Understanding lesbians' healthcare behaviour: the case of breast self-examination

Lesbians' risk of breast cancer is a much-debated issue in health research because lesbians are believed to be at higher risk of the disease than are heterosexual women. This belief is based upon particular risk factors for breast cancer, which are said to be more prevalent in lesbians; and upon differences in preventive health behaviours: in particular, lesbians are said to be less likely to practise breast self-examination (BSE). This paper presents data collected as part of the UK Lesbians and Healthcare Survey (n = 1066) focusing on lesbians who report never practising BSE (n = 218, 20%) and the explanations they offer for their healthcare behaviours. It identifies six types of explanation for not practising BSE: (i) "I don't know what I'm looking for"; (ii) "I've never got into the habit"; (iii) "I'm frightened in case I find something"; (iv) "I don't think I'm at much risk"; (v) "I'm uncomfortable with my body"; and (vi) "My partner does it for me". These findings are important for increasing understanding of lesbians' healthcare behaviour and for developing health promotion materials relevant to their needs.

Communication skills training for health care professionals working with cancer patients, their families and/or carers

BACKGROUND

Research suggests communication skills do not reliably improve with experience and considerable effort is dedicated to courses improving communication skills for health professionals. The evaluation of such courses is of importance to enable evidence-based teaching and practice.

OBJECTIVES

To assess whether communication skills training is effective in changing behaviour of health professionals in cancer care with regard to communication/interaction with patients.

SEARCH STRATEGY

We searched CENTRAL (Cochrane Library Issue 3 2001), MEDLINE (1966 to November 2001), EMBASE (1980 to November 2001), PsycInfo (1887 to November 2001), CINAHL (1982 to November 2001), AMED (1985 - October 2001), Dissertation Abstracts International (1861 to March 2002) and EBM Reviews (1991 to March/April 2001). Reference lists of relevant articles were searched.

SELECTION CRITERIA

Randomized controlled trials or controlled before and after studies of communication skills training in cancer health professionals, measuring changes in behaviour/skills using objective and validated scales.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Although 2822 references were considered, only two trials involving 232 health professionals were included. One provided an intensive three-day course then assessed oncology doctors interacting with a total of 640 patients; the other provided a modular course then used role plays with oncology nurses for skill assessment. In one trial, course attendees used more focused questions (34% increase, probability < 0.005), focused and open questions (27% increase, p = 0.005), expressions of empathy (69% increase, p < 0.005) and appropriate responses to cues (38% increase, p < 0.05) at follow up than non-attendees. No significant differences were found between attendees and non-attendees in use of leading questions. From baseline to follow up in the same study, attendees had significantly different changes in rates of leading questions (relative risk 0.72, p < 0.05), focused questions (Relative Risk 1.25, p < 0.005), open questions (RR 1.17, p < 0.05) and empathy (RR 1.50, p = 0.005). The only significant difference in observed communication skills in the second trial was that the trained group were more in control of the follow-up interview than the untrained group (p < 0.05). Both studies investigated differences in summarising, interrupting and checking but found none.

REVIEWER'S CONCLUSIONS

The training programmes assessed by these trials appear to be effective in improving cancer care professionals communication skills. It is not known whether the training would be effective if taught by other educators, nor has any trial compared the efficacy of both programmes.

Magnitude of microelectrode refinement in pallidotomy and thalamotomy

The relative accuracy of starting point algorithms in microelectrode-guided stereotactic pallidotomy and thalamotomy was evaluated using postoperative magnetic resonance imaging (MRI) data. Multiplanar reformations were performed to align postoperative MRI in anterior-posterior, dorsal-ventral and mediolateral planes. Three-dimensional distance and direction from the pallidal and thalamic stereotactic starting points to the respective radiofrequency lesions were measured. Similar magnitude of microelectrode refinement in pallidotomy and thalamotomy suggested similar accuracy of algorithms used to set the stereotactic starting point. Fewer microelectrode-recording tracts were required to identify optimal lesioning sites in thalamotomy compared to pallidotomy. Lesions were consistently localized anterior and superior to the starting point and a refined starting point algorithm may reduce the number of microelectrode recording tracts.

