A short report of satisfaction levels amongst Irish trainees in psychiatry with out of hours and emergency assessments.

OBJECTIVES: On-call and crisis psychiatry is a very challenging aspect of psychiatric training. This study aimed to describe the experiences of psychiatric trainees on-call in hospitals, emergency departments and psychiatric units in Ireland. METHODS: In total, 193 psychiatric trainees in Ireland were emailed a survey in 2017. The survey included questions regarding the duties expected of the trainee, frequency of on-call obligations, un-rostered hours worked, level of senior support, assessment facilities available and doctors' satisfaction with the on-call experience. RESULTS: Overall, 68 trainees responded to the survey. In total, 35% of respondents reported dissatisfaction with their experience of on-call and crisis psychiatry, 46% reported that they were not provided with training in risk assessment and 21% of respondents stated that there was not a suitable room available to perform their assessments. CONCLUSIONS: This survey has raised important issues facing those on the frontline of psychiatric services in Ireland. Of particular concern are resource issues faced by trainees and the need for further training and support related to risk assessment when on-call. Remedying these issues may lead to a decreased rate of dropout as well as a safer and better environment for patients and doctors alike.

Defining the Optimal Treatment Strategy in Patients With Uterine Serous Carcinoma.

AIMS: Uterine serous carcinoma (USC) is an aggressive subtype of endometrial cancer with high rates of relapse and death. As adjuvant therapy might be beneficial in early-stage disease, the impact of standard complete surgical staging is questioned. Therefore, we wanted to explore the optimal treatment strategy for women diagnosed with USC. MATERIALS AND METHODS: A retrospective multicentre study of women diagnosed with primary USC in the UK and the Netherlands. Treatment strategy in relation to overall survival and progression-free survival was recorded and evaluated with Kaplan-Meier and Cox regression analysis. Furthermore, primary surgical staging and/or adjuvant treatment in relation to patterns of recurrence were evaluated. RESULTS: In total, 272 women with a median age of 70 years were included. Most patients presented with International Federation of Gynecology and Obstetrics (FIGO) stage I disease (44%). Overall, 48% of patients developed recurrent disease, most (58%) with a distant component. Women treated with chemotherapy showed significantly better overall survival (hazard ratio 0.50, 95% confidence interval 0.31-0.81; P = 0.005) and progression-free survival (hazard ratio 0.48, 95% confidence interval 0.28-0.80; P = 0.04) in multivariable analysis. Furthermore, even in surgically staged women with FIGO stage IA disease, a high recurrence rate of 42% was seen. CONCLUSION: Women with USC who received adjuvant chemotherapy showed better survival rates compared with those who received other or no adjuvant treatment. The benefit of adjuvant chemotherapy was observed across all tumour stages, including surgically staged FIGO stage IA. These data question the role of surgical staging in the absence of macroscopic disease in USC.

Lessons for rabies control and elimination programmes: a decade of One Health experience from Bali, Indonesia.

Since the emergence of rabies on Bali, Indonesia, in 2008, the Indonesian Government and other stakeholders have implemented disease control and prevention activities with the aim of re-securing Bali's freedom from dog-mediated rabies. The authors report on the lessons learned during these efforts, and their applicability to other regions where canine rabies is endemic, as well as to rabies-free populations that are at risk from incursions. To eliminate rabies from Bali will require time and commitment, as well as a combination of approaches employing the principle of One Health. Efforts should be directed towards well-coordinated, highcoverage, annual dog vaccination campaigns using high-quality vaccines, and enhanced surveillance focused on investigations of biting animals. Bali, an island, is an ideal target for achieving freedom from rabies, but the logistics of vaccinating its very large, free-roaming dog population are challenging. Lessons can be drawn from Bali for other large and dense dog populations, where dog management and rabies control appear difficult. Well-trained teams with nets can rapidly catch and vaccinate large numbers of dogs where central-point vaccination is insufficient, and post vaccination surveys of collared dogs can be used to evaluate coverage and target supplementary vaccination. However, careful planning is required to ensure that all communities are reached during such campaigns and that sufficient vaccine is available over the following years. Effective communication strategies are needed to coordinate intersectoral activities, and to keep communities engaged, particularly during the 'end game', when the risk of rabies appears only minimal. An effective One Health approach to eliminate rabies requires long-term planning, multisectoral communication and coordination, and sustained effort, using tried and tested methods.

