Objective: Although several previous studies have investigated the association between psychosocial factors and the survival of lung cancer patients, most previous studies were flawed by severe methodological limitations. The purpose of the present study was to use a rigorous study design to investigate the association between relevant psychosocial factors and survival after a diagnosis of inoperable non-small cell lung cancer (NSCLC).Methods: The subjects were 122 consecutive newly diagnosed patients with inoperable NSCLC. Patients coping with cancer, psychological distress, clinical depression, and social support were evaluated after diagnosis but before treatment and 2 months later. After a 2-year follow-up period, 108 patients had died. The survival data were censored for the remaining 14 patients. The influence of psychosocial factors after diagnosis but before treatment on survival time was analyzed using a Cox regression, with adjustments for well-established (definite and/or possible) prognostic factors. The stability of the investigated psychosocial factors was also examined.Results: None of the examined psychosocial factors significantly predicted survival time among the patients with inoperable NSCLC. Among the biomedical factors that were examined, advanced clinical stage, a high serum lactate dehydrogenase level, and not receiving chemotherapy were independently associated with shorter survival periods. Most of the psychosocial factors exhibited a moderate to high stability.Conclusions: We found little convincing evidence that psychosocial factors after cancer diagnosis had a clinically relevant effect on the survival of inoperable patients with NSCLC. Copyright (c) 2008 John Wiley & Sons, Ltd.

INTRODUCTION: Cancer care can be described as a system or complex network of interventions delivered at various times and places with different intentions. CANCER CARE AS A SYSTEM: Cancer care can include medical treatments, psychosocial care, complementary and alternative medicine, self-care, as well as the process of healing and the context in which care is delivered. EVALUATING CANCER CARE: Whereas evaluating individual cancer treatments can be difficult, evaluating cancer care is even more challenging and requires a research framework that relies on methodologies capable of addressing its holistic, individualized, and complex nature. We suggest that research frameworks focused on studying complex or whole systems are a promising evaluation approach and an opportunity for further exploration.

ABSTRACT: BACKGROUND: The extent to which a health care intervention causes or facilitates health-related change is a key question in research. The need to quantify such change has led to the development of an increasing number of change indicators, to measure what have come to be known as 'outcomes'. In the context of medical research into the efficacy or effectiveness of an intervention the term 'outcomes' has often been interpreted to mean single endpoints with a linear cause and effect link to an external intervention. DISCUSSION: In this paper we present a critical analysis of the nature and interpretation of the 'outcomes' concept and of the assumptions that underpin it. Drawing on our own work and that of others, we analyse the problems that arise when the concept is applied to complex interventions and discuss the use of other models, such as programme theory, as a basis for alternative conceptualisations for indicators of change. Our analysis demonstrates that the interpretation of 'outcomes' that may be appropriate for clinical trials of pharmaceutical products, is problematic when used in evaluations of complex interventions in areas such as complementary medicine, palliative care, rehabilitation, and health promotion. The 'outcomes' concept may impose inappropriate patterns of thought and meaning. We present alternative models, such as those based on programme theory, which conceptualise health-related change as resulting from the interaction between intervention, process and context over time. In this framework both the intervention and the patient are defined as causal factors, because the result of the treatment is dependent on the resources of the patient - such as the body's ability to heal itself - and the impact of the patient's situation. SUMMARY: Evaluations based on a model such as programme theory will encompass a wide range of health-related changes that include aspects of process, such as new meanings and understanding, as well as longer term changes in health, wellbeing and health-related competences and behaviours.

Cancer care is multifactorial and patient centered. It can be described as a complex package of interventions, delivered at different times and places with different intentions, which interacts and cannot be evaluated in isolation. The authors discuss the evolving nature of cancer care and address the challenges faced by biomedical research methodology when applied to cancer care. In addition, they identify new research directions to meet these challenges. These include qualitative research, mixed methods research, and approaches based on systems thinking.

This cross-sectional study assessed the sociodemographic characteristics of families whose children used naturopathic medicine, the reasons for use, and whether naturopathic and conventional medicine were combined in treating children's conditions. Data were collected in British Columbia, Alberta and Ontario, Canada. Ninety-eight completed questionnaires were analyzed. The results showed that participants (parents) were most likely to be females, university educated, had household income >$60,000, and also saw a naturopathic doctor for themselves. The most common conditions for which children saw a naturopathic doctor included allergies, digestive problems and skin problems, and the most important reasons for use included using all possible options and having a more holistic approach to care. Most parents reported combining naturopathic and conventional care for their children. Study limitations, in particular, selection bias, were discussed.

