Social Isolation in Community-Dwelling Older Adults During COVID-19: Understanding the Role of Resilience.

The COVID-19 pandemic increased social isolation for many older adults, causing concern for their health and well-being. To enhance understanding of how community-dwelling older adults were impacted by prolonged social isolation during COVID-19, a qualitative descriptive study was conducted to: (1) explore the self-reported factors supporting their resilience during COVID-19 related social isolation, and (2) to help understand the intentional and unintentional outcomes of the government mandated health measures. A total of 19 community dwelling older adults were sampled. Factors that supported older adults' resilience during COVID-19 included maintaining positivity, drawing on historical experiences of resilience and finding opportunities to connect with their community. However, collective safety came with losses: such as time, freedom, opportunity, engagement, and initiative. The findings provide insight on contributing factors to resilience against social isolation in older adults and suggest the value of collective, community-based approaches to build resilience across variable contexts in this population.

Are phenome-wide association studies feasible in a developing country?

Phenome-wide association studies (PheWASs), a powerful approach that examines phenotypes associated with a genetic marker, have been used extensively in highly developed countries. Although there may be a clear need for PheWAS in a developing country such as the Philippines, limitations related to resources and practicality would make conducting them a challenge.

Importance of surgical assembly technique on the engagement of 12/14 modular tapers.

Fretting-corrosion at the modular taper junction in total hip replacements (THR), leading to implant failure, has been identified as a clinical concern and has received increased interest in recent years. There are many parameters thought to affect the performance of the taper junction, with the assembly process being one of the few consistently identified to have a direct impact. Despite this, the assembly process used by surgeons during THR surgery differs from a suggested 'ideal' process. For example, taper junctions of cutting tools should be pushed together rather than impacted, while ensuring as much concentricity as possible between the male and female taper and loading axis. This study devised six simple assembly methodologies to investigate how surgical variations affect the success of the compressive fit achieved at the taper interface compared to a controlled assembly method, designed to represent a more 'ideal' scenario. Key findings from this study suggest that a more successful and repeatable engagement can be achieved by quasi-statically loading the male and female taper concentrically with the loading axis. This was shown by a greater disassembly to assembly force ratio of 0.626 ± 0.07 when assembled using the more 'ideal' process, compared to 0.480 ± 0.05 when using a method closer to that used by a surgeon intraoperatively. Findings from this study can be used to help inform new surgical instrumentation and an improved surgical assembly method.

Dataset for the reporting of carcinoma of the bladder-cystectomy, cystoprostatectomy and diverticulectomy specimens: recommendations from the International Collaboration on Cancer Reporting (ICCR).

The International Collaboration on Cancer Reporting (ICCR) is a not for profit organisation whose goal is to produce standardised internationally agreed and evidence-based datasets for pathology reporting. With input from pathologists worldwide, the datasets are intended to be uniform and structured. They include all items necessary for an objective and accurate pathology report which enables clinicians to apply the best treatment for the patient. This dataset has had input from a multidisciplinary ICCR expert panel. The rationale for some items being required and others recommended is explained, based on the latest literature. The dataset incorporates data from the World Health Organization (WHO) 2016, and also from the latest (8th edition) TNM staging system of the American Joint Committee on Cancer (AJCC). Fifteen required elements and eight recommended items are described. This dataset provides all the details for a precise and valuable pathology report required for patient management and prognostication. This dataset is intended for worldwide use, and should facilitate the collection of standardised comparable data on bladder carcinoma at an international level.

Dataset for the reporting of urinary tract carcinoma-biopsy and transurethral resection specimen: recommendations from the International Collaboration on Cancer Reporting (ICCR).

The International Collaboration on Cancer Reporting (ICCR) is an alliance of major pathology organisations in Australasia, Canada, Europe, United Kingdom, and United States of America that develops internationally standardised, evidence-based datasets for the pathology reporting of cancer specimens. This dataset was developed by a multidisciplinary panel of international experts based on previously published ICCR guidelines for the production of cancer datasets. It is composed of Required (core) and Recommended (noncore) elements identified on the basis of literature review and expert consensus. The document also includes an explanatory commentary explaining the rationale behind the categorization of individual data items and provides guidance on how these should be collected and reported. The dataset includes nine required and six recommended elements for the reporting of cancers of the urinary tract in biopsy and transurethral resection (TUR) specimens. The required elements include specimen site, operative procedure, histological tumor type, subtype/variant of urothelial carcinoma, tumor grade, extent of invasion, status of muscularis propria, noninvasive carcinoma, and lymphovascular invasion (LVI). The recommended elements include clinical information, block identification key, extent of T1 disease, associated epithelial lesions, coexistent pathology, and ancillary studies. The dataset provides a structured template for globally harmonized collection of pathology data required for management of patients diagnosed with cancer of the urinary tract in biopsy and TUR specimens. It is expected that this will facilitate international collaboration, reduce duplication of effort in updating current national/institutional datasets, and be particularly useful for countries that have not developed their own datasets.

