Impact of family history risk assessment on surgical decisions and imaging surveillance at breast cancer diagnosis.

INTRODUCTION: In June 2013, the National Institute for Health and Care Excellence (NICE) published guidance on the management of women with a family history (FH) of breast cancer (BC) and a personal diagnosis of BC. When diagnosed with BC, pressure of timely treatment takes priority and there is potential for a significant FH to be overlooked. This can affect treatment options and follow-up imaging (FUI) surveillance. METHODS: The practice in our breast unit was compared with the NICE guidance with regard to arranging appropriate FUI and referral to the genetics team for women diagnosed with BC with a FH of BC. Data were obtained retrospectively on 200 women with BC, identified from the breast multidisciplinary team meetings from January to March 2014. Initial audit showed poor compliance with recording of FH. A standardised history taking proforma was produced for clinic use. A re-audit was conducted on a further 200 women between May and July 2016. RESULTS: In the initial audit, FH was taken in 151 women (76%) compared with 174 women (87%) in the re-audit. Thirty-seven women (25%) were thought to be of moderate risk (MR) or high risk (HR) based on FH in the first audit. Re-audit identified 35 women (20%) with MR or HR FH. Under half (43%) of the women of HR were referred to the genetics team initially; this increased to 70% in the second audit. While almost half (46%) of the women with MR or HR had inappropriate FUI in the initial audit, this fell to 11% in the re-audit. CONCLUSIONS: A proportion of women diagnosed with BC would fall into the MR or HR categories as defined in the NICE FH guidance. Inadequate recording of FH could result in inadequate FUI surveillance and in some cases missing the opportunity for a genetic referral to assess suitability for gene testing.

Breast implant associated anaplastic large cell lymphoma: The UK experience. Recommendations on its management and implications for informed consent.

BACKGROUND: Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare, Non-Hodgkin lymphoma arising in the capsule of breast implants. BIA-ALCL presents as a recurrent effusion and/or mass. Tumours exhibit CD30 expression and are negative for Anaplastic Lymphoma Kinase (ALK). We report the multi-disciplinary management of the UK series and how the stage of disease may be used to stratify treatment. METHODS: Between 2012 and 2016, 23 cases of BIA-ALCL were diagnosed in 15 regional centres throughout the UK. Data on breast implant surgeries, clinical features, treatment and follow-up were available for 18 patients. RESULTS: The mean lead-time from initial implant insertion to diagnosis was 10 years (range: 3-16). All cases were observed in patients with textured breast implants or expanders. Fifteen patients with breast implants presented with stage I disease (capsule confined), and were treated with implant removal and capsulectomy. One patient received adjuvant chest-wall radiotherapy. Three patients presented with extra-capsular masses (stage IIA). In addition to explantation, capsulectomy and excision of the mass, all patients received neo-/adjuvant chemotherapy with CHOP as first line. One patient progressed on CHOP but achieved pathological complete response (pCR) with Brentuximab Vedotin. After a mean follow-up of 23 months (range: 1-56) all patients reported here remain disease-free. DISCUSSION: BIA-ALCL is a rare neoplasm with a good prognosis. Our data support the recommendation that stage I disease be managed with surgery alone. Adjuvant chemotherapy may be required for more invasive disease and our experience has shown the efficacy of Brentuximab as a second line treatment.

Oxygen exchange and C-reactive protein predict safe discharge in patients with H1N1 influenza.