INTRODUCTION: Historically, health professionals have used information developed for parents to promote child immunization. Few studies have specifically examined the effectiveness of this information in meeting parents' needs. While the literature emphasizes the importance of clear, thorough, and unbiased information about child immunization, limited attention has been given to what this means from a parent's perspective. The aim of this study was to gain insight in parents' information needs regarding child immunization in order to improve and/or optimize information shared by rural health professionals. We explored:(1) whether any immunization information contributed to parents' decisions; and, if so, how (2) what types of information and content parents required;(3) the sources of information parents considered helpful and trustworthy; and (4) parents' suggestions on how information could be conveyed to them more effectively. METHODS: This was a descriptive qualitative study, using semi-structured interviews with legal-aged mothers responsible for decisions about immunizing their infant in the past year. The mothers were from the local rural communities south of Calgary, Alberta, Canada, within the boundaries of the Calgary Health Region. Public health nurses working in this area assisted with recruitment. Thirty-nine mothers expressed interest in the study. The investigator contacted respondents to answer questions they may have had as well as to gather more socio-demographic information. This assisted in drawing a sample that reflected a variety of ages, education levels, and decisions made about immunization. Interviews were conducted by the principal investigator. Data collection and analysis took place simultaneously. Data collection continued until saturation was reached. All three investigators were involved in data analysis and data interpretation to ensure quality of the results. RESULTS: Eleven interviews were conducted. Participants were all mothers, most of whom lived in a stable relationship. Five mothers made the decision to fully immunize their child. The other mothers were varied in their decisions which included waiting to immunize the child until s/he was older, choosing vaccines selectively, being undecided about immunizing, and not immunizing. There were three mothers who had made a different decision about immunization with previous children. Three mothers were first-time parents. Five major themes were identified:(1) factors influencing mothers' decisions;(2) mothers' worries in making their decision;(3) mothers' perceptions about 'good' information;(4) mothers' information needs; and (5) mothers' recommendations to health professionals who convey immunization information to parents. CONCLUSION: The study had some limitations. Only mothers responded to the request for participation and the geographical area of the study was limited to the rural area where those particular public health nurses worked. Participants provided insightful perspectives on the subject of information on child immunization and how that information is conveyed to them. Feedback from the nurses also indicated the results were useful and thought-provoking. Future research in this area, using larger and more diverse populations, would benefit health professionals developing and conveying immunization information to parents. Key words: Canada, decision-making, immunization, infancy and childhood, information needs.

OBJECTIVE: To identify and evaluate surgical management of women with uterine fibroids. DESIGN: Retrospective analysis of mandatory surgical data sent to the Institute for Quality Assurance. SETTING: Data collection from 1998 to 2004 in Hesse, Germany. PATIENT(S): 34,814 women who underwent surgery for uterine fibroids. INTERVENTION(S): Patients were treated with either myomectomy or hysterectomy. MAIN OUTCOME MEASURE(S): Statistical analysis of mandatory surgical parameters. RESULT(S): Altogether, 4975 (14.3%) women had myomectomies, and 29,839 (85.7%) had hysterectomies. Age was an important determinant of surgical procedure; hysterectomy was preferred for patients over 40 (odds ratio 4.3; 95% confidence interval: 4.1-4.5). Laparoscopic myomectomy rates increased from 25.9% in 1998 to 41.9% in 2004; during the same period, the proportion of conversion procedures and abdominal approaches fell from 15.6% to 2.9% and 38.9% to 30.9%, respectively. Intraoperative complication rates were similar for myomectomy (1.1%) and hysterectomy (1.0%), but postoperative complication rates were higher for hysterectomy (5.8%) than myomectomy (3.2%). CONCLUSION(S): The increasing use of endoscopic procedures was an important feature in this series and appeared to be safe. The reduction of conversion rates and intraoperative complications might be related to improvements in surgical skill. Acceptance of the benefits of endoscopic approaches seems to have promoted its steady growth as a primary surgical approach.

OBJECTIVE:: To determine dietary supplementation practices and opinions, preferred means for dietary supplement (DS) education, and antidoping opinions among elite Canadian athletes varying in age and gender. DESIGN:: A descriptive, cross-sectional survey. SETTING:: Elite athlete training centers in Calgary, Canada and surrounding area. PARTICIPANTS:: A total of 582 high-performance athletes (314 male, 268 female). MAIN OUTCOME MEASURES:: High-performance athletes representing 27 sports with a mean age of 19.96 +/- 3.91 years completed a validated questionnaire assessing DS practices and opinions by recall. Sport categories included varsity, Canadian Sport Centre Calgary (CSCC), and National Sport School (NSS). RESULTS:: There was extensive DS use, with 88.4% of participants taking >/=1 DS (mean of 3.08 +/- 1.87 DS per user) during the previous 6 months. Overall, sport drinks (22.4%), sport bars (14.0%), multivitamins and minerals (13.5%), protein supplements (9.0%), and vitamin C (6.4%) were most frequently reported. Older athletes were significantly more likely to report greater DS usage; to be advised by teammates, health food store retailers, and magazines; to prefer supplementation education via individual interviews; to claim awareness of anti-doping rules; and to perceive anti-doping compliance. Relative to gender, significant differences were observed for the types of DS reported; supplementation advisors; justifications for DS use; and awareness of anti-doping regulations. CONCLUSIONS:: Utilization of this validated and reliable questionnaire has the potential for broad use and provides insight into the factors that influence DS use in elite athletes.