Long-term experiences of pain after a fragility fracture.

Little is known about long-term pain after a fragility fracture. In this secondary analysis, we determined that pain continues to influence many patients' lives more than 1 year after a fracture and that health care providers do not seem to adequately recognize or manage these long-term consequences. INTRODUCTION: We characterized perspectives on long-term pain among men and women who had sustained a fragility fracture. METHODS: We conducted a secondary analysis of qualitative data from 67 individuals recruited in three primary studies (47-89 years old; 55 women, 12 men). Eligible individuals from the primary studies were those who had reported pain related to their fracture beyond 6 months. Data about reported pain were re-analyzed using qualitative description as articulated by Sandelowski. RESULTS: Thirty-four individuals (47-89 years old; 4 men; 8 had sustained a vertebral fracture) reported pain related to their fracture in the primary studies. Thirty-one (91%) participants had sustained a fragility fracture at least 1 year previously (range 1-13 years). Patients described long-term pain beyond typical fracture healing times, generally unrelieved by analgesics, which affected their mobility, functional activity, independence, sleep, and energy. Health care providers were perceived to under-estimate timelines regarding the decrease of post-fracture pain and to not manage that pain. Participants reported that pain management was inadequate and that they developed their own strategies to respond to it. CONCLUSIONS: Pain continues to influence many patients' lives more than 1 year after a fragility fracture. Patient narratives could be useful to help health care providers to better recognize and manage this long-term consequence of fractures.

The role of family physicians in cancer care: perspectives of primary and specialty care providers.

BACKGROUND: Currently, the specific role of family physicians (fps) in the care of people with cancer is not well defined. Our goal was to explore physician perspectives and contextual factors related to the coordination of cancer care and the role of fps. METHODS: Using a constructivist grounded theory approach, we conducted telephone interviews with 58 primary and cancer specialist health care providers from across Canada. RESULTS: The participants-21 fps, 15 surgeons, 12 medical oncologists, 6 radiation oncologists, and 4 general practitioners in oncology-were asked to describe both the role that fps currently play and the role that, in their opinion, fps should play in the future care of cancer patients across the cancer continuum. Participants identified 3 key roles: coordinating cancer care, managing comorbidities, and providing psychosocial care to patients and their families. However, fps and specialists discussed many challenges that prevent fps from fully performing those roles: ■ The fps described communication problems resulting from not being kept "in the loop" because they weren't copied on patient reports and also the lack of clearly defined roles for all the various health care providers involved in providing care to cancer patients.■ The specialists expressed concerns about a lack of patient access to fp care, leaving specialists to fill the care gaps. The fps and specialists both recommended additional training and education for fps in survivorship care, cancer screening, genetic testing, and new cancer treatments. CONCLUSIONS: Better communication, more collaboration, and further education are needed to enhance the role of fps in the care of cancer patients.

Challenges and insights in implementing coordinated care between oncology and primary care providers: a Canadian perspective.

We report here on the current state of cancer care coordination in Canada and discuss challenges and insights with respect to the implementation of collaborative models of care. We also make recommendations for future research. This work is based on the findings of the Canadian Team to Improve Community-Based Cancer Care Along the Continuum (canimpact) casebook project. The casebook project identified models of collaborative cancer care by systematically documenting and analyzing Canadian initiatives that aim to improve or enhance care coordination between primary care providers and oncology specialists. The casebook profiles 24 initiatives, most of which focus on breast or colorectal cancer and target survivorship or follow-up care. Current key challenges in cancer care coordination are associated with establishing program support, engaging primary care providers in the provision of care, clearly defining provider roles and responsibilities, and establishing effective project or program planning and evaluation. Researchers studying coordinated models of cancer care should focus on designing knowledge translation strategies with updated and refined governance and on establishing appropriate protocols for both implementation and evaluation.

A prospective cohort study examining medical and social factors associated with engagement in life activities following total hip replacement.

