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Résumé:Dans cette étude transversale, on a mesuré l'étendue et la satisfaction de la collaboration entre les médecins et les infirmières praticiennes (IP) travaillant dans des maisons de soins de longue durée en Ontario. Des questionnaires, qui incluaient les instruments Mesure de Collaboration Courante et Satisfaction du Prestataire avec la Collaboration Courante, ont été envoyés par la poste aux IP et aux médecins avec qui les IP travaillent le plus fréquemment. La comparaison de 14 questionnaires appariés entre les IP et les médecins a démontré des niveaux de collaboration similaires. Cependant, les médecins étaient considérablement plus satisfaits avec la collaboration que les IP (z= -2.67, p= 0.008). La majorité des médecins (85%) et des IP (86%) ont indiqués que la collaboration se produisait et 96 pour cent des médecins et 79 pour cent des IP étaient satisfaits avec la collaboration. Environ un tiers des médecins ont indiqués que les IP ont eu un effet négatif sur leurs revenus mais leur satisfaction avec la collaboration n'a pas changée par rapport à ceux qui ont rapporté un effet positif. En général, ces médecins et ces IP collaborent dans la prestation des soins et sont satisfaits de leur collaboration.Abstract:This survey assessed the extent of and satisfaction with collaboration between physicians and nurse practitioners (NPs) working in Ontario long-term care homes. Questionnaires, which included the Measure of Current Collaboration and Provider Satisfaction with Current Collaboration instruments, were mailed to NPs and physicians with whom the NP most frequently worked. The 14 matched-pairs of NPs and physicians reported similar levels of collaboration; however, physicians were significantly more satisfied with collaboration than were NPs (z= -2.67, p= 0.008). The majority of physicians (85%) and NPs (86%) indicated that collaboration was occurring, and 96 per cent of physicians and 79 per cent of NPs were satisfied with their collaboration. About one third of physicians reported that the NP had a negative effect on their income, but their satisfaction with collaboration did not differ from those who reported a positive effect. Overall, these physicians and NPs collaborate in delivering care and are satisfied with their collaboration.

The core binding factor beta gene (CBFB), essential to bone morphogenesis, is located at 16q22.1. Homozygous deficiency of CBFB leads to ossification defects in mice. CBFB forms a heterodimer with RUNX2 (CBFA1) during embryonic bone development. RUNX2 mutations lead to cleidocranial dysplasia in humans. We describe an infant boy with an interstitial deletion of 16q21q22, delayed skull ossification, cleft palate, and heart anomalies who had a difficult course in infancy but eventually improved and is healthy. He was found to have CBFB haploinsufficiency, but did not have mutations in RUNX2. We suggest that 16q21q22 deletion be considered when there are antenatal or postnatal findings of enlarged cranial sutures with or without cleft palate. The finding of CBFB haploinsufficiency in our case and the similarity of cranial ossification defects with a mouse model of CBFB deletion suggest a role for CBFB in cranial bone development in humans. © 2006 Wiley‐Liss, Inc.

In the routine assessment of fetal anatomy, careful attention is paid to demonstrating the presence or absence of fetal anomalies. These may be isolated findings or part of a larger complex. The assessment is usually not performed with the thought of documenting the presence of a neoplastic lesion. Although rare, both benign and malignant neoplasms do occur in the fetus. This article demonstrates the level of detail that can be obtained with modern high-resolution ultrasound equipment in the assessment of fetal neoplasia. In some cases, such as with sacrococcygeal teratoma, the diagnosis can be made prenatally. In other instances, postnatal examinations are needed to confirm the diagnosis.

In the routine ultrasound assessment of fetal anatomy, care is taken to identify fetal anomalies that may occur as isolated abnormalities or as part of a larger, more complex syndrome of fetal anomalies. Many syndromes have been described in the literature, some of which can be identified by ultrasound. This article reviews the spectrum of fetal abnormalities that can be seen with modern high-resolution ultrasound equipment and that can be associated with such complex syndromes as trisomies 21, 18, and 13; triploidy; Turner syndrome; osteogenesis imperfecta; achondroplasia; and thanatophoric dwarfism.

Ultrasonography has become an integral part of obstetrics practice. However, the role of this modality differs over the course of the pregnancy. In the first trimester, the primary role of ultrasonography is to confirm the presence of a live intrauterine pregnancy. In the second trimester, ultrasonography is mainly employed to assess fetal anatomy. In the third trimester, the major role of ultrasonography is to assess fetal well-being. This article reviews the role of ultrasonography in the first trimester of pregnancy.

This study assesses the health-related quality-of-life (HRQL) effects of chorionic villi sampling (CVS) and genetic amniocentesis (GA), including both process and outcomes of prenatal diagnosis. The HRQL of 126 women participating in a randomized controlled clinical trial of CVS versus GA in Toronto and Hamilton, Ontario, was assessed in four interviews at weeks 8, 13, 18, and 22 of pregnancy. Statistical analyses included analysis of variance, repeated measures analysis of covariance, chi-square, Fisher's exact test, Student's t-tests, and paired t-tests. Utility scores for patients undergoing CVS exceeded those for GA patients at week 18 (p = 0.04). Utility scores for hypothetical health states did not differ significantly by trial arm. CVS results in slightly improved HRQL during prenatal diagnosis. This advantage needs to be weighed against the high disutility patients attach to infrequent outcomes associated with pregnancy losses, equivocal diagnoses, and diagnostic inaccuracy.