BACKGROUND: : Pandemic influenza has potential to overwhelm healthcare resources. There is uncertainty over performance of existing triage tools for hospital admission and discharge decisions. AIM: : Our aim was to identify clinical criteria that predict safe discharge from hospital and develop a pragmatic triage tool to guide physician decision-making. DESIGN: : We retrospectively examined an existing database of patients who presented to the Royal Liverpool University Hospital during the 2010-11 influenza pandemic. METHODS: Inclusion criteria: patients ≥18 years, with PCR confirmed H1N1 influenza. Exclusion criteria: died in the emergency department or case notes unavailable. Successful discharge was defined as discharge within 24 h of presentation and no readmission within 7 days. RESULTS: Eighty-six patients were included and 16 were successfully discharged. Estimated P/F ratio and C-reactive protein predicted safe discharge in a multivariable logistic regression model (AUC 0.883). A composite univariate predictor (estimated P/F minus C-reactive protein, AUC 0.877) was created to calculate specific cut off points for sensitivity and specificity. A pragmatic decision tool was created to incorporate these thresholds and relevant guidelines. Discharge: SpO 2 (in air) ≥ 94% and CRP <50. Observe: SpO 2 ≥ 94% and CRP >50 or SpO 2 ≤ 93% and CRP <50. Admit: SpO 2 ≤ 93% and CRP >50. CONCLUSIONS: We identified that oxygen exchange and CRP, a marker of acute inflammation, were the most important predictors of safe discharge. Our proposed simple triage model requires validation but has the potential to aid clinical decisions in the event of a future pandemic, and potentially for seasonal influenza.

Parasitic infection of the male breast.

Breast lumps are commonly seen in clinical practice, yet deeper exploration of this particular case presented an unusual diagnostic challenge.

'Chemobrain': concentration and memory effects in people receiving chemotherapy - a descriptive phenomenological study.

There is an international literature which claims that there is a link between chemotherapeutic agents and cognitive impairment. Deficits in concentration and memory can have a major impact on decision making about education and careers, and on general quality of life. The literature to date is generally anecdotal, or reports on quantitative research that does not address patients' interpretations of impaired cognition. It was the intention of this study to capture experiences and perceptions of cognitive impairment as told by people receiving chemotherapy. A descriptive phenomenological approach was employed and four participants were interviewed twice. Analysis was conducted using Nvivo software alongside Hycner's analysis framework so that researchers could produce narratives to represent experiences for each case. The description for each case illuminates uniqueness and commonality. 'Chemobrain' is a significant and important issue for many patients but they are often unaware, prior to chemotherapy, that cognition may be affected. There is no shared understanding between patients and healthcare professionals and there is a lack of information about the phenomena which disempower patients. Healthcare professionals should develop knowledge and skills to recognise and address chemotherapy-induced cognitive impairment.

Case report of bilateral inflammatory breast cancer.

Inflammatory breast cancer (IBC) is a rare entity that makes up 1-3% of breast cancers. As the diagnosis of IBC is mainly clinical, for the inexperienced the clinical appearance can mimic mastitis leading to diagnostic delay and it is often associated with a poor prognosis. Very few cases of bilateral IBC are reported in the literature, all of which have been synchronous. We report an unusual case of bilateral metachronous IBC each with complete clinico-pathological response after treatment with neoadjuvant chemotherapy and surgery on both occasions.

Men with cancer: is their use of complementary and alternative medicine a response to needs unmet by conventional care?

This qualitative study aims to investigate why men with cancer choose to use complementary and alternative medicine (CAM), and whether CAM is used to fill 'gaps' in conventional cancer care or as an 'alternative' to conventional treatment. Interviews were carried out with 34 CAM users recruited from a National Health Service (NHS) oncology department, an NHS homeopathic hospital and a private cancer charity offering CAM. Participants used therapies to improve quality of life, to actively 'fight' the disease and possibly prolong life, but rarely as an alternative to conventional treatment. Many were initially sceptical about CAM, but took a 'pragmatic' and 'consumerist' approach to getting their needs met. Gaps in conventional care included: lack of empathy and support during and after treatment, poor continuity of care, and lack of advice on self-help, diet and lifestyle. The skills of CAM therapists may enable them to tap into the underlying needs of men in a way that health professionals do not always have the time or the skills to achieve.

Factors that predict infant disorganization in mothers classified as U in pregnancy.