OBJECTIVES: Studies show limited improvement in the frequency of engaging in life activities after joint replacement. However, there is a paucity of research that has examined factors, including other life events, which influence engagement following total hip replacement (THR). This research sought to identify factors associated with engaging in life activities following THR. METHODS: A prospective cohort study was conducted with 376 people who had a THR for osteoarthritis (OA). Data were collected pre-surgery and 1 year post-surgery. The primary outcome was change in frequency in engagement in life activities (Late Life Disability Index (LLDI): higher scores indicate higher frequency of engagement (range 0-80)). Analyses included multivariable regression. Factors considered included: positive/negative life events, a new comorbidity, another joint replacement and complications post-surgery. RESULTS: Participants' mean age was 64 years; 46% were male. 68% of participants had at least one comorbidity pre-surgery; 36% reported at least one new comorbidity after surgery. The mean change in LLDI frequency was an increase of 6.29 (±8.10). 36% reported one or more positive impact life events in the year following surgery; 63% reported one or more negative life events. The number of positive life events (beta = 1.24; 95% CI: 0.49, 1.99) was significantly associated with change in LLDI frequency after adjusting for age, sex, education, body mass index (BMI), comorbidities pre-surgery, number of symptomatic joints and pre-surgery pain and function, LLDI limitations and depression. CONCLUSIONS: These findings highlight the significant influence of social factors and life circumstances on engagement in life activities following THR.

Impact of psychological characteristics in self-management in individuals with traumatic spinal cord injury.

STUDY DESIGN: Cross-sectional survey. OBJECTIVE: To examine the association between psychological characteristics in self-management and probable depression status in individuals with a traumatic spinal cord injury (SCI). SETTING: Community-dwelling individuals with traumatic SCI living across Canada. METHODS: Individuals with SCI were recruited by email via the Rick Hansen Institute as well as an outpatient hospital spinal clinic. Data were collected by self-report using an online survey. Standardized questionnaires were embedded within a larger survey and included the Hospital Anxiety and Depression Scale (HADS), the short version of the Patient Activation Measure (PAM), the Moorong Self-Efficacy Scale (MSES) and the Pearlin-Schooler Mastery Scale (PMS). RESULTS: Individuals with probable depression (n=25) had lower self-efficacy (67.9 vs 94.2, P<0.0001), mastery (18.9 vs 22.9, P<0.0001) and patient activation (60.4 vs 71.6, P<0.0001) as well as higher anxiety (9.0 vs 5.5, P<0.0001), compared with their non-depressed counterparts (n=75). A logistic regression determined that lower self-efficacy and mastery scores as well as less time since injury were associated with depression status (P=0.002; P=0.02 and P=0.02, respectively). Individuals with higher anxiety scores were almost 1.5 times more likely to be depressed, while older age was positively associated with depression status (P=0.016 and P=0.024, respectively). CONCLUSION: Interventions for depression in SCI, including a self-management program, should target factors such as self-efficacy and mastery, which could improve secondary medical complications and overall quality of life.

Understanding why people do or do not engage in activities following total joint replacement: a longitudinal qualitative study.

OBJECTIVE: Numerous studies report large and significant improvements in basic mobility and activities of daily living following total hip or knee replacement (TJR). Nevertheless, quantitative research has shown minimal increase in participation in activities that benefit overall health. This study explored why people do or do not engage in activities following hip or knee TJR. METHOD: This was a longitudinal qualitative study. Sampling was guided by constructivist grounded theory and data collected using open-ended, semi-structured interviews. Participants were recruited using maximum variation sampling based on age, sex and joint replaced (hip or knee). Data were analysed using a constant comparative approach and coded for thematic patterns and relationships from which overarching themes were constructed. RESULTS: Twenty-nine patients participated in interviews prior to, and 8 and 18 months post following TJR. A high degree of variability with regard to participants' return to activities was found and five emergent themes were identified that accounted for this variability. These themes highlight the importance of issues beyond medical factors alone, such as socio-cultural factors that partially determine participants' participation in activity following TJR. CONCLUSION: Findings suggest that multi-faceted experiences impact participation in activity following TJR. These experiences include changes in identity and lifestyle that preclude a 'return to normal'. There is an urgent need for supports to increase people's activity post-TJR in order to facilitate enhancement of post-surgery levels of engagement. Approaches that take into consideration more personalized interventions may be critical to promoting healthy aging in people with TJR.

Non-pharmacological strategies used by patients at high risk for future fracture to manage fracture risk--a qualitative study.