Objective: The purpose of the present study was to fully explore the descriptions of patients' experiences of change after receipt of whole systems of complementary and alternative medicine (CAM) treatment. The aim was to develop an understanding of "unstuckness," including characterization of states, processes, and modifying factors. Design: This was a secondary descriptive qualitative analysis, using techniques borrowed from phenomenology and grounded theory. Setting/location: Three existent datasets collected at two different universities in the United States and Canada were used in the secondary analysis. Participants: Patients with chronic illnesses (including cancer and multiple nonmalignant conditions) who were treated with different packages of care were interviewed for the primary three studies (n = 76 with over 150 interview sessions). Complete data sets from these participants were used in this secondary analysis. Outcome measures/data collection techniques: Original transcripts were coded asking specific research questions about the experience of change subsequent to whole systems treatments. Results: Data clearly indicated experiential differences between stuckness, unsticking, and unstuckness. Descriptors and characteristics of each state were identified, as was an initial grounded theory of change or transformation that occurs as an outcome of whole medical systems of CAM. Conclusions: The results provide preliminary conceptualizations and descriptions of the impact that CAM whole systems interventions may have on the individual' s life courses. This constitutes a first step in the identification, measurement, and evaluation of whole systems outcomes in a clinical setting. The emerging conceptualization of the process from stuckness to transformation may also provide a link between clinical research and systems science theory.

GOALS OF WORK: This study assessed the impact of acculturation on the prevalence of traditional Chinese medicine and other complementary and alternative medicine (TCM/CAM) use in newly diagnosed Chinese cancer patients. The individual determinants of TCM/CAM use among patients were also investigated. MATERIALS AND METHODS: A consecutive sample of Chinese cancer patients treated at the British Columbia Cancer Agency was surveyed at admission using a 15-item questionnaire. Items included TCM/CAM use, sociodemographics, as well as medical and cultural factors. Data were analyzed using bivariate methods including Pearson's X (2) test and Student's t test. As well, multiple logistic regression was used to obtain the final causal model. MAIN RESULTS: Of the 230 respondents, 57% completed the survey in Chinese and 94% were immigrants. The average age was 59. Participants had a mean disease duration of approximately 2 months and 79% had already received at least one conventional treatment. Overall, TCM/CAM was used by 47% of respondents. Herbal remedies, vitamins/minerals, and prayer were the most commonly used therapies. Multivariable analysis showed that prior TCM/CAM use (p < 0.001), having received conventional treatment(s)(p = 0.029), and being less acculturated (p = 0.028) were associated with TCM/CAM use. CONCLUSIONS: Prevalence and type of use were found to vary as a function of the degree of acculturation. Health care practitioners would be well advised to discuss TCM/CAM use with their patients, especially those who are less acculturated to Western society, since they are the most likely users of TCM/CAM.