Compliance testing of medical diagnostic x-ray equipment: three years' experience at a major teaching hospital in Western Australia

The impact of a formal compliance testing program has been evaluated three years post-implementation on a major teaching hospital (Sir Charles Gairdner Hospital) with 46 x-ray tubes located throughout 37 rooms. The mandatory program, implemented by the statutory authority in January 1997, called for all medical (including chiropractic and dental) equipment used in human diagnosis to be tested at prescribed frequencies using established protocols. The application of the required test methods demonstrated various non-compliance issues. Notices of non-compliance were received for approximately 60% of the equipment in the hospital following the equipment's first annual test. The reasons for, and the significance of, failure varied according to equipment category, test category, equipment use and equipment age. However, at the end of the third year of testing, approximately 75% of the tested x-ray units satisfied the compliance criteria. The main reasons for non-compliance were found to be design limitations of old technology and the current radiation legislation that makes it difficult for some older equipment to meet the relatively stringent criteria.

ABA-based chemical signalling: the co-ordination of responses to stress in plants

There is now strong evidence that the plant hormone abscisic acid (ABA) plays an important role in the regulation of stomatal behaviour and gas exchange of droughted plants. This regulation involves both long-distance transport and modulation of ABA concentration at the guard cells, as well as differential responses of the guard cells to a given dose of the hormone. We will describe how a plant can use the ABA signalling mechanism and other chemical signals to adjust the amount of water that it loses through its stomata in response to changes in both the rhizospheric and the aerial environment. The following components of the signalling process can play an important part in regulation: (a) ABA sequestration in the root; (b) ABA synthesis versus catabolism in the root; (c) the efficiency of ABA transfer across the root and into the xylem; (d) the exchange of ABA between the xylem lumen and the xylem parenchyma in the shoot; (e) the amount of ABA in the leaf symplastic reservoir and the efficiency of ABA sequestration and release from this compartment as regulated by factors such as root and leaf-sourced changes in pH; (f) cleavage of ABA from ABA conjugates in the leaf apoplast; (g) transfer of ABA from the leaf into the phloem; (h) the sensitivity of the guard cells to the [ABA] that finally reaches them; and lastly (i) the possible interaction between nitrate stress and the ABA signal.

How best to support bereaved children

A recommendation arising from a recent conference on child bereavement was that specific services and interventions should be developed for such children. Yet, in the current climate of evidence-based practice, it is not clear how such a recommendation can be justified.

Rapid low temperature-induced stomatal closure occurs in cold-tolerant Commelina communis leaves but not in cold-sensitive tobacco leaves, via a mechanism that involves apoplastic calcium but not abscisic acid

Commelina communis stomata closed within 1 h of transferring intact plants from 27 degrees C to 7 degrees C, whereas tobacco (Nicotiana rustica) stomata did not until the leaves wilted. Abscisic acid (ABA) did not mediate cold-induced C. communis stomatal closure: At low temperatures, bulk leaf ABA did not increase; ABA did not preferentially accumulate in the epidermis; its flux into detached leaves was lower; its release from isolated epidermis was not greater; and stomata in epidermal strips were less sensitive to exogenous ABA. Stomata of both species in epidermal strips on large volumes of cold KCl failed to close unless calcium was supplied. Therefore, the following cannot be triggers for cold-induced stomatal closure in C. communis: direct effects of temperature on guard or epidermal cells, long-distance signals, and effects of temperature on photosynthesis. Low temperature increased stomatal sensitivity to external CaCl(2) by 50% in C. communis but only by 20% in tobacco. C. communis stomata were 300- to 1,000-fold more sensitive to calcium at low temperature than tobacco stomata, but tobacco epidermis only released 13.6-fold more calcium into bathing solutions than C. communis. Stomata in C. communis epidermis incubated on ever-decreasing volumes of cold calcium-free KCl closed on the lowest volume (0.2 cm(3)) because the epidermal apoplast contained enough calcium to mediate closure if this was not over diluted. We propose that the basis of cold-induced stomatal closure exhibited by intact C. communis leaves is increased apoplastic calcium uptake by guard cells. Such responses do not occur in chill-sensitive tobacco leaves.

