A Systematic Review and Meta-analysis of Clinical Outcomes in Autologous Breast Reconstruction Using Internal Mammary Artery Perforators as Recipient Vessels.

Recipient vessel selection is vital for successful autologous free-flap breast reconstruction. Internal mammary artery perforators have gained interest as a recipient vessel option. However, previous studies on their microsurgical safety and efficacy are limited and inconsistent. Thus, we conducted a systematic review and meta-analysis to assess the safety and effectiveness of using internal mammary artery perforators as recipient vessels in breast reconstruction. Methods: The protocol has been previously published in PROSPERO (CRD42020190020). The PubMed, Scopus, Web of Science, and PROSPERO databases were searched. Two independent reviewers evaluated the articles for inclusion in the study. Study quality was assessed using the Newcastle-Ottawa Scale and the MINORS instrument (Methodological Index for Non-Randomized Studies). Results: Of the 361 articles screened, 13 studies were included (313 patients with 318 flaps; 223 unilateral, 31 bilateral, mean average age 51.2 and mean BMI 27.8 ± 1.9). The mean overall success rate was 99.8%, the pooled surgical success rate was 100% [95% confidence interval (CI): 97%-100%], and the overall rate of complications was 11% (95% CI: 7%-18%). The most common complication was vascular-related to microanastomoses, with an incidence of 5% (95% CI: 2%-10%). The fat necrosis rate was 3% (95% CI: 2%-6%). Conclusions: This study verified that internal mammary artery perforator vessels are reliable in breast reconstruction, with a high success rate and a relatively low complication rate. Moreover, in selected microsurgical breast reconstruction patients, internal mammary artery perforators may be the primary recipient vessel choice over the internal mammary artery or thoracodorsal vessels.

Reaction mechanism of the Me3AuPMe3-H2 plasma-enhanced ALD process.

The reaction mechanism of the recently reported Me3AuPMe3-H2 plasma gold ALD process was investigated using in situ characterization techniques in a pump-type ALD system. In situ RAIRS and in vacuo XPS measurements confirm that the CH3 and PMe3 ligands remain on the gold surface after chemisorption of the precursor, causing self-limiting adsorption. Remaining surface groups are removed by the H2 plasma in the form of CH4 and likely as PHxMey groups, allowing chemisorption of new precursor molecules during the next exposure. The decomposition behaviour of the Me3AuPMe3 precursor on a Au surface is also presented and linked to the stability of the precursor ligands that govern the self-limiting growth during ALD. Desorption of the CH3 ligands occurs at all substrate temperatures during evacuation to high vacuum, occurring faster at higher temperatures. The PMe3 ligand is found to be less stable on a gold surface at higher substrate temperatures and is accompanied by an increase in precusor decomposition on a gold surface, indicating that the temperature dependent stability of the precursor ligands is an important factor to ensure self-limiting precursor adsorption during ALD. Remarkably, precursor decomposition does not occur on a SiO2 surface, in situ transmission absorption infrared experiments indicate that nucleation on a SiO2 surface occurs on Si-OH groups. Finally, we comment on the use of different co-reactants during PE-ALD of Au and we report on different PE-ALD growth with the reported O2 plasma and H2O process in pump-type versus flow-type ALD systems.

Thermal atomic layer deposition of gold nanoparticles: controlled growth and size selection for photocatalysis.

Gold nanoparticles have been extensively studied for their applications in catalysis. For Au nanoparticles to be catalytically active, controlling the particle size is crucial. Here we present a low temperature (105 °C) thermal atomic layer deposition approach for depositing gold nanoparticles on TiO2 with controlled size and loading using trimethylphosphino-trimethylgold(iii) and two co-reactants (ozone and water) in a fluidized bed reactor. We show that the exposure time of the precursors is a variable that can be used to decouple the Au particle size from the loading. Longer exposures of ozone narrow the particle size distribution, while longer exposures of water broaden it. By studying the photocatalytic activity of Au/TiO2 nanocomposites, we show how the ability to control particle size and loading independently can be used not only to enhance performance but also to investigate structure-property relationships. This study provides insights into the mechanism underlying the formation and evolution of Au nanoparticles prepared for the first time via vapor phase atomic layer deposition. Employing a vapor deposition technique for the synthesis of Au/TiO2 nanocomposites eliminates the shortcomings of conventional liquid-based processes opening up the possibility of highly controlled synthesis of materials at large scale.