From the foregoing description of the histological changes in the leptomeninx it is quite evident that we are dealing with a chronic, stationary, healing form of tuberculous inflammation. This statement is substantiated, in the first place, by the clinical history. The only reasonable interpretation of the symptoms would establish the duration of the process as four months. The imaginable contingency that there existed first a meningeal syphilitic lesion that was dispersed by the iodide of potassium only to be followed by a tuberculous infection is so remote and unlikely that it need not be discussed. At all events the tuberculous leptomeningitis, which presented a typical distribution, began insidiously, existed at times in a latent condition, and pursued a very anomalous course, marked by a relative mildness of all the symptoms, and thus it came about that when an apparent or real improvement followed the administration of iodide of potassium able observers were induced to make an erroneous diagnosis. Death occurred as a result of an intercurrent infection. The long duration of the process is also shown, anatomically, by the thick layer of firm, translucent and gelatinous material that matted together the structures at the base, and also by the evident adhesions between the pia and the brain. The histological examination furnishes proof positive of the correctness of the conclusion in regard to the peculiar character of this process because it shows:(1) That the tuberculous proliferation is uniform in development and has reached nearly the same stage of evolution throughout the entire extent of the leptomeninx involved; it is not a process that has advanced by exacerbations and irregular extensions; the lesions are, generally speaking, of nearly the same age everywhere and must have begun at about the same time.(2) That only a very limited degree of caseous degeneration is present, pointing to an early arrest of the activity of the tubercle bacillus or to a very decided diminution or attenuation of its virulence.(3) That the subendothelial intimal proliferations of epithelioid cells, so generally found in acute tuberculous leptomeningitis,* have in this case become more or less completely changed into distinct fibrous tissue in which but very slight, if any, direct evidence of its tuberculous origin can be found. It is only by recognizing that the chronic endarteritis is most marked in correspondence with the most advanced adventitial tuberculous changes, and by finding an imperfect, much altered giant cell in one district of intimal thickening, that we were able to establish the direct kinship of the endovascular changes with those of the pia in general.(4) That acute inflammatory changes, in the form of emigration of polymorphonuclear leucocytes and of fibrinous exudation, are entirely absent in all parts of the district involved. The presence of a turbid serous fluid is of course not at all inconsistent with the view that the anatomical changes are of long duration.(5) That the granulation tissue present is, in general, undergoing fibrillation and contains a rich supply of enabryonal capillary vessels as well as of larger blood-vessels of evidently new formation. The absence of any considerable extent of polymorphonuclear leucocytic infiltration in this tissue has already been referred to. The cells in the granulation tissue correspond to the cells of embryonal or formative connective tissue. Vacuolation is rarely present.(6) That the unusually large number of giant cells present are remarkably free from evidences of necrosis and degeneration of the character ordinarily observed in tuberculous proliferations, that they do not contain in demonstrable form tubercle bacilli, and that the majority of the giant cells seem to be separating into individual cells and smaller masses often with, but sometimes also without, evidences of nuclear disintegration. The possibility that these phenomena may signify fusion instead of the sundering of cells will be discussed below. For these reasons there can be no doubt that the general claim that we are dealing with an instance of chronic, healing tuberculous meningitis must be regarded as established beyond dispute. The growth of tubercle bacilli in the glycerine-agar tubes, inoculated with the fluid from the pial meshes, and the demonstration of tubercle bacilli, though in very small numbers, between the cells of the embryonal tissue, furnish the positive evidence that we are actually dealing with a tuberculous process due to living and not to dead bacilli. The degree of virulence of the cultures of tubercle bacilli was, unfortunately perhaps, not studied. The presence of living tubercle bacilli in a tissue free from active and acute changes characteristic of tuberculosis demonstrates that, whatever the actual degree of virulence of the bacilli may have been, the tissue in which they were found was at this time relatively immune from their action. The manner in which this immunity was produced, and in which the process of healing was initiated, need not be discussed at this time any further than to again direct attention to the fact that the bacilli lost their virulency as regards the cells in this leptomeninx before these cells underwent any marked degree of degeneration. The cells of the tuberculous proliferations survived the further action of the bacilli whose original effect it was to initiate cell accumulation or proliferation; the cells also retained sufficient vitality to develop, in some instances at any rate, into formative cells according as their origin would dictate, e. g. into fibroblasts. That fibroblasts are formed only by embryonal connective tissue cells, and not by wandering cells, such as the large mononuclear leucocytes, we are well aware, is possibly still a disputable assumption, and we do not consider it pertinent to discuss the question any further in connection with this study, but would only emphasize the point that some of the cells of tuberculous proliferations may, under favorable circumstances, become formative cells, and, furthermore, that the amount of formative tissue produced may be far in excess of what is actually needed for purposes of repair only. Surely the appearances here noted indicate that the bacillus of tuberculosis has the power to stimulate fixed cells to multiply, unless one assumes that all, or almost all, the formative cells here seen are derived from wandering cells attracted by the presence of the bacillus and its products. As to the ultimate fate of the formative and other cells in this healing tuberculous tissue