Cancer prevention in cancer predisposition syndromes: A protocol for testing the feasibility of building a hereditary cancer research registry and nurse navigator follow up model.

Monogenic, high penetrance syndromes, conferring an increased risk of malignancies in multiple organs, are important contributors to the hereditary burden of cancer. Early detection and risk reduction strategies in patients with a cancer predisposition syndrome can save their lives. However, despite evidence supporting the benefits of early detection and risk reduction strategies, most Canadian jurisdictions have not implemented programmatic follow up of these patients. In our study site in the province of Newfoundland and Labrador (NL), Canada, there is no centralized, provincial registry of high-risk individuals. There is no continuity or coordination of care providing cancer genetics expertise and no process to ensure that patients are referred to the appropriate specialists or risk management interventions. This paper describes a study protocol to test the feasibility of obtaining and analyzing patient risk management data, specifically patients affected by hereditary breast ovarian cancer syndrome (HBOC; BRCA 1 and BRCA 2 genes) and Lynch syndrome (LS; MLH1, MSH2, MSH6, and PMS2 genes). Through a retrospective cohort study, we will describe these patients' adherence to risk management guidelines and test its relationship to health outcomes, including cancer incidence and stage. Through a qualitative interviews, we will determine the priorities and preferences of patients with any inherited cancer mutation for a follow up navigation model of risk management. Study data will inform a subsequent funding application focused on creating and evaluating a research registry and follow up nurse navigation model. It is not currently known what proportion of cancer mutation carriers are receiving care according to guidelines. Data collected in this study will provide clinical uptake and health outcome information so gaps in care can be identified. Data will also provide patient preference information to inform ongoing and planned research with cancer mutation carriers.

Cesarean delivery rates among family physicians versus obstetricians: a population-based cohort study using instrumental variable methods.

BACKGROUND: Previous research suggests that family physicians have rates of cesarean delivery that are lower than or equivalent to those for obstetricians, but adjustments for risk differences in these analyses may have been inadequate. We used an econometric method to adjust for observed and unobserved factors affecting the risk of cesarean delivery among women attended by family physicians versus obstetricians. METHODS: This retrospective population-based cohort study included all Canadian (except Quebec) hospital deliveries by family physicians and obstetricians between Apr. 1, 2006, and Mar. 31, 2009. We excluded women with multiple gestations, and newborns with a birth weight less than 500 g or gestational age less than 20 weeks. We estimated the relative risk of cesarean delivery using instrumental-variable-adjusted and logistic regression. RESULTS: The final cohort included 776 299 women who gave birth in 390 hospitals. The risk of cesarean delivery was 27.3%, and the mean proportion of deliveries by family physicians was 26.9% (standard deviation 23.8%). The relative risk of cesarean delivery for family physicians versus obstetricians was 0.48 (95% confidence interval [CI] 0.41-0.56) with logistic regression and 1.27 (95% CI 1.02-1.57) with instrumental-variable-adjusted regression. INTERPRETATION: Our conventional analyses suggest that family physicians have a lower rate of cesarean delivery than obstetricians, but instrumental variable analyses suggest the opposite. Because instrumental variable methods adjust for unmeasured factors and traditional methods do not, the large discrepancy between these estimates of risk suggests that clinical and/or sociocultural factors affecting the decision to perform cesarean delivery may not be accounted for in our database.

A Review of Effective Youth Engagement Strategies for Mental Health and Substance Use Interventions.

The majority of adult mental health and substance use (MH&SU) conditions emerge in adolescence. Prevention, diagnosis, and treatment programs targeting this age group have a unique opportunity to significantly impact the well-being of the future generation of adults. At the same time, youth are reluctant to seek treatment and have high rates of dropout from interventions. An emphasis on youth engagement in prevention and treatment interventions for MH&SU results in better health outcomes for those youth. This literature review was undertaken to evaluate opportunities to improve youth engagement in MH&SU programs. The intent was to determine best practices in the field that combined community-level improvement in clinical outcomes with proven strategies in engagement enhancement to inform program development at a local level. The results discuss 40 studies, reviews, and program reports demonstrating effective youth engagement. These have been grouped into six themes based on the underlying engagement mechanism: youth participation in program development, parental relationships, technology, the health clinic, school, and social marketing. A broad range of tools are discussed that intervention developers can leverage to improve youth engagement in prevention or treatment programs.

Family practice versus specialist care for low-risk obstetrics: examining patient satisfaction in Newfoundland and Labrador.

OBJECTIVE: To investigate patient satisfaction with 3 models of low-risk obstetrics care: solo care by a GP, group care by GPs, and specialist care. DESIGN: Three-arm study comparing results of a self-administered, anonymous questionnaire. SETTING: Two academic family practices and the labour and delivery ward in St John's, Nfld. PARTICIPANTS: A total of 220 women deemed to have low-risk pregnancies; 82 women completed the questionnaire (37% response rate). MAIN OUTCOME MEASURES: Patient satisfaction scores obtained from a modified version of the Patient Expectations and Satisfaction with Prenatal Care instrument. RESULTS: Low-risk maternity patients' satisfaction with obstetric care provided by GPs in a group-care setting was equivalent to that with obstetric care provided by GPs working solo and greater than that with obstetric care provided by specialists. CONCLUSION: Patients found that group care by GPs was an acceptable means of receiving obstetric services in a low-risk setting. Therefore, a group practice model might provide an attractive means for FPs to keep obstetrics within the scope of primary care.

Effect of the position of the meiotic spindle on the outcome of intracytoplasmic sperm injection.

The position of the meiotic spindle in relation to the injection site has been a matter of concern since intracytoplasmic sperm injection (ICSI) was developed. Disruption of the spindle may result in cell death or aneuploidy, and it is therefore essential to avoid injecting directly into the area of the spindle. Before the development of the PolScope, it was only possible to visualize the spindle after fixing and staining oocytes. The PolScope allows the spindle to be visualized in living oocytes, and thus their subsequent development can be followed. Studies have shown that the spindle is not, as had been assumed, always adjacent to the polar body. However, the proportion of oocytes in which the spindle is significantly displaced is low, and the displacement is not necessarily associated with poor oocyte and embryo development. Even oocytes in which no spindle is visualized may go on to fertilize and develop normally, and the evidence indicates that disruption of the spindle is not a significant factor in determining the likelihood of aneuploidy and developmental anomalies. Indeed, it has been suggested that injecting spermatozoa closer to the site of the spindle may in fact improve the outcome.