This pictorial review demonstrates the spectrum of fetal abnormalities that can be associated with fetal chromosomal abnormalities and identified using modern high-resolution ultrasound equipment. Abnormalities can be isolated or can occur as part of a complex of findings and include anomalies of the head, neck, face, cardiovascular system, abdomen, urinary tract, and musculoskeletal system. The most common chromosomal abnormalities encountered are Down syndrome, Turner syndrome, trisomies 18 and 13, and triploidy.

When attention is paid to the details of normal and abnormal fetal head and neck anatomy, abnormalities that normally would be missed at prenatal ultrasonography can routinely be diagnosed. Five basic views are used to assess the fetal head and neck: a transverse view of the head in the plane of the cavum septum pellucidum and cerebellum, a sagittal and a coronal view of the face to visualize the nose and lips, a sagittal view of the cervical spine, and a transverse view of the orbits to measure the biorbital and interorbital distances. Thickened nuchal fold, a common sign of Down syndrome, can be assessed with transverse images of the head. Transverse views are also useful to demonstrate cystic hygroma, occipital meningocele, and encephalocele, all of which can be associated with other severe anomalies. Micrognathia, cleft lip and palate, and macroglossia, which are best depicted with sagittal and coronal views of the face, are also associated with other fetal abnormalities. Visualization of these entities should prompt further search and amniocentesis. Lymphangioma of the tongue appears similar to macroglossia but is an isolated anomaly. Transverse views through the orbits are helpful for demonstrating orbital teratoma, orbital encephalocele, and hypo- and hypertelorism (the latter two being associated with other abnormalities). Sagittal views of the neck can demonstrate cystic hygroma, teratoma, and an enlarged thyroid.

Using nominal group process to develop a measure of quality of life, two groups of aphasic patients and a group of rehabilitation clinicians generated separate lists of important functional communication situations. Comparison of the lists by raters who were blind to their source revealed that the two patient lists were more similar to each other than were either of the patient lists to the clinician list; clinicians underestimate the patients' focus on social needs; patients, rather than clinicians, generated the more specific and concrete situations, which are of use in a quality-of-life measure. The study demonstrates that language-disabled adults can generate items for a quality-of-life measure (hence, this should be possible in almost anyother disease group), and that clinician-generated items are not fully representative of patient values.

Sixty nursing homes were randomly allocated to receive or not to receive a quality assurance intervention. The experimental intervention included the use of predeveloped quality assurance packages, the services of a quality assurance consultant, and the process of working through the quality assurance cycle with one of two principal indicator conditions. Two prevalent health problems, hazardous mobility and constipation, were selected as the principal indicator conditions. To detect co-intervention, one of two hidden secondary indicator conditions (potential skin breakdown and urinary incontinence) was assessed in each facility. In the control nursing homes, both the principal and secondary indicator conditions were hidden from staff. The care for 1,525 residents was examined before and after the intervention using a retrospective record review initiated for the study purposes. Improvement in management of the principal conditions, hazardous mobility and constipation, was greater in the experimental group (P< 0.03 and P< 0.005, respectively). Neither group changed its management of the hidden conditions. Behavior change was achieved using quality assurance-linked interventions. Further research should focus on refining quality assurance interventions that provide staff education and motivational strategies.

The majority of informal care providers for community-dwelling patients with Alzheimer's disease are members of the patient's family. Most family caregivers are predominantly women, usually the spouse or adult daughter of the patient. Care is provided principally by a single individual, the primary caregiver, with a number of other individuals, termed secondary caregivers, providing supplementary assistance. The burden or stress associated with caring for the Alzheimer's disease patient often is daunting. Although numerous attempts have been made to devise methods for assessing the burden on caregivers, precise measurement of the impact of caregiving is elusive. A framework that allows for recognition of the relationship among important variables in the evaluation of caregiver burden should include the elements of background and context of stress, the nature of stressors, mediating factors, and outcomes or manifestations of the stress.

In cancer care, as in all human services, increasing financial constraints have led to an emphasis on the identification and prioritization of needs. Qualitative studies directed at a broad examination of the psychosocial implications of surviving cancer have identified a number of problem areas for survivors. However, problem areas, although providing a firm base for further investigation, do not necessarily reflect the needs of survivors. Indeed, research designed to provide a rationale for the efficient disbursement of limited resources requires the specific quantitative identification of unmet needs, particularly those for which technologies and skills are sufficiently developed. The current study examined the needs of 362 adult patients from two distinct geographic areas in Ontario, Canada, who had received curative treatment for a malignancy not less than six months before the beginning of the study. In general, the frequency of survivors who expressed a need in any particular area was lower than expected on the basis of qualitative reports in the literature. Thus, although there is a general impression that the negative consequences of surviving cancer are frequent, the actual prevalence appears to be relatively low.