no final statements can be made. It must be remembered that it is only one stage in the process of healing that is dealt with. The well marked evidences of fibrillation, the quite extensive formation of new vessels, the absence of evidences of degenerative changes in the uninuclear cells, all point to the production of new fibrous tissue as sure to occur, but it seems quite probable that occasional epithelioid cells may undergo or have undergone dropsical or other forms of degeneration, although it is certainly apparent that so far as the small cells are concerned the involution of the tuberculous tissue is not occurring through disintegration. Perhaps the most interesting feature in this case is the opportunity it affords to study the changes in the giant cells of healing, non-degenerated tuberculous tissue. In the first place, the large number of giant cells is quite remarkable. The general characters of the tissue in which they are found recall the fact that giant cells are regarded as quite constant elements in chronic mild tuberculosis; often the giant cells are the only cells that contain bacilli (Koch). In this instance the giant cells do not contain bacilli that are demonstrable by the usual methods; neither do they contain bodies that can be definitely interpreted as degenerate forms of bacilli such as those found by Metchnikoff, Stchastny, Weicker, and others, in the giant cells of Spermophilus guttatus, in avian and in human tuberculosis. Metchnikoff states, however, that he knows of the occurrence of such degenerate forms only in the Spermophilus guttatus under the circumstances mentioned, and in the rabbit and guinea-pig in mammalian tuberculosis, but not in man; consequently, the manner in which the giant cells rid themselves of the bacilli undoubtedly present in their interior at some time during their existence, must as yet remain without any explanation. In the description of the histological changes the various appearances presented by the giant cells are described somewhat minutely. The essential observations made concern, in my opinion, the further fate of giant cells which are still found to persist in healing nondegenerated tuberculous tissue. It was, I believe, quite conclusively shown that the consecutive changes appear to consist in the breaking up of the nuclei, the removal of the detritus by phagocytes, and the formation of a few apparently viable uninuclear cells in the case of more degenerated, exhausted giant cells, while other, and, as it would seem, better preserved or younger giant cells, separate into a number of individual, uninuclear cells with but little or no nuclear disintegration. Objection might be raised to this interpretation of the appearances in the giant cells. While no one could very well dispute the view that part of the giant cells are undergoing retrogressive and absorptive changes with the production of some viable cells, a question might well be raised concerning the nature of the process taking place in those giant cells that have been spoken of as splitting up or dividing into uninuclear cells and smaller multinucleated masses without much evidence of nuclear disintegration. It might be claimed that the process is one of fusion of many cells to form giant cells, and not one of division of fully formed giant cells into small cells. But a broad view of the processes described speaks against fusion. In the first place we are not dealing with a stage of tuberculous proliferation (Baumgarten), or cell accumulation (Metchnikoff), in which one would look for the production of giant cells, no matter which view concerning the histogenesis of tubercle be assumed as the correct one, because it has been demonstrated that, from whichever point of view the lesions are examined, the same positive conclusion that they are in the process of healing is reached; there is, therefore, no occasion for the formation of new giant cells in such wide-spread degree throughout the district involved. It might he claimed that the cells became arrested and, as it were, fixed in the act of fusion which was taking place in the early stage of the meningitis, but it would be difficult to understand the nature of the stimulus that could hold the cells together in such a peculiar manner for such a long time. It must be remembered that bacilli or bacillary detritus could not be found among the incomplete or in the complete giant cells. In the second place the difference between the cells that are undergoing disintegration and those regarded as dividing is essentially, to a certain extent at any rate, one of degree, because in the first instance there is not much, if any, doubt but that viable smaller cells are also formed, and in the second instance some, though often very slight, evidence of nuclear fragmentation is nearly always present; it would also be correct to infer that in advanced subdivision of a giant cell much, and perhaps all, of the nuclear detritus produced might have been removed up to the last trace; finally, the two extremes of these changes in the giant cells are connected by transition stages passing by gradation from the one to the other. Hence it is justifiable to conclude, for the time being, that in healing non-degenerated tuberculous tissue, the multinucleated giant cells may in part disintegrate and undergo absorption, in part form viable small cells; that both these changes may, and usually do, affect the same cell, but that in one class of cells-presumably the older or the more exhausted-the retrogressive process is predominant, while in a second class of cells-presumably the young and vigorous-the progressive changes are the more marked. In this connection it may be pointed out that while there cannot very well be any question but that we are dealing only with dividing and not coalescing cells, yet if this conclusion should be disputed and found incorrect, then the only remaining alternative would be to infer that this tissue furnished a unique and striking example of the formation of plasmodial masses by fusion in human tuberculosis, a conclusion to which many pathologists would refuse to subscribe, if for no other reason than because it is not in accordance with the almost universally accepted teachings of Baumgarten and Weigert in regard to the mode of formation of the giant cells in tuberculosis. Believing as I do that the giant cells under consideration are in the act of division and not at all of fusion, there remain to be discussed some of the histological and other features presented by the dividing cells. Many of the giant cells, perhaps the majority, contain