Suite à l'émergence de la rage à Bali (Indonésie) en 2008, le gouvernement indonésien et d'autre parties prenantes ont introduit des mesures de contrôle et de prévention de la maladie afin de sécuriser le statut précédemment indemne de Bali au regard de la rage transmise par les chiens. Les auteurs font le point sur les enseignements tirés de cette expérience et évaluent sa pertinence pour d'autres régions, par exemple celles où la rage canine est endémique ou qui possèdent des populations indemnes de rage mais exposées au risque d'une incursion du virus. L'élimination de la rage à Bali est une entreprise qui prendra du temps et exigera une grande détermination ainsi que le recours combiné à diverses méthodes suivant les principes Une seule santé. Les efforts devront s'orienter vers des campagnes annuelles de vaccination des chiens, qu'il faudra coordonner avec soin en assurant une couverture élevée et en faisant appel à des vaccins de haute qualité, et vers une surveillance accrue avec notamment l'investigation de tout chien responsable de morsure. De par son insularité, Bali constitue un territoire idéal pour réussir l'élimination totale de la rage, mais la logistique requise pour la vaccination est lourde, en plus du défi majeur que posent les effectifs importants de chiens errants. Les leçons tirées de l'expérience de Bali peuvent se révéler fructueuses dans d'autres régions dotées de populations canines denses et nombreuses et où les opérations de gestion de ces populations et de lutte contre la rage se présentent sous un jour peu favorable. Dans les contextes où il n'y a pas suffisamment de centres de vaccination, les chiens peuvent être capturés et vaccinés en grand nombre par des équipes bien entraînées et disposant de filets, tandis que le suivi post-vaccinal des chiens enregistrés offre un bon moyen d'évaluer la couverture vaccinale et de cibler les besoins supplémentaires. Il est essentiel de bien planifier ces campagnes afin de s'assurer qu'elles ont touché toutes les communautés et que les stocks de vaccins sont suffisants pour les années à venir. Des stratégies efficaces de communication sont nécessaires pour coordonner les activités intersectorielles et pour maintenir le niveau de motivation des communautés, en particulier en fin de campagne car les risques de rage sont alors perçus comme étant minimes. Pour être efficace, une approche Une seule santé d'élimination de la rage requiert une planification sur le long terme, une communication multisectorielle et des efforts de longue haleine recourant à des méthodes éprouvées.

Desde que en 2008 la rabia hizo su aparición en Bali (Indonesia), el Gobierno del país y otras partes interesadas han llevado a cabo una serie de actividades de control y prevención de la enfermedad con el objetivo de devolver a la isla la condición de «libre de la rabia transmitida por perros¼. Los autores dan cuenta de las enseñanzas extraídas de esta labor y examinan la viabilidad de aplicarlas a otras regiones donde la rabia canina es endémica, así como a poblaciones libres de rabia que corren peligro de sufrir incursiones de la enfermedad. Para eliminar la rabia de Bali hará falta tiempo y dedicación, así como una combinación de métodos regida por los principios de Una sola salud. Convendría centrar el trabajo en campañas anuales de vacunación de perros bien coordinadas, de amplia cobertura y realizadas con vacunas de gran calidad, que se acompañen de una vigilancia más intensa centrada en la investigación de los casos de animales mordedores. Por su condición insular, Bali ofrece condiciones idóneas para lograr la eliminación de la rabia, pero la logística de las vacunaciones es muy aparatosa y las poblaciones de perros vagabundos plantean grandes problemas. De la experiencia balinesa cabe extraer enseñanzas útiles para otras zonas que albergan poblaciones de perros amplias y densas, donde la gestión de estas poblaciones y la lucha antirrábica parecen resultar dificultosas. Allí donde la vacunación centralizada no baste, cabe desplegar equipos bien formados y provistos de redes que puedan capturar y vacunar rápidamente a un gran número de perros, empleando después, eventualmente, estudios posvacunales de los perros con collar identificativo para evaluar la cobertura y seleccionar objetivos de vacunación complementaria. Sin embargo, para llegar a todas las comunidades en el curso de tales campañas y tener la seguridad de disponer de un suministro suficiente de vacunas en los años subsiguientes hace falta una minuciosa planificación. Se necesitan asimismo dispositivos eficaces de comunicación para coordinar las actividades intersectoriales, y también hay que mantener movilizadas a las comunidades, especialmente en la fase final, cuando el riesgo de rabia parece ser mínimo. Todo método eficaz de eliminación de la rabia que parta de los postulados de Una sola salud exige planificación a largo plazo, comunicación y coordinación multisectoriales y una labor sostenida, con empleo de métodos de probada y contrastada eficacia.

Radiation-related toxicities and outcomes in endometrial cancer: are obese women at a disadvantage?