The objective of this study was to examine the physical and emotional health status, self-perceived problems, and needs of newly diagnosed cancer patients to determine and plan supportive care strategies. A cross-sectional survey of newly diagnosed cancer patients attending a regional cancer center during a 6-month period was performed. Patients with breast, colorectal, head and neck, lung, and prostate carcinoma as well as nonmelanoma of the skin were selected randomly. Patients were interviewed prior to their first appointment at the clinic. Physical health status was assessed using the Symptom Distress Scale, psychologic health status was assessed with the General Health Questionnaire (GHQ), day-to-day functioning with the Rapid Disability Scale, and social support with the modified Sarason's Social Support Scale. Perceived needs were assessed in a number of ways, including identification of patients' specific social concerns and informational needs, and by asking them to list their current problems or concerns. Of 156 eligible patients, 134 completed the interview. One hundred and twenty-nine patients (96%) reported current symptoms that included fatigue (66%), worried outlook (61%), difficulty sleeping (48%), and pain (42%). Forty-four patients (33%) were identified as psychologically distressed with a GHQ score of ≥ 6. One hundred and fourteen patients (85%) had informational needs, 89 (66%) indicated ≥ 1 social concerns, and 55 (41%) reported a need for assistance with day-to-day living. Patients with newly diagnosed cancer commonly report symptoms related to fatigue, pain, and psychologic distress. Other frequently reported issues relate to the need for information and social concerns regarding the patients' ability to take care of their home and maintain family and other relationships. Awareness of these issues is important for planning supportive care interventions for newly diagnosed cancer patients. Cancer 1997; 80:1518-24. © 1997 American Cancer Society.

A randomized trial of family caregiver support for the home management of older people suffering from moderate to severe progressive irreversible dementia was conducted in an urban center in southern Ontario. Thirty caregivers were allocated to receive the experimental intervention consisting of: caregiver‐focused health care, education about dementia and caregiving, assistance with problem solving, regularly scheduled in‐home respite, and a self‐help family caregiver support group. Thirty control subjects received conventional community nursing care. Before completion of the intervention, 18 (30%) were withdrawn, almost equally from each group. The most frequent reason was long‐term institutionalization of the demented relative (n = 10). At baseline, caregivers in both groups were suffering from above‐average levels of depression and anxiety. After the six‐month intervention period, we found neither experimental nor control group improved in these areas. However, the experimental group showed a clinically important improvement in quality of life, experienced a slightly longer mean time to long‐term institutionalization, found the caregiver role less problematic, and had greater satisfaction with nursing care than the control group.

Archie Cochrane stated in 1979 that “Of all medical specialties it is in obstetrics and gynaecology in which clinical practice is least likely to be supported by scientific evidence.” The gauntlet was, thus, thrown down. An international effort led by the National Perinatal Epidemiology Unit in Oxford, England sought to identify all randomized trials, completed, in progress, and planned in perinatal medicine. This led to the creation of the Oxford Database of Clinical Trials, and two landmark publications reviewing the evidence from these trials: Effective Care in Pregnancy and Childbirth, and A Guide to Effective Care in Pregnancy and Childbirth. This has also provided a model for the rest of medicine and has led directly to the international Cochrane Collaboration.

A Les phases latente et évolutive du travail sont définies.

The prevalence of urinary incontinence in different types of settings is reviewed. Some of the influences on the prevalence estimates are examined. Finally, methodologic issues that should be considered by clinicians reviewing the literature and by researchers are discussed.

The purpose of this study was to evaluate the extent to which a new patient information package (NPIP) or a mini version of the same package (mini-NPIP) reduces emotional distress and meets the informational needs of patients arriving at a tertiary cancer centre for the first time. A comprehensive package, NPIP, consisting of procedural information regarding cancer centre location, description of the health care team, treatment services, research, educational activities, accommodation and community services provided at the centre; and a condensed version of the same package, mini-NPIP, were developed. Consecutive patients with newly diagnosed breast, gynaecological, lung and prostate cancer, referred to the centre for the first time were prerandomised to receive NPIP, mini-NPIP or no information package. Patients randomised to NPIP or mini-NPIP were mailed the information package at least one week before their first appointment. On arrival at the centre, patients were administered the Brief Symptom Inventory (BSI) which measures psychological distress, and interviewed regarding preferences for information and acceptability of the information packages. Of 465 randomised patients, 161 were excluded post-randomisation and 304 completed the entire interview: 100 were randomised to the NPIP, 102 to the mini-NPIP and 102 to the control group. Emotional distress as measured by the BSI was similar for all groups (P = 0.98). Most patients preferred to receive the information (98%), receive it before the first appointment (84%) and by mail (79%). These preferences were more evident for those given the information packages. The majority of patients found the information packages easy to understand (88%) and useful (89%), and no differences were detected between packages. The cost of production and dissemination of NPIP was more than double the cost for mini-NPIP: $ 8.93 vs $ 3.98 (Canadian dollars) per patient. For patients presenting to a cancer centre for the first time, packages of procedural information do not appear to reduce psychological distress, but are preferred by patients. Given the cost of producing NPIP, mini-NPIP is the preferred approach.