Plasma-Enhanced Atomic Layer Deposition of Nanostructured Gold Near Room Temperature.

A plasma-enhanced atomic layer deposition (PE-ALD) process to deposit metallic gold is reported, using the previously reported Me3Au(PMe3) precursor with H2 plasma as the reactant. The process has a deposition window from 50 to 120 °C with a growth rate of 0.030 ± 0.002 nm per cycle on gold seed layers, and it shows saturating behavior for both the precursor and reactant exposure. X-ray photoelectron spectroscopy measurements show that the gold films deposited at 120 °C are of higher purity than the previously reported ones (<1 at. % carbon and oxygen impurities and <0.1 at. % phosphorous). A low resistivity value was obtained (5.9 ± 0.3 µΩ cm), and X-ray diffraction measurements confirm that films deposited at 50 and 120 °C are polycrystalline. The process forms gold nanoparticles on oxide surfaces, which coalesce into wormlike nanostructures during deposition. Nanostructures grown at 120 °C are evaluated as substrates for free-space surface-enhanced Raman spectroscopy (SERS) and exhibit an excellent enhancement factor that is without optimization, only one order of magnitude weaker than state-of-the-art gold nanodome substrates. The reported gold PE-ALD process therefore offers a deposition method to create SERS substrates that are template-free and does not require lithography. Using this process, it is possible to deposit nanostructured gold layers at low temperatures on complex three-dimensional (3D) substrates, opening up opportunities for the application of gold ALD in flexible electronics, heterogeneous catalysis, or the preparation of 3D SERS substrates.

Nested Basin-Sampling.

We report an embarrassingly parallel method for the evaluation of thermodynamic properties over an energy landscape exhibiting broken ergodicity, nested is the likelihood of the observed data D givenbasin-sampling (NBS). We also introduce the No Galilean U-Turn Sampler (NoGUTS), a new sampling scheme based on the No U-Turn Sampler (NUTS) introduced by Hoffman and Gelman (2014) that works with the Galilean Monte Carlo scheme introduced by Betancourt (2012) to aid the efficient generation of new live points. NoGUTS can be thought of as a form of reflective slice sampling with an automatic stopping criterion. We apply this approach to a benchmark atomic cluster of 31 Lennard-Jones atoms, which exhibits a low temperature solid-solid heat capacity peak. The calculated heat capacity is compared with results generated by parallel tempering (PT), basin-sampling parallel tempering (BSPT), and standard nested sampling (NS) simulations. NBS reproduces the full heat capacity curve predicted by PT and BSPT, while the NS calculation with similar computational cost fails to resolve the low-temperature solid-solid phase transition.

Rational Design of 5-(4-(Isopropylsulfonyl)phenyl)-3-(3-(4-((methylamino)methyl)phenyl)isoxazol-5-yl)pyrazin-2-amine (VX-970, M6620): Optimization of Intra- and Intermolecular Polar Interactions of a New Ataxia Telangiectasia Mutated and Rad3-Related (ATR) Kinase Inhibitor.

The DNA damage response (DDR) is a DNA damage surveillance and repair mechanism that can limit the effectiveness of radiotherapy and DNA-damaging chemotherapy, commonly used treatment modalities in cancer. Two related kinases, ataxia telangiectasia mutated (ATM) and ATM and Rad3-related kinase (ATR), work together as apical proteins in the DDR to maintain genome stability and cell survival in the face of potentially lethal forms of DNA damage. However, compromised ATM signaling is a common characteristic of tumor cells, which places greater reliance on ATR to mediate the DDR. In such circumstances, ATR inhibition has been shown to enhance the toxicity of DNA damaging chemotherapy to many cancer cells in multiple preclinical studies, while healthy tissue with functional ATM can tolerate ATR inhibition. ATR therefore represents a very attractive anticancer target. Herein we describe the discovery of VX-970/M6620, the first ATR inhibitor to enter clinical studies, which is based on a 2-aminopyrazine core first reported by Charrier ( J. Med. Chem. 2011 , 54 , 2320 - 2330 , DOI: 10.1021/jm101488z ).

Plastic Surgeon-Led Ultrasound.