OBJECTIVE: To assess the impact of body mass index (BMI) on radiotherapy toxicities in endometrial cancer patients. METHODS: This was a retrospective cohort study of women diagnosed with endometrial cancer between January 2006 and December 2014 at the Royal Cornwall Hospital Trust. Women who received radiotherapy as part of their treatment, including external beam radiotherapy (EBRT) and/or vaginal brachytherapy were included. Radiation-related toxicities were graded according to the Radiation Therapy Oncology Group (RTOG) guidelines. Toxicity outcomes were compared across BMI groups-non-obese (BMI <30 kg/m2) and obese (BMI ≥30 kg/m2)-according to radiotherapy treatment received (EBRT, brachytherapy or a combination). RESULTS: Of a total of 159 women who received radiotherapy, 110 were eligible for inclusion in the study. Sixty-three women had a BMI <30 kg/m2 and 47 women were obese. Obese women had poorer Eastern Cooperative Oncology Group performance status (P = 0.021) and more comorbidities (P < 0.001) compared to the non-obese group. Total (any) toxicity rates were 60.3, 72.7 and 52.0% for EBRT and brachytherapy (N = 63), single-mode EBRT (N = 22) and brachytherapy (N = 25), respectively. BMI was not associated with the incidence of acute and late radiation toxicities in the different radiotherapy groups, and there were no differences in individual complications between the BMI groups. CONCLUSION: When comparing obese to non-obese women, obesity does not negatively impact the incidence of radiation toxicities in endometrial cancer. However, toxicities remain an important challenge as they are common and negatively influence the quality of life (QoL) of survivors. Future studies need to further explore the role of BMI and possible interventions to improve toxicities and QoL.

Metastatic spinal cord compression from basal cell carcinoma of the skin treated with surgical decompression and vismodegib: case report and review of Hedgehog signalling pathway inhibition in advanced basal cell carcinoma.

We report a case of a 66-year-old man with locally advanced and metastatic basal cell carcinoma (BCC) causing spinal cord compression, which was treated with spinal surgery and subsequent vismodegib. The patient presented with a large fungating chest wall lesion and a metastasis in T8 that was causing cord compression. He had neurosurgical decompression of the T8 lesion and fixation of the spine. Punch biopsy from the fungating chest wall lesion showed a BCC with some malignant squamous differentiation (basosquamous). Histopathological examination of the metastatic lesion in T8 at the time of surgical decompression identified features identical to the punch biopsy. The patient was referred to the oncology clinic for adjuvant treatment. In light of his metastatic disease and the large area over his chest wall that could not fully be covered by radiotherapy, he was treated with the novel oral Hedgehog signalling pathway (HHSP) inhibitor vismodegib, which led to marked improvement.

Changing molecular profile of brain metastases compared with matched breast primary cancers and impact on clinical outcomes.

BACKGROUND: Breast cancer commonly metastasises to the brain, but little is known about changes in the molecular profile of the brain secondaries and impact on clinical outcomes. METHODS: Patients with samples from brain metastases and matched breast cancers were included. Immunohistochemical analysis for oestrogen receptor, progesterone receptor, p27kip1, cyclin D1, epidermal growth factor receptor, insulin like growth factor 1, insulin like growth factor 1 receptor, vascular endothelial growth factor A, transforming growth factor-ß and HER2 receptor was performed. Borderline HER2 results were analysed by fluorescent in situ hybridisation. Levels of expression were compared, with review of effect on clinical outcomes. RESULTS: A total of 41 patients were included. Of the patients, 20% had a change in oestrogen receptor or HER2 in their brain metastasis that could affect therapeutic decisions. There were statistically significant rises in brain metastases for p27kip1 (P=0.023) and cyclin D1 (P=0.030) and a fall in vascular endothelial growth factor A (P=0.012). Overall survival from the time of metastasis increased significantly with oestrogen receptor-positive (P=0.005) and progesterone receptor-positive (P=0.013) brain lesions and with a longer duration from diagnosis of the breast primary (P<0.001). CONCLUSIONS: In this cohort there were phenotypic differences in metastatic brain tumours compared with matched primary breast tumours. These could be relevant for aetiology, and have an impact on prognostication, current and future therapies.

Assessing the invariance of a culturally competent multi-lingual unmet needs survey for immigrant and Australian-born cancer patients: a Rasch analysis.

