Assessing Breast Cancer Risks to Improve Care for an Increased-Risk Population within Eastern North Carolina.

BACKGROUND The average lifetime risk of breast cancer for an American woman is 12.5%, but individual risks vary significantly. Risk modeling is a standard of care for breast cancer screening and prevention with recommended tools to stratify individual risks based on age, family history, breast density, and a host of other known risk factors. Because of a lack of resources rurally, we have not consistently met this standard of care within all of North Carolina.METHODS We implemented a quality improvement project to assess the risk for breast cancer by gathering data on community risks. We implemented an evidence-based tool (Tyrer-Cuzick) for quantifying risk within a mostly rural population of Eastern North Carolina and developed customized services for women meeting elevated-risk definition. These services included additional imaging for elevated-risk women and a risk-reduction program. We also assessed genetic risks for hereditary breast and ovarian cancer in our at-risk population using National Comprehensive Cancer Network (NCCN) guidelines based on family history and added local genetics extenders to help test more women. We analyzed data regularly using Plan-Do-Study-Act methods to improve outcomes over 1 year.RESULTS We screened a population of 4500 women at a community hospital over a 1-year period for their individual lifetime cancer risk and genetic risk. Breast cancer risk was quantitated at the time of mammography, and women were stratified into 3 groups for risk management. Within our screening population, 6.3% of women were at high risk (defined by a lifetime breast cancer risk greater than or equal to 20%) and another 8.1% were above-average risk (defined by a lifetime breast cancer risk of 15%-20%). These women (14.4%) could potentially benefit from additional risk-management strategies. Additionally, 20% of all unaffected women within a typical screening population of Eastern North Carolina met NCCN guidelines for hereditary breast cancer and ovarian cancer testing independent of their cancer risk score. Using a model of targeted intervention within a population with elevated risks can be helpful in improving outcomes.LIMITATIONS This population within Eastern North Carolina is mostly rural and represents a potentially biased population, as it involves older women undergoing annual mammography. It may not be broadly applicable to the entire population based on age, geography, and other risks.CONCLUSIONS This model for improving cancer risk assessment and testing at a small community hospital in Eastern North Carolina was successful and addressed a community need. We discovered a high rate of increased-risk women who can benefit from individualized risk management, and a higher percentage of women who potentially benefit from genetic testing. These higher cumulative risks may in part explain some of the disparities seen for breast-cancer-specific outcomes in some parts of the state.

Isavuconazole to prevent invasive fungal infection in immunocompromised adults: Initial experience at an academic medical centre.

OBJECTIVE: To evaluate clinical and economic outcomes associated with the use of isavuconazole as antifungal prophylaxis in high-risk immunocompromised patients. PATIENTS/METHODS: Retrospective, single-centre cohort study of patients who received isavuconazole prophylaxis. Outcomes assessed included breakthrough IFI, early discontinuation of isavuconazole for any reason and antifungal prophylaxis prescribed at discharge. The impact on inpatient drug expenditure was evaluated using current isavuconazole and posaconazole drug costs per observed isavuconazole days of therapy (DOT) during the study period. RESULTS: One hundred thirty-eight courses of isavuconazole prophylaxis were administered to 98 inpatients (2193 DOT). Relapsed/refractory acute myelogenous leukaemia was the indication for prophylaxis in over half (59.4%) of patients. Breakthrough IFI occurred in 8 (5.8%) courses. Suspected drug-related toxicities led to early discontinuation in 6 (4.3%) courses (five hepatotoxicity, one drug rash). At discharge, 24 (17.4%) courses lacked insurance coverage for isavuconazole. The formulary switch to isavuconazole prophylaxis resulted in an estimated mean drug cost savings of $128.25 per DOT relative to estimated posaconazole costs (P < 0.001). CONCLUSION: Isavuconazole may be an option for antifungal prophylaxis in high-risk immunocompromised adults and has the potential to produce significant inpatient drug cost savings. Further studies are needed to confirm the clinical efficacy and cost-effectiveness of isavuconazole in this role.

Dioxidomolybdenum(VI) complex featuring a 2,4-di-fluoro-substituted amine bis-(phenolate) ligand.

Synthetic complexes containing a cis-[MoO2]2+ core are well-established models for the molybdenum co-factor (Moco). Here we report the crystal structure of such a model complex bearing a tetra-dentate amine bis-(phenolate) ligand with fluorine substituents on the phenolate rings, namely, [2,2'-({[2-(di-methyl-amino)-eth-yl]aza-nedi-yl}bis-(methyl-ene))bis-(4,6-di-fluoro-phenolato)]dioxidomolybden-um(VI)), [Mo(C18H18F4N2O2)O2]. Distortion from idealized octa-hedral symmetry about the Mo center is evident in the large O=Mo=O angle [108.54 (4)°] and the small N-Mo-Ophenolate angles [79.79 (4), 81.21 (3), 77.83 (3), and 84.59 (3)°]. The dihedral angle between the phenolate rings is 60.06 (4)°, and π-π stacking is observed between aromatic rings related by inversion (1 - x, 1 - y, 1 - z). The lower data-collection temperature of 150 K vs room-temperature data collection reported previously [KOWXIF; Cao et al. (2014 ▸). Transit. Met. Chem. 39, 933-937] and larger 2θ range for data collection (5.8-66.6° versus 6-54.96°) led to a structure with lower R 1 and ωR 2 values (0.019 and 0.049 vs 0.0310 and 0.0566 for KOWXIF). Comparison of the metrical parameters with KOWXIF suggests that this dataset offers a more realistic depiction of bonding within the MoVI=O moiety.

A call to action: Preparing a disability-competent health care workforce.

People with disabilities make up the largest minority population in the country, yet our health care workforce is unprepared to meet their needs. Two initiatives - and the Alliance for Disability in Health Care Education's Disability Competencies and the Resources for Integrated Care Disability-Competent Care model-provide essential tools to build a health care workforce prepared to meet the health needs of people with disabilities. We note gaps in health education and continuing education curricula, document barriers to progress, and demonstrate how the two initiatives offer a clear roadmap to effect systemic change. Finally, we issue a call to action for health care education, practice, and research to ensure a health care workforce prepared to provide quality health care to people with disabilities.

Dalbavancin use in an academic medical centre and associated cost savings.

Dalbavancin is a lipoglycopeptide antibiotic with unique weekly dosing active against Gram-positive organisms. This retrospective study included 37 patients receiving a mean of 2.7 weeks of dalbavancin. Nine patients (24%) were re-admitted to the hospital within 30 days. A total of 617 hospital days were saved, estimated to result in US$1 495 336 in savings and a mean cost avoidance of US$40 414 per patient. Dalbavancin provides a valuable antibiotic option that may minimise healthcare expenditure.