BACKGROUND: Portable high-frequency ultrasound is a useful adjunct to a plastic surgeon's practice. With a short learning curve, this patient-friendly imaging modality has a variety of uses that aid patient management/treatment plans. The authors describe clinical cases and review the literature regarding ultrasound performed by the surgeon. METHODS: The Sonosite S-Nerve machine with the L25X transducer was used (depth, 4.3 cm). Clinical cases that ordinarily would have been referred to the radiology department were taken from the day-to-day practice of the senior author (M.G.). The clinical scenarios ranged from acute presentations to planned elective settings. RESULTS: Ultrasound was a useful adjunct in a variety of applications, ranging from acute hand trauma visualizing neurovascular bundles and tendons, to elements of reconstructive breast surgery such as fat grafting over an implant and scar release. The ultrasound machine was also used for determination of the depth and size of collections such as seromas to facilitate drainage, for identification of lymph nodes before transfer, and for acute presentations of conditions ranging from undiagnosed swelling to foreign body localization. CONCLUSIONS: The portable ultrasound machine has become an invaluable tool in the senior author's practice. In a short time and with a short learning curve, the authors' unit identified numerous applications for its use. From a patient perspective, it is noninvasive/nonpainful and has no deleterious radiation effects, and treatment plans can be enacted without delay. It is highly recommended that surgeons become familiar with this imaging modality and assimilate it into their daily practice. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Optimal Alignment of Structures for Finite and Periodic Systems.

Finding the optimal alignment between two structures is important for identifying the minimum root-mean-square distance (RMSD) between them and as a starting point for calculating pathways. Most current algorithms for aligning structures are stochastic, scale exponentially with the size of structure, and the performance can be unreliable. We present two complementary methods for aligning structures corresponding to isolated clusters of atoms and to condensed matter described by a periodic cubic supercell. The first method (Go-PERMDIST), a branch and bound algorithm, locates the global minimum RMSD deterministically in polynomial time. The run time increases for larger RMSDs. The second method (FASTOVERLAP) is a heuristic algorithm that aligns structures by finding the global maximum kernel correlation between them using fast Fourier transforms (FFTs) and fast SO(3) transforms (SOFTs). For periodic systems, FASTOVERLAP scales with the square of the number of identical atoms in the system, reliably finds the best alignment between structures that are not too distant, and shows significantly better performance than existing algorithms. The expected run time for Go-PERMDIST is longer than FASTOVERLAP for periodic systems. For finite clusters, the FASTOVERLAP algorithm is competitive with existing algorithms. The expected run time for Go-PERMDIST to find the global RMSD between two structures deterministically is generally longer than for existing stochastic algorithms. However, with an earlier exit condition, Go-PERMDIST exhibits similar or better performance.

Use of key performance indicators in histological dissection.

AIMS: Reports into standards in the National Health Service and quality in pathology have focused on the way we work in pathology and how to provide assurance that this is of a high standard. There are a number of external quality assurance schemes covering pathology and histopathology specifically; however, there is no scheme covering the process of histological surgical dissection. This is an area undergoing development, emerging from the sole preserve of medically qualified pathologists to a field populated by a number of highly trained biomedical scientists, but remains without any formal quality assurance. METHODS: This work builds on Barnes, taking the guidance of the Royal College of Pathologists (RCPath)and Institute of Biomedical Science (IBMS)to form a series of key performance indicators relating to dissection. These were developed for use as an indicator of individual practice, highlighting areas of variation, weakness or strength. Once identified, a feedback event provided opportunities to address these errors and omissions, or to enable areas of strength to be shared. RESULTS: The data obtained from the checklists demonstrate a large variation in practice at the outset of this study. The use of the checklists alone served to reduce this variation in practice, the addition of the training event showed further reduction in variation. The combination of these two tools was an effective method for enhancing standardisation of practice. CONCLUSIONS: The results of this work show that training events serve to reduce variation in practice by, and between, dissectors, driving up standards in dissection-directly addressing the needs of the modern pathology service.

Crowdsourcing for translational research: analysis of biomarker expression using cancer microarrays.