PURPOSE: The purpose of this study was to assess the invariance of a culturally competent multi-lingual unmet needs survey. METHODS: A cross-sectional study was conducted among immigrants of Arabic-, Chinese- and Greek-speaking backgrounds, and Anglo-Australian-born controls, recruited through Cancer Registries (n = 591) and oncology clinics (n = 900). The survey included four subscales, with newly developed items addressing unmet need in culturally competent health information and patient support (CCHIPS), and items adapted from existing questionnaires addressing physical and daily living (PDL), sexuality (SEX) and survivorship (SURV) unmet need. The survey was translated into Arabic, Chinese and Greek. Rasch analysis was carried out on the four domains. RESULTS: Whilst many items were mistargeted to less prevalent areas of unmet need, causing substantial floor effects in person estimates, reliability indices were acceptable. The CCHIPS domain showed differential item functioning (DIF) for cultural background and language, and the PDL domain showed DIF for treatment phase and gender. The results for SEX and SURV domains were limited by floor effects and missing responses. All domains showed adequate fit to the model after DIF was resolved and a small number of items were deleted. CONCLUSIONS: The study highlights the intricacies in designing a culturally competent survey that can be applied to culturally and linguistically diverse groups across different treatment contexts. Overall, the results demonstrate that this survey is somewhat invariant with respect to these factors. Future refinements are suggested to enhance the survey's cultural competence and general validity.

Unmet needs in immigrant cancer survivors: a cross-sectional population-based study.

PURPOSE: Social suffering, language difficulties, and cultural factors may all make the cancer experience more difficult for immigrants. This study aimed to document unmet needs, and variables associated with these, in a population-based sample of first-generation immigrants and Anglo-Australians who had survived cancer. METHODS: Participants were recruited via Australian cancer registries. Eligible cancer survivors had a new diagnosis 1-6 years earlier and were aged between 18 and 80 years at diagnosis. Eligible immigrant participants and parents were born in a country where Arabic, Chinese (Mandarin, Cantonese, and other dialects), or Greek is spoken, and they spoke one of these languages. A random sample of English-speaking Anglo-Australian-born controls was recruited. RESULTS: Five hundred ninety-six patients (277 immigrants) were recruited to the study (response rate, 26%). Compared to Anglo-Australians, the adjusted odds ratio of Chinese immigrants for at least one unmet information/support need was 5.1 (95% CI 3.1, 8.3) and for any unmet physical need was 3.1 (95% CI 1.9, 5.1). For Greek, these were 2.0 (95% CI 1.1, 4.0) and 2.7 (95% CI 1.4, 5.2). Arabic patients had elevated, but not statistically significant, odds ratios compared to Anglo-Australians. Written information and having a specialist, support services, and other health professionals who spoke their language were in the top ten unmet needs amongst immigrants. CONCLUSION: Immigrant cancer survivors, several years after initial diagnosis, are more likely to have an unmet need for information or for help with a physical problem than Anglo-Australians. They strongly desire information and support in their own language.

Preserved cognitive function is associated with suicidal ideation and single suicide attempts in schizophrenia.

OBJECTIVE: Suicide is the leading cause of death in schizophrenia. An association between suicidal behavior and both higher and lower cognitive ability in schizophrenia has been reported. To clarify this relationship, we investigated whether the relationship between suicidality and neurocognition varied according to differences in suicidal ideation and behavior. METHODS: Three hundred and ten patients with DSM-IV diagnoses of schizophrenia or schizoaffective disorder were categorized based on patient and staff interviews as either non-suicide attempters, non-attempters expressing suicidal ideation, single suicide attempters, or multiple suicide attempters. These groups were compared on a neuropsychological battery examining current general cognitive ability, episodic and working memory, and attentional control. RESULTS: Neuropsychological performance in those with a history of suicidal ideation (n=63), and those who had made one suicide attempt (n=48) was comparable. Together, these groups outperformed patients with no history of either suicidal behavior or ideation (n=172) on measures of IQ, episodic memory and working memory. Only differences in global cognition remained significant after controlling for between-group differences in depressive symptoms. Those who had either expressed suicidal ideation and/or made a single suicide attempt demonstrated trend level advantages in neuropsychological tests over those that had made multiple suicide attempts. DISCUSSION: These findings support earlier evidence of an association between suicidality and neurocognitive ability in schizophrenia. Specifically, these data suggest that patients who have contemplated suicide or made a single suicide attempt have better cognitive functioning than those who have not. Suicidality in multiple attempters, who do not perform better in neurocognitive tests than those who have neither contemplated nor attempted suicide, is likely to be influenced by factors other than neurocognitive ability.

A comparison of the FACT-G and the Supportive Care Needs Survey (SCNS) in women with ovarian cancer: unidimensionality of constructs.