larger and smaller vacuoles in the protoplasm. The exact significance of this vacuolation is not always clear. When the vacuolation accompanies an evident solution of the nucleus (karyolysis), there cannot be any doubt but that we are in the presence of a distinctly retrogressive process. Vacuoles are also most numerous in the giant cells that present other evidences of degeneration, such as coarseness of the granules in the protoplasm and extensive nuclear disintegration, but they occur as well around nuclei that stain deeply, around cells that seem to be separating from the giant cell, and even about nuclei that present mitoses. The formation of vacuoles seems to be responsible, to a certain extent at any rate, for the diminution in the volume of disintegrating and dividing giant cells, as shown by the clear spaces that form about them; these spaces are too large and occur too uniformly to be attributed solely to artificial shrinking produced by the hardening in alcohol. Further undoubted evidence of retrogression in certain giant cells is the occurrence of nuclear disintegration, or karyorhexis, which sets free larger and smaller chromatin masses that are recognized in the giant cell as well as in the interior of the phagocytes usually found around such cells. Almost all the polymorphonuclear leucocytes found in this tissue are met with around giant cells with broken-up nuclei. In many nuclei of disintegrating giant cells can be noted appearances that correspond well to certain stages in the complicated karyorhexis observed in anaemic necrosis by Schmaus and Albrecht; some of the nuclei with budding processes correspond particularly well with those in certain of their drawings; the interior of giant cells of tuberculous tissue may, it would seem, present conditions favorable to the development of this series of postnecrotic nuclear change. Vacuolation, karyolysis and karyorhexis are the essential steps that lead to destruction of the whole or parts of some of the giant cells; associated with these processes there is usually observed a splitting up of the body of the giant cell into irregular fragments with as well as without nuclei; and, as described, more or less phagocytosis of the resulting remnants of various kinds is seen. But evident degenerative and necrotic processes in a giant cell may be associated with progressive changes. While some nuclei undergo vacuolation or break up, others seem to become richer in chromatin and to stain more deeply at the same time that they seem to acquire cell bodies quite distinct from the protoplasm of the giant cells: this hyperchromatosis does not, therefore, seem to be a stage in karyorhexis. A very few but undoubted karyokinetic figures were found, together with evidences of division of the cell body formed in the giant cell protoplasm. Precisely similar changes are described by Klebs in healing pulmonary tuberculosis of the guinea-pig; the nuclei of the giant cells became rich in chromatin and karyokinetic figures occurred. Krückmann among others has found occasional mitoses in giant cells around foreign bodies, as well as elsewhere, but it would seem that such mitoses have always been interpreted as indicating the probable mode of formation of the giant cells rather than of their involution. The question of mitosis in existing multinucleated cells has recently been studied by Krompecher, who concludes that the individual nuclei of such cells may undoubtedly divide by mitosis, either simultaneously or at separate times. Division by amitosis can also occur, but mitosis is the only progressive form of division, amitosis being a retrogressive, disintegrating process that must be looked upon as an evidence of degeneration of the nucleus. Ziegler states that in division of giant cells whose nuclei have multiplied by mitosis it may happen that the separating cell remains enclosed in the protoplasm of the mother cell. A singular phase in the involution of the giant cells in this pia is to be found in the existence of progressive changes side by side with nuclear necrosis and with degeneration; this finding indicates that giant cells may contain many independent elements which, though apparently fused into one large cell, may preserve their individuality so that while some nuclei die, others proliferate and perhaps feed on the remnants of their dead brethren and form new, viable small cells. The nuclei in giant cells may be looked upon as representing independent centres, capable at times of existing even though the cell protoplasm is disintegrated. Many of the giant cells separate into individual cells, unaccompanied or unassociated with much evidence of necrosis. These cells may be regarded as the more vigorous forms. Here also are observed occasional mitoses-but on the whole extremely few-and very constantly an evident increase in the amount of chromatin in the nuclei of the new cells as compared with the amount ordinarily found in the nuclei of giant cells. These deductions concerning the persistence of the vitality of some of the nuclei, even in the presence of molecular and morphological changes in the cytoplasm and in other nuclei of the giant cell that lead to disintegration, are not entirely without the support of previous observations on cells, which, although made under different conditions, are nevertheless, it would seem, applicable to cells in general. Thus the brilliant investigations of Loeb upon the effects of various unfavorable surroundings, such as absence of oxygen or reduction of the amount of water, upon the cleavage of eggs of many kinds, show that the conditions which arrest development are qualitatively alike for nucleus and protoplasm, but quantitatively less for the protoplasm; when the irritability of the protoplasm is suspended the nucleus may segment without segmentation of the protoplasm, but upon re-establishment of favorable conditions the protoplasm may divide into about as many spheres as there are nuclei preformed-the nucleus persists, preserves the irritability of the cell and stimulates the protoplasm to segmentation. From the appearances of the giant cells here described it would seem, then, that some nuclei are able to maintain their vitality longer than others in the same cell, and under certain conditions to stimulate parts of the protoplasm to segment; in other cells all the nuclei have, as a rule, preserved their irritability. The groups of cells formed by the dividing of the giant cells can be traced by studying the process at the different stages in the different parts of the tissue. They assume an oval or spindle-shaped