BACKGROUND: Academic pathology suffers from an acute and growing lack of workforce resource. This especially impacts on translational elements of clinical trials, which can require detailed analysis of thousands of tissue samples. We tested whether crowdsourcing - enlisting help from the public - is a sufficiently accurate method to score such samples. METHODS: We developed a novel online interface to train and test lay participants on cancer detection and immunohistochemistry scoring in tissue microarrays. Lay participants initially performed cancer detection on lung cancer images stained for CD8, and we measured how extending a basic tutorial by annotated example images and feedback-based training affected cancer detection accuracy. We then applied this tutorial to additional cancer types and immunohistochemistry markers - bladder/ki67, lung/EGFR, and oesophageal/CD8 - to establish accuracy compared with experts. Using this optimised tutorial, we then tested lay participants' accuracy on immunohistochemistry scoring of lung/EGFR and bladder/p53 samples. RESULTS: We observed that for cancer detection, annotated example images and feedback-based training both improved accuracy compared with a basic tutorial only. Using this optimised tutorial, we demonstrate highly accurate (>0.90 area under curve) detection of cancer in samples stained with nuclear, cytoplasmic and membrane cell markers. We also observed high Spearman correlations between lay participants and experts for immunohistochemistry scoring (0.91 (0.78, 0.96) and 0.97 (0.91, 0.99) for lung/EGFR and bladder/p53 samples, respectively). CONCLUSIONS: These results establish crowdsourcing as a promising method to screen large data sets for biomarkers in cancer pathology research across a range of cancers and immunohistochemical stains.

Cost Utility of Omalizumab Compared with Standard of Care for the Treatment of Chronic Spontaneous Urticaria.

BACKGROUND: Chronic spontaneous urticaria (CSU) negatively impacts patient quality of life and productivity and is associated with considerable indirect costs to society. OBJECTIVE: The aim of this study was to assess the cost utility of add-on omalizumab treatment compared with standard of care (SOC) in moderate or severe CSU patients with inadequate response to SOC, from the UK societal perspective. METHODS: A Markov model was developed, consisting of health states based on Urticaria Activity Score over 7 days (UAS7) and additional states for relapse, spontaneous remission and death. Model cycle length was 4 weeks, and total model time horizon was 20 years in the base case. The model considered early discontinuation of non-responders (response: UAS7 ≤6) and retreatment upon relapse (relapse: UAS7 ≥16) for responders. Clinical and cost inputs were derived from omalizumab trials and published sources, and cost utility was expressed as incremental cost-effectiveness ratios (ICERs). Scenario analyses included no early discontinuation of non-responders and an altered definition of response (UAS7 <16). RESULTS: With a deterministic ICER of £3183 in the base case, omalizumab was associated with increased costs and benefits relative to SOC. Probabilistic sensitivity analysis supported this result. Productivity inputs were key model drivers, and individual scenarios without early discontinuation of non-responders and adjusted response definitions had little impact on results. ICERs were generally robust to changes in key model parameters and inputs. CONCLUSIONS: In this, the first economic evaluation of omalizumab in CSU from a UK societal perspective, omalizumab consistently represented a treatment option with societal benefit for CSU in the UK across a range of scenarios.

The microvascular anastomotic coupler for venous anastomoses in free flap breast reconstruction improves outcomes.

BACKGROUND: Venous couplers are ubiquitous around the world and are a useful tool for the reconstructive microsurgeon. A systematic review of coupler performance studies demonstrated a thrombosis rate range of 0% to 3%, whilst the average time of using the device is 5 minutes. There is sparse published data on cost analysis and the impact of operator experience on the anastomotic coupler device success. Improvements in outcomes other than time benefits have also not been shown. This study aims to address these deficiencies in the literature. METHODS: A retrospective clinical study was undertaken, aiming to compare equivalent groups of patients that had free flap surgery with venous micro-anastomoses with those that had sutured anastomoses. The cohort comprised all patients undergoing microsurgical breast reconstruction at the St Andrew's Centre for Plastic Surgery & Burns from January 2009 to December 2014. RESULTS: Between January 2010 to December 2014, 1,064 patients underwent 1,206 free flap breast reconstructions. The average age of patients was 50 years. Seventy percent of patients underwent mastectomy and immediate reconstruction during this period with the remaining 30% having a delayed reconstruction. The 1,206 free flaps comprised of 83 transverse myocutaneous gracilis (TMG) flaps, and 1,123 deep inferior epigastric artery perforator (DIEP) flaps. In total the coupler was used in 319 flaps, 26% of the cohort. There was a statistically significant clinical benefit in using the anastomotic coupler for venous anastomosis. Overall, the return to theatre rate was 12.69% whilst the overall flap loss rate was 0.75%. The overall coupler failure rate was significantly less at 1.4% whilst sutured vein failure rate was 3.57% (P=0.001). CONCLUSIONS: The anastomotic coupler for venous anastomosis in free flap surgery is associated with reduced operating times, reduced take-backs to theatre and cost benefits. This is the first study to demonstrate clear clinical benefits to anastomotic couplers, and suggests that these may be the gold standard for venous microanastomosis. With increasing experience with their use and technological advances, these outcomes may continue to improve.

