Hospice care in Calgary: Survey of family physicians on their knowledge, experience, and attitudes.

OBJECTIVE: To explore Calgary family physicians' knowledge about hospices, their attitudes toward the referral process, and their understanding of barriers to referral for hospice care. DESIGN: Surveys were mailed to 400 randomly selected participants. The survey contained 18 questions related to hospice care, physician experience, attitudes, and perceived barriers to making a hospice referral. SETTING: Calgary, Alta. PARTICIPANTS: Family physicians. MAIN OUTCOME MEASURES: Survey responses were analyzed quantitatively using the (2) goodness-of-fit test, Kruskal-Wallis tests, and logistic regression analyses to examine univariate associations. Qualitative analysis of open-ended questions was done by content analysis and thematic coding. RESULTS: In total, 104 surveys were mailed back. Family physicians agreed that palliative care in a hospice setting can greatly improve quality of life for patients, but only 2 of 6 knowledge questions about hospice care were answered correctly by most. Family physicians with special areas of interest or subspecialties were more likely to feel well-informed about hospice referrals (P = .017), indicated a higher comfort level discussing hospice and palliative care (P = .030), and were less likely to defer discussing it with patients (P = .023). Physicians with a special interest in palliative medicine were more likely to correctly answer the knowledge questions (P < .034) and to be familiar with the referral process (P < .001), patient eligibility (P < .001), and the palliative home care program (P = .003). Qualitative analysis revealed support for palliative home care and consultation services but concerns about caregiver coping and family issues. Concerns about disengagement of family physicians and uncertainty about the referral process are obstacles to referral. CONCLUSION: While Calgary family physicians are appreciative of hospice care, there are knowledge gaps. It is important to engage family physicians in the referral process.

Vaginal birth after cesarean in California: before and after a change in guidelines.

PURPOSE: In 1999 the American College of Obstetricians and Gynecologists (ACOG) adopted more-restrictive guidelines for vaginal birth after cesarean delivery (VBAC). This study assesses trends in VBAC in California and compares neonatal and maternal mortality rates among women attempting VBAC delivery or undergoing repeat cesarean delivery before and after this guideline revision. METHODS: The 1996 through 2002 California Birth Statistical Master Files were used to identify 386,232 California residents who previously gave birth by cesarean delivery and had a singleton birth planned in a California hospital. RESULTS: Attempted VBAC deliveries decreased significantly from 24% before to 13.5% after guideline revision (P <.001). Neonatal mortality rates per 1,000 live births for attempted VBAC deliveries were not different from repeat cesarean delivery rates among neonates weighing > or =1,500 g in either the study periods 1996 to 1999 or 2000 to 2002. Neonatal mortality rates for attempted VBAC deliveries were higher for repeat cesarean deliveries among neonates weighing <1,500 g in the same periods (attempted VBAC: 1996-1999, 253.2; 95% Poisson confidence interval [CI], 197.7-308.6; 2000-2002, 336.8; CI, 254.3-419.4; repeat cesarean delivery: 1996-1999, 59.1; CI, 48.3-69.9; 2000-2002, 60.5, CI, 48.4-72.5). Maternal death rates per 100,000 live births for attempted VBAC deliveries were similar for both periods (1996-1999, 2.0; CI, 0.1-11.0; 2000-2002, 8.5; CI, 1.0-30.6). CONCLUSIONS: Neonatal and maternal mortality rates did not improve despite increasing rates of repeat cesarean delivery during the years after the ACOG 1999 VBAC guideline revision. Women with infants weighing > or =1,500 g encountered similar neonatal and maternal mortality rates with VBAC or repeat cesarean delivery.

Triage documentation-based decision support to improve infectious disease risk screening and mitigate exposure.

Multidisciplinary focus group review of current triage practice identified gaps in identification of potentially infectious diseases. Modifications were made to triage and nursing assessment forms that were easy to maneuver, rapidly modifiable, and provided documentation-based decision support to expedite infection prevention measures. Development of a decision support infectious disease risk screening tool enhances outbreak preparedness, occupational safety, and response.

Histopathologic examination to confirm diagnosis of periapical lesions: a review.

Most periapical lesions are represented by inflammatory cysts, granulomas, abscesses or fibrous scars. These inflammatory conditions are often termed "endodontic lesions" because pulpal necrosis is the initiating event in their pathogenesis. Although rare, other clinically confusing periapical lesions have been extensively documented in numerous case reports and short case series. These lesions represent a wide range of pathosis, including various developmental cysts, infections, benign but locally aggressive lesions, and malignancies. The literature describing these lesions and the value of a histopathologic examination in diagnosis is reviewed.