form, becoming more and more like the formative and endothelioid cells of young connective tissue, but their ultimate fate cannot be determined because it concerns essentially only one limited period in the involution of the tissue. It may be said with reasonable certainty, however, that the new cells do not form blood-vessels, but as regards their forming lymph-vessels nothing definite can be concluded. It would not be safe to draw any definite conclusions, from the appearances described, with regard to the origin and the mode of formation of the giant cells. The resulting small cells in general resemble very much endothelial and formative cells, but some of them are, at certain stages at any rate, not unlike large mononuclear leucocytes; their final fully developed or mature condition being unknown, no positive inference can be drawn as to their pre-giant-cell origin. The evidence points to the fact that the most probable origin of the giant cells, as indicated by their form and the apparent future career of their descendants, would be the fixed mesoblastic cells of the pia. In regard to the mode of formation of the giant cells it is quite clear that it must involve some process which is not incompatible with the viability of the small cells which may spring from the giant cells. Whether this would speak more in favor of formation by fusion than by karyokinesis of a single cell without division of the cell body cannot be well determined, and as long as authors are not agreed upon the question of the production of living, procreative cells by amitosis (direct segmentation, direct and indirect fragmentation) it would not be profitable to discuss the compatibility or incompatibility of the views of those investigators who trace the origin of giant cells to amitotic division, with the progressive changes that giant cells have been shown to be capable of. The fact that giant cells in tuberculous tissue, under certain conditions, undergo progressive changes and separate into small, living cells proves that they are not, as claimed by Baumgarten, Weigert and others, necrobiotic elements that are doomed to destruction from their very inception. On the other hand it lends more strength, if that were necessary, to the teleological view urged by Metchnikoff that they are living, defensive cells (whatever their origin may be), formed for the distinct purpose, like plasmodial masses in general, of isolating and removing foreign, harmful bodies, in this case the tubercle bacillus, and, having accomplished their object without being destroyed or exhausted, or the cause of their formation being removed or neutralized in some way, they, or their nuclei, may retain enough irritability to form a larger or smaller number of living, small, uninuclear cells.

An Undergraduate Nurse Employment Demonstration Project (UNDP) was implemented in four Health Service Areas in British Columbia with a concurrent evaluation study. This demonstration project comprised the development and implementation of a new position in the BC healthcare system. The position enabled third- and fourth-year nursing students to be employed at their level of education. The purposes of the evaluation were to explore the feasibility and outcomes of this type of paid undergraduate student nurse employment. The three-year project and evaluation included both implementation and outcome analysis. The implementation evaluation design was descriptive and prospective, involving multiple data sources. The outcome evaluation design was quasi-experimental, with intervention and comparison groups. Learning outcomes for undergraduate nurses were increased confidence, organizational ability, competency and ability to work with a team. Workplace outcomes were increased unit morale, help with workload and improved patient care. New graduates with undergraduate nurse experience reported less time required for orientation and transition than other graduates who did not have this experience, and workplace nurses viewed these new graduates as more job-ready than other new graduates. After 21 months, new graduates with undergraduate nurse experience were less likely to move to other employment than other new graduates. Results from the four Health Service Areas indicated that the paid undergraduate nurse position was feasible and that outcomes benefited students, new graduates and workplaces. The undergraduate nurse position is now being implemented throughout all Health Service Areas in British Columbia.By 2000, concerns in British Columbia about the nursing workforce, workplace and patient safety had escalated to the point where diverse stakeholder groups were prepared to work together in new ways to prepare nursing graduates to be more job-ready, to recruit and retain new graduates and to retain existing nurses. Stakeholder groups were administrators, labour organizations, professional associations, educators and government. One idea to support job readiness and retention focussed on the feasibility of implementing cooperative education for nursing students. The effort was unsuccessful owing to lack of funding, but resulted in a review of the literature on cooperative education and other work-study programs. Cooperative education connects classroom learning with paid work experience for the purpose of enhancing students' education (Fitt and Heverly 1990; Heinemann and De Falco 1992; Ryder 1987). Reported benefits for students were improved job preparation and graduate retention (Ishida et al. 1998), additional staffing and reduction in orientation time (Cusack 1990; Ishida et al. 1998), increased practice judgment (Cusack 1990; Siedenberg 1989) and better workload management (Ross and Marriner 1985). A work-study model reported in the literature offered benefits similar to those of cooperative education, with greater flexibility in design. An example was the University of Texas Health Science Center at Houston's collaborative work-study scholarship program with local hospitals (Kee and Ryser 2001). Students in second clinical semesters were employed as unlicensed personnel by hospitals. The students, as unlicensed personnel, worked to the level of their nursing preparation. Reported benefits for students were academic credit, financial assistance, interaction with multidisciplinary teams, opportunity to refine clinical skills, understanding of nurses' roles and guaranteed interview for positions on graduation (Kee and Ryser 2001). Benefits for practice organizations were skilled help, the opportunity to recruit new nurses and increased interaction with a university nursing