaking Caribbean and South Asian) participating in the Ethnocultural Communities Facing AIDS Study. Specific recommendations are presented for HIV-prevention programming based on the research results.

Adult respiratory distress syndrome: outcome in a community hospital.

BACKGROUND: Published reports indicate that survival rates of patients with adult respiratory distress syndrome have not improved dramatically since the first report of the condition in 1967. However, changes in ventilator strategies and improved critical care management may result in better survival rates in patients with well-defined, severe adult respiratory distress syndrome. OBJECTIVES: To report the outcomes of patients with adult respiratory distress syndrome treated in a community hospital and compare these findings with those in previously published reports. METHODS: A retrospective study design was used. All patients diagnosed with adult respiratory distress syndrome (N = 47) over a 2-year period were studied. RESULTS: For the study patients, the survival rate was 64%; 29% died from respiratory failure alone. Analysis demonstrated that advanced age was not associated with mortality. Pressure-control ventilation was used for 31 patients and there was no significant difference in the presence of barotrauma in the pressure-control mode vs volume ventilation. CONCLUSION: This survival rate exceeds most recently reported rates and thus supports the idea that improvement in treatment of adult respiratory distress syndrome is occurring.

Venovenous extracorporeal life support in traumatic bronchial disruption and adult respiratory distress syndrome using surface-heparinized equipment: case report.

Venovenous extracorporeal membrane oxygenation and carbon dioxide removal was utilized to support a patient with traumatic bronchial disruption and associated injuries. With use of surface-heparinized perfusion equipment, low levels of anticoagulation were maintained allowing surgical repair of the bronchial injury and recovery from acute respiratory failure without significant hemorrhage.