Preoperative computed tomography angiography for planning DIEP flap breast reconstruction reduces operative time and overall complications.

BACKGROUND: The approach and operative techniques associated with breast reconstruction have steadily been refined since its inception, with abdominal perforator-based flaps becoming the gold standard reconstructive option for women undergoing breast cancer surgery. The current study comprises a cohort of 632 patients, in whom specific operative times are recorded by a blinded observer, and aims to address the potential benefits seen with the use of computer tomography (CT) scanning preoperatively on operative outcomes, complications and surgical times. METHODS: A prospectively recorded, retrospective review was undertaken of patients undergoing autologous breast reconstruction with a DIEP flap at the St Andrews Centre over a 4-year period from 2010 to 2014. Computed tomography angiography (CTA) scanning of patients began in September 2012 and thus 2 time periods were compared: 2 years prior to the use of CTA scans and 2 years afterwards. For all patients, key variables were collected including patient demographics, operative times, flap harvest time, pedicle length, surgeon experience and complications. RESULTS: In group 1, comprising patients within the period prior to CTA scans, 265 patients underwent 312 flaps; whilst in group 2, the immediately following 2 years, 275 patients had 320 flaps. The use of preoperative CTA scans demonstrated a significant reduction in flap harvest time of 13 minutes (P<0.013). This significant time saving was seen in all flap modifications: unilateral, bilateral and bipedicled DIEP flaps. The greatest time saving was seen in bipedicle flaps, with a 35-minute time saving. The return to theatre rate significantly dropped from 11.2% to 6.9% following the use of CTA scans, but there was no difference in the total failure rate. CONCLUSIONS: The study has demonstrated both a benefit to flap harvest time as well as overall operative times when using preoperative CTA. The use of CTA was associated with a significant reduction in complications requiring a return to theatre in the immediate postoperative period. Modern scanners and techniques can reduce the level of ionising radiation, facilitating patients being able to benefit from the advantages that this preoperative planning can convey.

Stacked and bipedicled abdominal free flaps for breast reconstruction: considerations for shaping.

BACKGROUND: Stacked and bipedicled abdominal flaps are useful in women who require a large breast reconstruction but have relative paucity of abdominal tissue. A new classification system is described to assist the surgeon in achieving the best possible aesthetic outcome. METHODS: A retrospective review of 25 consecutive stacked and/or bipedicled deep inferior epigastric perforator (DIEP) flap reconstructions was assessed from 2009 to 2014. Demographic data and key variables were prospectively collected in our breast reconstruction database and an aesthetic classification devised. There are four main subtypes, (I) folded; (II) divided; (III) coned; and (IV) divided and folded. Each of these subtypes can be moulded in a symmetrically or asymmetrically fashion depending on the contralateral breast shape together with distribution and consistency of fat within the abdominal flap. RESULTS: Of the 25 patients, three-quarter were immediate reconstruction, with an average age of 48 years and a median follow-up of 2 years 10 months. Just over half the patients (57%) had bipedicle flaps with two recipient donor vessels with the remaining 43% had stacked flaps. The most common recipient sites are the thoracodorsal vessels (62%) and intercostal perforators (26%). The average abdominal pannus weight was 610 grams (SD: 320 grams), with a hemi-abdominal weight of 305 grams. Two patients had haematomas, of which one lost their reconstruction. Another patient had a venous congestion flap which was salvaged. CONCLUSIONS: Bipedicled or stacked abdominal flaps allow the all four zones of the abdominal tissue to be used in unilateral breast reconstruction. The approach of tailoring the abdominal flaps to match the contralateral breast reconstruction is largely an art form. The paper aims to bring some meaningful system to aid the surgeon to achieve the best possible outcome with the components presented to them.

Indocyanine green-based fluorescent angiography in breast reconstruction.