System validation and work practice efficiency gains of a new localization method for stereotactic radiotherapy

The increased procedural demands of stereotactic localization techniques when compared with conventional treatment practices reduces machine efficiency, an outcome likely to be greatly magnified by the introduction of fractionation to stereotactic techniques. Currently in Australia and New Zealand there are no guidelines for the definition of efficiency. We sought to devise a system to simultaneously validate the accuracy and efficiency of the technique. The frameless relocation methods employed in the Medtronic Sofamor Danek (MSD) stereotactic radiotherapy (SRT) system were studied in the clinical setting. Accuracy has been determined according to the accumulation of errors throughout the planning and treatment process. The clinical demands of the system (staffing and resources) were analysed relative to conventional treatment approaches. Timing studies indicate a mean time of 19.7 min for treatment of a daily SRT fraction (4-5 arcs, single isocentre). Cost and staffing requirements are similar to those for conventional radiotherapy. It is concluded that with the system used, SRT is efficient for routine clinical implementation, with the level of efficiency increasing with increasing patient numbers. It is recommended that a common acceptance standard be developed to allow cross-institutional comparison of the clinical efficiency of new treatment techniques.

Congress shows changing face of palliative care

The 7th congress of the European Association for Palliative Care in Palermo, Sicily offered not only a break from the dismal British weather, but also a snapshot of the current state of palliative care in Europe and beyond. The picture presented was of a healthy, mature and confident discipline, which can encompass professionals from a wide range of backgrounds: medicine, nursing, social care, pastoral care. Over 450 posters and 260 presentations highlighted the diversity of palliative care practice, which perhaps more than any other specialty reflects the prevailing views of society in the country in which it is practised. Nowhere is this more obvious than in the ethics of palliative care.

Commodification arguments for the legal prohibition of organ sale

The commercial trading of human organs, along with various related activities (for example, advertising) was criminalised throughout Great Britain under the Human Organ Transplants Act 1989. This paper critically assesses one type of argument for this, and similar, legal prohibitions: commodification arguments. Firstly, the term 'commodification' is analysed. This can be used to refer to either social practices or to attitudes. Commodification arguments rely on the second sense and are based on the idea that having a commodifying attitude to certain classes of thing (e.g. bodies or persons) is wrong. The commodifying attitude consists of three main elements: denial of subjectivity, instrumentality, and fungibility. Secondly, in the light of this analysis, the claim that organ sale involves commodifying the human body is examined. This claim is found to be plausible but insufficient to ground an argument against organ sale, because the very same commodifying attitude is likely to be present in cases of (unpaid) organ donation. It is also argued that commodifying bodies per se may not be wrong. Thirdly, the view that organ sale involves commodifying persons is examined. Although this and the claim that it is wrong to commodify persons are probably true, there is--it is argued--little reason to regard organ sale as worse in this respect than other widely accepted practices, such as the buying and selling of labour. The conclusion is that although commodification is a useful ethical concept and although commodification arguments may sometimes be successful, the commodification argument against organ sale is not persuasive. This is not to say, though, that there are no arguments for prohibition--simply that this particular justificatory strategy is flawed.

Comparisons between a pencil beam and two fan beam dual energy X-ray absorptiometers used for measuring total body bone and soft tissue

A pencil beam Hologic QDR 1000W scanner (1000), a fan beam QDR 4500A scanner (4500) and a fan beam Lunar Expert scanner (Expert) were compared for bone mineral and body composition measurement accuracy. Phantoms were scanned with each instrument to assess magnification effects and to compare calibrations for bone mineral and fat proportion. 41 volunteers were scanned with both the 1000 and the 4500, and 21 patients with both the 4500 and the Expert. The height of a bone within the body affected the measured bone mineral content (BMC) and, to a lesser extent, the bone mineral density (BMD). There were differences in calibration against recognized standards for fat proportion between the three instruments. The 1000 underestimated low fat proportions and the 4500 underestimated high fat proportions. Fat results for the Expert were closer to nominal values. Comparisons on volunteers showed that measured mean total body BMD was 4% higher and BMC was 7% higher with the 1000 compared with the 4500; some regional differences were greater. Mean values of per cent fat were equal, but the total and regional regression coefficients were well above unity. Mean BMD was 3% higher and mean BMC was 10% higher with the Expert compared with the 4500, but most regression coefficients for these comparisons were less than unity. Mean values of per cent fat were equal, but regression coefficients were above unity. Errors due to magnification are acceptable. Differences between the instruments are appreciable, but can be accommodated by cross-calibration.