program. While nurse education stakeholders in British Columbia were exploring options, the concept of undergraduate student nurse employment was initiated by a group of fourth-year students at the University of Victoria who were completing the course "Nurses Influencing Change." The students were concerned about having enough practice experience to meet increasing nursing competency requirements and their survival as new graduates given workplace realities. Debt load also was a concern because extensive student practicum time limited opportunities for paid employment during the nursing education program. Students found that the idea of paid undergraduate nurse positions, based on the student employment model in Alberta, was supported by nurse leaders, many practising nurses and nursing faculty who also were concerned about meeting patient care standards and adequately preparing nursing students. In 2000, the BC Ministry of Health Services funded an Undergraduate Nurse Demonstration Project (UNDP)- one type of paid employment for undergraduate student nurses - in four Health Service Areas linked with four schools of nursing. A concurrent three-year evaluation study examined the feasibility and outcomes of the UNDP (Gamroth et al. 2004). This paper summarizes the findings of the evaluation. Evaluation Research An Undergraduate Nurse Employment Demonstration Project (UNDP) was implemented in four Health Service Areas in British Columbia with a concurrent evaluation study. This demonstration project comprised the development and implementation of a new position in the BC healthcare system. The position enabled third- and fourth-year nursing students to be employed at their level of education. The purposes of the evaluation were to explore the feasibility and outcomes of this type of paid undergraduate student nurse employment. The three-year project and evaluation included both implementation and outcome analysis. The implementation evaluation design was descriptive and prospective, involving multiple data sources. The outcome evaluation design was quasi-experimental, with intervention and comparison groups. Learning outcomes for undergraduate nurses were increased confidence, organizational ability, competency and ability to work with a team. Workplace outcomes were increased unit morale, help with workload and improved patient care. New graduates with undergraduate nurse experience reported less time required for orientation and transition than other graduates who did not have this experience, and workplace nurses viewed these new graduates as more job-ready than other new graduates. After 21 months, new graduates with undergraduate nurse experience were less likely to move to other employment than other new graduates. Results from the four Health Service Areas indicated that the paid undergraduate nurse position was feasible and that outcomes benefited students, new graduates and workplaces. The undergraduate nurse position is now being implemented throughout all Health Service Areas in British Columbia. By 2000, concerns in British Columbia about the nursing workforce, workplace and patient safety had escalated to the point where diverse stakeholder groups were prepared to work together in new ways to prepare nursing graduates to be more job-ready, to recruit and retain new graduates and to retain existing nurses. Stakeholder groups were administrators, labour organizations, professional associations, educators and government. One idea to support job readiness and retention focussed on the feasibility of implementing cooperative education for nursing students. The effort was unsuccessful owing to lack of funding, but resulted in a review of the literature on cooperative education and other work-study programs. Cooperative education connects classroom learning with paid work experience for the purpose of enhancing students' education (Fitt and Heverly 1990; Heinemann and De Falco 1992; Ryder 1987). Reported benefits for students were improved job preparation and graduate retention (Ishida et al. 1998), additional staffing and reduction in orientation time (Cusack 1990; Ishida et al. 1998), increased practice judgment (Cusack 1990; Siedenberg 1989) and better workload management (Ross and Marriner 1985). A work-study model reported in the literature offered benefits similar to those of cooperative education, with greater flexibility in design. An example was the University of Texas Health Science Center at Houston's collaborative work-study scholarship program with local hospitals (Kee and Ryser 2001). Students in second clinical semesters were employed as unlicensed personnel by hospitals. The students, as unlicensed personnel, worked to the level of their nursing preparation. Reported benefits for students were academic credit, financial assistance, interaction with multidisciplinary teams, opportunity to refine clinical skills, understanding of nurses' roles and guaranteed interview for positions on graduation (Kee and Ryser 2001). Benefits for practice organizations were skilled help, the opportunity to recruit new nurses and increased interaction with a university nursing program. While nurse education stakeholders in British Columbia were exploring options, the concept of undergraduate student nurse employment was initiated by a group of fourth-year students at the University of Victoria who were completing the course "Nurses Influencing Change." The students were concerned about having enough practice experience to meet increasing nursing competency requirements and their survival as new graduates given workplace realities. Debt load also was a concern because extensive student practicum time limited opportunities for paid employment during the nursing education program. Students found that the idea of paid undergraduate nurse positions, based on the student employment model in Alberta, was supported by nurse leaders, many practising nurses and nursing faculty who also were concerned about meeting patient care standards and adequately preparing nursing students.

Although the physiological and biochemical changes that occur during the acute stress response have been well-characterized, the contrasting changes that underlie the relaxation response evoked by various mind-body techniques are less understood. To help guide future mind-body research, we present a conceptual model that integrates patterns of change at the physiological and molecular levels. In addition, we point to future research opportunities and discuss how repeated elicitation of these responses could influence the health of patients.