The unresolved (U) state of mind in parents has been validated by its association with infant attachment disorganization (D), yet all studies show a transmission gap, and a proportion of individuals classified as U have infants who are not D. This paper reports on 31 mothers who showed the characteristic lapses in thinking and reasoning of the unresolved/disorganized state of mind in relation to stillbirth (U(sb)), when assessed with the Adult Attachment Interview (AAI) in the pregnancy after stillbirth. Seventeen (55%) of their infants were D at 1 year old. We evaluate social, attachment, and psychiatric variables to establish whether there are differences in U(sb) individuals that will predict infant D. In this population of U mothers, social and attachment factors did not predict infant D, but U(sb) mothers of non-D infants showed significantly higher levels of depression and of intrusive thoughts on the posttraumatic stress disorder (PTSD) scale in pregnancy, and showed higher levels of intrusive thoughts when the infant was 1 year old. We discuss possible interpretations of these findings.

Factors associated with the unresolved classification of the Adult Attachment Interview in women who have suffered stillbirth.

The "unresolved" state of mind with respect to loss or trauma as assessed in the Adult Attachment Interview is common in clinical and forensic groups, as well as in mothers whose infants are classified as disorganized in their attachment relationship to them. However, questions remain about what the unresolved state represents and what factors predict the unresolved state. This case controlled study reports on 64 women who had suffered stillbirth and who were pregnant with their next child. The study explores attachment, psychiatric, and social factors associated with the unresolved state or higher unresolved scores with respect to stillbirth. Women who had experienced stillbirth were more likely to be unresolved than control women. Although a similar number of stillbirth and control women had experienced childhood trauma, only women who had experienced stillbirth were unresolved with respect to this trauma, suggesting the unresolved state may be evoked or reevoked by subsequent traumatic loss. Higher unresolved scores in relation to stillbirth were predicted by childhood trauma, poor support from family after the loss, and having a funeral for the infant. The results are discussed in terms of the woman's sense of being causal in the loss.

Work-site hypertension prevalence and control in three Central European Countries.

Compared to Austria, cerebrovascular stroke (CVS) mortality is three times higher in Hungary, and twice as high in Slovakia. We hypothesized that this is due to better treatment and control of hypertension in Austria. To test this hypothesis, we carried out a cross-sectional survey of 'blue collar' employees on work sites in each of these countries. Blood pressure screening was carried out at three work sites in Austria, one in Hungary and one in Slovakia. A standardized protocol was followed in each of these countries. The Bp-TRU(TM) measuring instrument was used to provide accurate reproducible readings and eliminate interobserver error. After the exclusion of missing data and women, the study population included 323 males screened in Austria, 600 in Hungary, and 751 in Slovakia. The mean ages of the respondents ranged from 35 to 42 years. The prevalence of hypertension was 29% in Austria, 28% in Hungary and 40% in Slovakia. Of those identified as hypertensive, 73% in Austria, 45% in Hungary and 67% in Slovakia were newly diagnosed as a result of this screening. Of those treated for hypertension, 10% in Austria, 15% in Hungary and 5% in Slovakia were controlled. The differences in CVS mortality cannot be explained by better control of hypertension in Austria but indicate the involvement of other determinants.

User involvement in UK cancer services: bridging the policy gap.

Recent UK government initiatives aim to increase user involvement in the National Health Service (NHS) in two ways: by encouraging service users to take an active role in making decisions about their own care; and by establishing opportunities for wider public participation in service development. The purpose of this study was to examine how UK cancer service users understand and relate to the concept of user involvement. The data were collected through in-depth interviews, which were analysed for content according to the principles of grounded theory. The results highlight the role of information and communication in effective user involvement. Perhaps more importantly, this study suggests that the concept of user involvement is unclear to many cancer service users. This paper argues the need for increased awareness and understanding of what user involvement is and how it can work.

Assessment of guidelines for good practice in psychosocial care of mothers after stillbirth: a cohort study.