Introduction and implementation of the basic treatment equivalent in a Varian-based department

The increasing popularity of 3-D planning leads to procedural alterations as both workload and resource utilization increase. Although the complexity of the techniques has increased (as well as the set-up and treatment times), the workload statistics must still include the number of fields treated. It is commonly known that machine statistics of fields treated per day do not accurately represent workload because there are major differences between techniques. A mantle treatment technique and an opposed spine technique both have (statistically) two fields, although the set-up requirements and treatment times are very different. A basic treatment equivalent (BTE) formula was reported in early 1999 by Delaney et al. and incorporates a large number of variables inherent in patient treatment. The formula considers different factors that affect overall treatment time, and aims to represent a more accurate treatment time indicator. The aim of introducing the BTE into the Department of Radiation Oncology at Sir Charles Gairdner Hospital was to create a more accurate scheduling system and even out workloads on all treatment units. Therefore the BTE formula was used to assess accuracy of treatment times in order to determine if the values could be relied upon as accurate time indicators. Patients undergoing a variety of treatment techniques were timed for the duration of their treatment procedure, and their treatment times compared to the time estimated using the BTE formula. A few minor alterations were made to the equation for treatment units with multi-leaf collimation (MLC). A trial conducted at Sir Charles Gairdner Hospital found that, using the BTE formula (with a few modifications required for the MLC treatment units), of 60 patients timed for the duration of their set-up and treatment, 85% of values were in the range of +/- 3 min, and 95% were in the range of +/- 5 min of the estimated times. Through the routine use of the BTE equation a more sensitive indication of treatment machine workload can be found. Advantages such as: (i) a more accurate measure of treatment workload (for comparison with other departments) and (ii) increased scheduling accuracy will succeed over the currently accepted system of fields per hour.

The nurses' voice is heard

During the last decade, nurses in the United Kingdom have demonstrated how visionary they can be and how they can influence the standard of care that patients with cancer and their families receive. Standards of Care for Cancer Nursing (Royal College of Nursing Cancer Nursing Society (RCN CNS), 1991) was an innovative document that encapsulated cancer nurses’ belief that cancer is a chronic or life-threatening disease that is a major health problem in our society. It emphasized the leading role that nurses play in all cancer settings, from health promotion to palliative care. It outlined the standards of care a patient should expect to receive, particularly in the areas of information, family care, psychological care, symptom control, prevention and continuity of nursing care. Furthermore, it emphasized that high standards of nursing care would only be achieved if an ongoing assessment of individuals’ needs, detailed planning and an evaluation of care and support were considered routine care.

Comparison of actual pallidotomy lesion location with expected stereotactic location

Accuracy of pallidotomy lesion placement was assessed by comparing actual lesion locations with expected pallidotomy lesion locations based on stereotaxy. Actual and expected lesions were compared in anteroposterior, dorsoventral and lateral axes. In 22 pallidotomies, actual lesion locations were determined using axial MR images. Expected lesion locations were calculated using a starting point derived from preoperative computerized tomography, displacements from the starting point based on microelectrode-driven electrophysiological refinement, and the trajectory angle of the lesioning tract relative to the anterior-posterior commissural plane. On average, actual lesion locations were found 2.91 +/- 2.23 mm posterior, 3.22 +/- 2.49 mm ventral, and 0.05 +/- 1.80 mm lateral compared to the expected lesion location. Discrepancies between the actual lesion and expected lesion locations may be mostly accounted for by posterior and ventral lesion spread from the exposed electrode tip, in-plane and volume averaging effects associated with MR images, and possible brain shifting during surgery. However, despite the remaining small differences between actual and expected lesion location, good clinical outcome of reduced dyskinesias and 'off' time along with UPDRS-based improvement in mentation, motor and activity of daily living measures was observed.