BACKGROUND: Fluorescent angiography (FA) has been useful for assessing blood flow and assessing tissue perfusion in ophthalmology and other surgical disciplines for decades. In plastic surgery, indocyanine green (ICG) dye-based FA is a relatively novel imaging technology with high potential in various applications. We review the various FA detector systems currently available and critically appraise its utility in breast reconstruction. METHODS: A review of the published English literature dating from 1950 to 2015 using databases, such as PubMed, Medline, Web of Science, and EMBASE was undertaken. RESULTS: In comparison to the old fluorescein dye, ICG has a superior side effect profile and can be accurately detected by various commercial devices, such as SPY Elite (Novadaq, Canada), FLARE (Curadel LLC, USA), PDE-Neo (Hamamatsu Photonics, Japan), Fluobeam 800 (Fluoptics, France), and IC-View (Pulsion Medical Systems AG, Germany). In breast reconstruction, ICG has established as a safer, more accurate tracer agent, in lieu of the traditional blue dyes, for detection of sentinel lymph nodes with radioactive isotopes ((99m)-Technetium). In prosthesis-based breast reconstruction, intraoperative assessment of the mastectomy skin flap to guide excision of hypoperfused areas translates to improved clinical outcomes. Similarly, in autologous breast reconstructions, FA can be utilized to detect poorly perfused areas of the free flap, evaluate microvascular anastomosis for patency, and assess SIEA vascular territory for use as an alternative free flap with minimal donor site morbidity. CONCLUSIONS: ICG-based FA is a novel, useful tool for various applications in breast reconstruction. More studies with higher level of evidence are currently lacking to validate this technology.

Lymphatic mapping and preoperative imaging in the management of post-mastectomy lymphoedema.

Early detection and diagnosis of upper extremity lymphoedema in patients after mastectomy and axillary lymph node clearance is important in order to treat disease before it is too advanced to achieve favourable outcomes. Patients with disease refractory to conservative management can be efficiently assessed for diagnosis and surgical intervention using advanced lymphatic imaging techniques. The current paper highlights the more readily available of these: lymphoscintigraphy, indocyanine green (ICG) lymphangiography and immunofluorescence, magnetic resonance lymphangiography (MRL) and computed tomographic lymphangiography in combination or individually. With such techniques, both diagnosis and treatment of lymphoedema has become more readily achieved, with lymphatico-venous and lymphatico-lymphatic anastomosis, and lymph node transfer now increasingly common undertakings.

Microsurgical Reconstruction of Large Oncologic Chest Wall Defects for Locally Advanced Breast Cancer or Osteoradionecrosis: A Retrospective Review of 26 Cases over a 5-Year Period.

BACKGROUND: Locally advanced breast cancer (LABC) and chest wall osteoradionecrosis (ORN) often require extensive and composite tissue resection, including muscles, ribs, pleura, and lung parenchyma. As such, these cases necessitate complex reconstructive procedures for skeletal chest wall reconstruction and soft tissue resurfacing of extensive defects. Traditional local and regional flaps are often inadequate, and many such cases are prospectively labeled "unresectable." METHODS: We report a single-center experience with the microsurgical reconstruction of such defects over a 5-year period. Between 2007 and 2011, 1,077 microvascular reconstructive cases following breast cancer resection were performed, of which 26 cases comprised LABC or ORN requiring reconstruction. Surgical indications, defect parameters, choice of reconstruction, and outcomes were assessed. RESULTS: Thirty free flap microsurgical reconstructions were undertaken in 26 cases, with a 96.2% flap survival rate. Complications were low, and mean hospital stay was 8.7 days. An algorithmic approach to management is presented. CONCLUSION: Wide resection and microvascular free tissue transfer provide versatile solutions for the reconstruction of extensive chest wall defects. With good reported perioperative outcomes even in advanced cases, surgical resection of LABC may offer a useful approach in difficult and/or palliative cases.

Police Mental Health Partnership project: Police Ambulance Crisis Emergency Response (PACER) model development.

OBJECTIVES: To review internationally recognized models of police interactions with people experiencing mental health crises that are sometimes complex and associated with adverse experience for the person in crisis, their family and emergency service personnel. To develop, implement and review a partnership model trial between mental health and emergency services that offers alternative response pathways with improved outcomes in care. METHODS: Three unique models of police and mental health partnership in the USA were reviewed and used to develop the PACER (Police Ambulance Crisis Emergency Response) model. A three month trial of the model was implemented and evaluated. RESULTS: Significant improvements in response times, the interactions with and the outcomes for people in crisis were some of the benefits shown when compared with usual services. CONCLUSIONS: The pilot showed that a partnership involving mental health and police services in Melbourne, Australia could be replicated based on international models. Initial data supported improvements compared with usual care. Further data collection regarding usual care and this new model is required to confirm observed benefits.