UNLABELLED: We examined patients' self-management of bone health and fracture risk, particularly behaviors other than medication use and seeking diagnostic testing. Awareness of fracture risk was accompanied by positive lifestyle changes in participants' lives such as being careful. Future research should evaluate how lifestyle changes mitigate fracture risk. INTRODUCTION: We examined patients' understanding of bone health and self-management decisions regarding bone health and fracture risk, particularly behaviors other than medication use and seeking diagnostic testing. METHODS: A phenomenological (qualitative) study was conducted. English-speaking patients, 65+ years old, who were "high risk" for future fracture and prescribed pharmacotherapy after being screened through a post-fracture osteoporosis initiative were eligible. Patients were interviewed for 1-2 h and were asked to discuss perceptions of bone health status (bone densitometry results and perceived fracture risk), recommendations received for bone health, and lifestyle changes since their most recent fracture. We analyzed the data guided by Giorgi's methodology. RESULTS: We interviewed 21 fracture patients (6 males and 15 females), aged 65 to 88 years old. With the exception of one participant, all participants appeared to understand that they had low bone mass and were at risk of sustaining another fracture. Most participants (n = 20) were predominantly concerned about being careful, and they focused their responses on personal and environmental factors that they perceived to be modifiable. Participants also spoke about strategies to manage their bone health such as exercise, having a healthy diet and taking supplements, and using aids and devices. Non-pharmacological strategies used by patients appeared to be independent of current use of pharmacotherapy. CONCLUSIONS: Awareness of fracture risk was accompanied by a number of positive lifestyle changes in participants' lives such as being careful and engaging in exercise. Future research needs to evaluate how lifestyle changes such as being careful mitigate fracture risk.

A systematic review of surgical biopsy for LCIS found at core needle biopsy - do we have the answer yet?

BACKGROUND: The natural history of lobular carcinoma in-situ (LCIS) suggests that women are at increased risk of subsequent invasive breast cancer. Questions of effective management for women with this lesion have led to the need for evidence-based guidance and, in particular, guidance regarding management after LCIS is found at core needle biopsy (CNB). METHODS: A systematic review was conducted to determine the most appropriate management for women with LCIS found at CNB. A comprehensive search of the scientific literature was conducted to identify the literature pertaining to this population. Critical appraisal of the literature, data extraction and a narrative synthesis of the results were conducted. The outcome of interest was upgrade of diagnosis to invasive breast cancer or ductal carcinoma in-situ (DCIS). RESULTS: Sparse data, with limited generalisability and considerable uncertainty, are available for women with LCIS at CNB. Nine studies were identified that met pre-specified inclusion criteria. The reported estimates of upgrade of diagnosis from LCIS to invasive breast cancer or DCIS ranged from 2% to 25%. The body of evidence was limited by its retrospective nature, risk of selection bias and poor generalisability to all women with LCIS at CNB. Further, higher quality research is required to determine the best approach for women with LCIS at CNB with any certainty.

Factors predictive of immediate breast reconstruction following mastectomy for invasive breast cancer in Australia.

PURPOSE: To investigate person, cancer and treatment determinants of immediate breast reconstruction (IBR) in Australia. METHODS: Bi-variable and multi-variable analyses of the Quality Audit database. RESULTS: Of 12,707 invasive cancers treated by mastectomy circa 1998-2010, 8% had IBR. This proportion increased over time and reduced from 29% in women below 30 years to approximately 1% in those aged 70 years or more. Multiple regression indicated that other IBR predictors included: high socio-economic status; private health insurance; being asymptomatic; a metropolitan rather than inner regional treatment centre; higher surgeon case load; small tumour size; negative nodal status, positive progesterone receptor status; more cancer foci; multiple affected breast quadrants; synchronous bilateral cancer; not having neo-adjuvant chemotherapy, adjuvant radiotherapy or adjuvant hormone therapy; and receiving ovarian ablation. CONCLUSIONS: Variations in access to specialty services and other possible causes of variations in IBR rates need further investigation.

Moving balance and mobility evidence in to action: a primer in knowledge translation.