Fulfilling patients' wishes: palliative care at home

As the ageing population increases, a major dilemma for palliative care service provision in the United Kingdom over the next century will be where patients are cared for. Historically, palliative care has been provided by hospices, but it is now recognized that patients wish to be cared for and die at home.

Thinking differently about thinking positive: a discursive approach to cancer patients' talk

There is an extensive social science and psycho-oncology literature on coping with cancer which claims that "thinking positive" is correlated with--and, by extension, causally implicated in--individuals' morbidity and mortality rates, and their overall level of mental health. Drawing on our own data, in which groups of women with breast cancer talk about "thinking positive", this paper interrogates the basis of such claims from a discursive perspective, by challenging the data analyses upon which they are based. We show that previous literature overwhelmingly relies on self-report data, which are taken as offering more or less accurate depictions of speakers' psychological states (i.e. their mental adjustment or coping style). A discursive approach, by contrast, explores talk as a form of action designed for its local interactional context, and pays detailed attention to what statements about "thinking positive" actually mean for speakers in the contexts in which they occur. We show that "thinking positive" functions not as an accurate report of a internal cognitive state, but rather as a conversational idiom, characterised by vagueness and generality, and summarising a socially normative moral requirement; we also show that even those breast cancer patients who report "thinking positive" can also actively resist its moral prescriptions. Finally, we sketch out the implications of our analysis for analyses of cancer patients' talk more generally and for future research on coping with cancer.

Pallidotomy microelectrode targeting: neurophysiology-based target refinement

OBJECTIVE

Microelectrode recording can refine targeting for stereotactic radiofrequency lesioning of the globus pallidus to treat Parkinson's disease. Multiple intraoperative microelectrode recording/stimulating tracks are searched and assessed for neuronal activity, presence of tremor cells, visual responses, and responses to kinesthetic input. These physiological data are then correlated with atlas-based anatomic data to approximate electrode location. On the basis of these physiological properties, one or more tracks are selected for lesioning. This study analyzes the track physiological factors that seem most significant in determining the microelectrode recording track(s) that will be chosen for pallidal lesioning.

METHODS

Thirty-six patients with Parkinson's disease underwent microelectrode-guided pallidotomy. Between one and five microelectrode recording tracks were made per patient. Usually, one (n = 23) or two (n = 12) of these tracks were lesioned. Electrode positions in the x (mediolateral) and y (anteroposterior) axes were recorded and related to track neurophysiological findings and final lesion location. The stereotactic location and sequence of microelectrode tracks were recorded and plotted to illustrate individual search patterns. These patterns were then compared with those noted in other patients. Neurophysiological data obtained from recording tracks were analyzed. A retrospective analysis of track electrophysiology was performed to determine the track characteristics that seemed most important in the surgeon's choice of the track to lesion. Track physiological properties included general cell spike amplitude, tremor synchronous neuronal firing, kinesthetically responsive neuronal firing, and optic track responses (either phosphenes reported by the patient during track microstimulation or neuronal firing in response to light stimulus into the patient's eyes). Orthogonally corrected postoperative magnetic resonance images were used to confirm the anatomic lesion locations.

RESULTS

In patients who had a single mapped track lesioned, specific track electrophysiological characteristics identified the track that would be lesioned most of the time (20 of 24 patients). Tracks that exhibited a combination of tremor synchronous firing, joint kinesthesia, and visual responsivity were lesioned 17 (85%) of 20 times. Analysis of intraoperative electrode movement in the x and y axes indicated a significant subset of moves but did not result in microelectrode positioning closer to the subsequently lesioned track. Accuracy of initial electrode movement in the x and y axes was most highly correlated with a measure of first-track electrophysiological activity. The number of microelectrode recording tracks did not correlate with clinical outcome. Anatomic analysis, using postoperative magnetic resonance imaging, revealed that all lesions were placed in the globus pallidus. Most patients (35 of 36) improved after surgery.

CONCLUSION

The level of electrophysiological activity in the first track was the best predictive factor in determining whether the next microelectrode move would be closer to the ultimately lesioned track. The analysis of electrode track location and neurophysiological properties yields useful information regarding the effectiveness of microelectrode searching in the x and y axes. Within an institution, the application of this modeling method may increase the efficiency of the microelectrode refinement process.