PURPOSE: Health-related quality of life (HRQoL) and unmet needs (needs) questionnaires offer alternative perspectives for assessing cancer patients' concerns. We examined whether the conceptual differences underlying these alternative approaches yield corresponding empirical differences. METHODS: Eight-hundred and seventy-four women with ovarian cancer completed the Functional Assessment of Cancer Therapy scale (FACT-G; HRQoL) and the Supportive Care Needs Survey (SCNS-SF34; needs) every 3 months for 2 years. Correlational analysis, exploratory and confirmatory factor analysis (EFA/CFA), and Rasch analysis tested the relationship between patients' responses to similar domains and similar items across the two questionnaires. RESULTS: Strong correlations were found between items with virtually identical wording (0.67-0.75), while moderate to strong correlations (0.55-0.65) were found for those with very similar wording. EFA identified two common domains across the two questionnaires: physical and psychological. For each common domain, CFA indicated models involving a single construct with systematic variation within each questionnaire fit best. Rasch analysis including very similar items within the physical and psychological domains (separately) demonstrated strong evidence of unidimensionality. CONCLUSIONS: The high degree of similarity between patient responses to items addressing the same or very similar concerns suggests either that HRQoL and needs approaches do not reflect different constructs or that patients may not be able to differentiate between the severity of a concern and the level of need associated with that concern, especially when these are assessed in quick succession.

Unilateral balsalazide-induced eosinophilic pneumonia in an ulcerative colitis patient.

We report a case of unilateral eosinophilic pneumonia secondary to balsalazide monotherapy for ulcerative colitis. After commencing balsalazide, the patient presented with a history of cough, progressive dyspnoea and lethargy. Blood counts revealed peripheral eosinophilia. Her chest radiograph showed left-sided infiltration, and high-resolution computerised tomography demonstrated widespread nodular shadowing and ground glass opacifiction in the left lung. The right lung was normal. Transbronchial lung biopsy confirmed eosinophilic pneumonia. There was rapid clinical and radiological improvement after with-drawing balsalazide. Drug-induced eosinophilic pneumonia has been described with mesalazine and sulfasalazine, but no case reports of balsalazide-induced eosinophilic pneumonitis have been found.

Experiences with vaccination in countries endemically infected with highly pathogenic avian influenza: the Food and Agriculture Organization perspective.

Vaccination has been used extensively for the control and prevention of highly pathogenic avian influenza (HPAI) caused by viruses of the H5N1 subtype in endemically infected countries. The Food and Agriculture Organization views vaccination as a legitimate aid in the control and prevention of infection and disease caused by HPAI viruses but does not see it as a panacea. Vaccination should be used as just one in a number of measures used together to reduce the effect and risk of infection. It will be required for a considerable time in endemically infected countries. The methods used in Vietnam in implementing blanket vaccination against H5N1 HPAI viruses demonstrate the steps that should be considered when introducing vaccination. So far, it has not been possible to determine the precise effect of vaccination in endemically infected countries because it has been used in combination with other measures. Well managed vaccination campaigns will reduce the incidence of infection in poultry and therefore reduce the risk to humans from these viruses. Vaccination was implemented to protect both poultry and humans, with a major goal being to reduce the risk of emergence of a human influenza pandemic virus. Economic analysis of vaccination should focus on cost-effectiveness of proposed strategies. Ex-ante and ex-post evaluation of vaccination campaigns should take into account the benefits generated in the poultry sector and for human health.

Field evaluation of an indirect ELISA for detection of brucellosis in lowland Bolivia.

Bovine brucellosis exists endemically at an estimated prevalence of 10% in the developing dairy industry of Santa Cruz in tropical Bolivia. This paper describes field testing of an FAO/IAEA indirect ELISA for brucellosis, as a possible replacement confirmatory test for the complement fixation test (CFT). The ELISA and CFT were compared on sera from 3 cattle populations: a non-vaccinated negative population, an S19-vaccinated negative population, and a brucellosis-positive population of unknown vaccination status. The CFT and ELISA showed excellent specificities of 100% and 98% respectively against the negative non-vaccinated group. The CFT maintained a specificity of 98% against the S19-vaccinated negative group, but ELISA specificity fell to 83% using a cut-off of 20% of positive control, and 94% using a cut-off of 40% of positive control. Against sera from the positive population, the ELISA gave many more positive reactions than the CFT, probably a combination of both higher sensitivity and lower specificity. It is concluded that as Santa Cruz is entering a phase of brucellosis control rather than eradication, the extra sensitivity of the ELISA is not valuable enough to risk a higher level of false positive reactions, especially as S19 vaccination is being increasingly used.