Knowledge generated by research into the control of posture and gait has many implications for individuals with balance and mobility impairments. Communicating such knowledge through conference presentations and peer-reviewed manuscripts is appropriate for some audiences, but does not effectively reach all potential knowledge users (for example: clinicians, policy-makers, and the public). Expanding interest in promoting evidence-based decision-making and practice to ensure that research results reach the target end-user has lead to the emergence of the field of knowledge translation (KT). The focus of KT is to improve the dissemination and uptake of knowledge in decision-making, and is grounded in a number of theoretical frameworks and its own rapidly expanding literature base. As many general principles of KT can be applied to the optimization of balance and mobility, the purpose of this review is to serve as a primer for gait and posture researchers. Two major models of KT are summarized: the National Institutes of Health (NIH) Roadmap and Knowledge-to-Action Framework. The principles outlined in these frameworks are applied to guidelines to assist researchers with developing their own evidence-based KT strategies. Examples of balance and mobility-specific KT activities are provided when appropriate, but there is a need for more studies that attempt to use evidence-based KT strategies to change practice in this particular field.

Randomized double-blind trial of beta-carotene and vitamin C in women with minor cervical abnormalities.

A double-blind, placebo-controlled, randomized, factorial study using a daily oral administration of 30 mg beta-carotene and/or 500 mg vitamin C was conducted in 141 women with colposcopically and histologically confirmed minor squamous atypia or cervical intra-epithelial neoplasia (CIN) I. Over approximately 2 years of follow-up, 43 lesions regressed to normal and 13 progressed to CIN II. The regression rate was slightly higher, but not significantly so, in those randomized to beta-carotene compared to no beta-carotene (hazard ratio = 1.58, 95% CI: 0.86-2.93, P = 0.14) and slightly lower, but not statistically significant, for those randomized to vitamin C compared to no vitamin C (hazard ratio = 0.65, 95% CI: 0.35-1.21, P = 0.17). In a model with no interaction, the progression rate was slightly higher in those randomized to beta-carotene (hazard ratio = 1.75, 95% CI: 0.57-5.36, P = 0.32) and also in those randomized to vitamin C (hazard ratio = 2.40, 95% CI: 0.74-7.80, P = 0.13). Neither of these were statistically significant. However, there was some evidence of an interaction effect of the two compounds on the progression rate (P = 0.052), with seven of the progressed lesions occurring in those randomized to both vitamins compared to a total of six in the three other groups. The currently available evidence from this and other trials suggests that high doses of these compounds are unlikely to increase the regression or decrease the progression of minor atypia and CIN I.

DRG cost weights--getting it right.

Inadequate cost weights are a major problem in casemix funding systems. Clinicians should understand the basis for the cost weights underpinning the hospital payment system in their State and their own hospital. Clinician managers need valid patient costing data if they are to benchmark and improve cost-effectiveness while maintaining and enhancing quality. The cost model approach for determining cost weights has inherent limitations, and, the alternative, detailed patient costing, requires efficient hospital information technology systems. A simplified approach to patient costs, which uses existing hospital data systems, may be useful for smaller hospitals. A better classification system and funding formulas incorporating reliable cost weights derived from patient costing should overcome many of the deficiencies in the current casemix payments systems.

Surgeons' opinions about the NHMRC clinical practice guidelines for the management of early breast cancer.

OBJECTIVE: To explore the opinions of surgeons about the NHMRC clinical practice guidelines for the management of early breast cancer (the Guidelines) and their views about and use of the accompanying Consumer's guide. DESIGN: Cross-sectional telephone survey. PARTICIPANTS AND SETTING: Surgeons throughout Australia who manage breast cancer, designated as "breast" or "general" (members or non-members of the Royal Australasian College of Surgeons' Section of Breast Surgery) and "urban" or "rural". RESULTS: Among 150 respondents (64% response rate) more than 80% of surgeons reported having read all or most of the Guidelines and believed they were useful in improving women's management and wellbeing, easy to understand, evidence-based, a good summary of recent evidence, and that they would assist agreement between women and healthcare providers. Surgeons agreed with most of the recommendations in the Guidelines, but 26% disagreed that "women should ideally be treated by a specialist who treats a large number of similar patients and who has access to the full range of treatment options in a multidisciplinary setting". In terms of medicolegal implications, 41% believed that the Guidelines would protect clinicians, while, of the 37% of surgeons who believed that they would expose doctors to increased problems, significantly more breast than general surgeons believed this (50% v. 19%; P < 0.001). Only 37% of surgeons routinely gave the Consumer's guide to all or more than half their patients. CONCLUSIONS: Surgeons are generally positive about the Guidelines, but certain issues should be addressed if they are to be optimally implemented, including confusion about the medicolegal implications, perceived difficulties with providing multidisciplinary care and poor use of the Consumer's guide.