BACKGROUND: Most maternity units have good practice protocols, advising that after stillbirth parents should be encouraged to see and hold their dead infant. Our aim was to assess whether adherence to these protocols is associated with measurably beneficial effects on the psychological health of mother and next-born child. This study forms part of a wider case-control study of the psychological effects of stillbirth. METHODS: We identified 65 women in the pregnancy after stillbirth, and enrolled matched controls for 60 of them. Outcome measures included depression, anxiety, and post-traumatic-stress disorder (PTSD) in pregnancy and 1 year after the next birth, and disorganised attachment behaviour in the next-born infant. Comparison variables included seeing and holding the stillborn infant, having a funeral, and keeping mementoes. FINDINGS: Behaviours that promote contact with the stillborn infant were associated with worse outcome. Women who had held their stillborn infant were more depressed than those who only saw the infant, while those who did not see the infant were least likely to be depressed (13 of 33, 39%, vs three of 14, 21%, vs one of 17, 6%; p=0.03). Women who had seen their stillborn infant had greater anxiety (p=0.02) and higher symptoms of PTSD than those who had not (p=0.02), and their next-born infants were more likely to show disorganised attachment behaviour (18 of 43, 42%, vs one of 12, 8%, p=0 x 04). Having a funeral and keeping mementoes were not associated with further adverse outcomes, but small numbers limited interpretation. INTERPRETATION: Our findings do not support good-practice guidelines, which state that failure to see and hold the dead child could have adverse effects on parents' mourning.

Disorganised attachment behaviour among infants born subsequent to stillbirth.

There is limited evidence that siblings of stillborn infants are more vulnerable to psychological problems. This case-controlled study examines the relationship between previous stillbirth and the next child's pattern of attachment and explores factors in the mother which may be associated with and which may explain the pattern of infant attachment. We examined 53 infants next-born after a stillbirth, and 53 control infants of primigravid mothers. Maternal demographic, psychiatric, and attachment data were collected in pregnancy, and self-report measures of depression collected in the first year. Infant attachment patterns to the mothers were assessed when the infants were 12 months old using the Ainsworth Strange Situation Procedure. Infants next-born after stillbirth showed significant increase in disorganisation of attachment to the mother compared with control infants (p < .04). The difference was not accounted for by differences in psychiatric symptoms or demography. It was strongly predicted by maternal unresolved status with respect to loss as measured in the Adult Attachment Interview, and less strongly by maternal experience of elective termination of pregnancy and by the mother having seen her stillborn infant. The study adds weight to previously reported clinical observations, that infants born after stillbirth may be at risk of an increase in psychological and behavioural problems in later childhood. The strong association between disorganisation of infant attachment and maternal state of mind with respect to loss suggests that the mother's state of mind may be causal, and raises interesting questions about the mechanism of intergenerational transmission. Given the existing evidence of later developmental problems, longer-term follow-up of these children would be valuable.

Incidence, correlates and predictors of post-traumatic stress disorder in the pregnancy after stillbirth.

BACKGROUND: Many women may suffer psychological symptoms after stillbirth and in the subsequent pregnancy. Stillbirth has not been demonstrated previously to be a stressor for post-traumatic stress disorder (PTSD). AIMS: To assess incidence, correlates and predictors of PTSD during and after the pregnancy following stillbirth. METHOD: A cohort study of pregnant women whose previous pregnancy ended in stillbirth. RESULTS: PTSD symptoms were prevalent in the pregnancy following stillbirth. Case-level PTSD was associated with depression, state-anxiety and conception occurring closer to loss. Symptoms generally resolved naturally by 1 year post-partum (birth of healthy baby). CONCLUSIONS: Women are vulnerable to PTSD in the pregnancy subsequent to stillbirth, particularly when conception occurs soon after the loss.

The use of a hydrofibre dressing in fulminating necrotizing fasciitis.

This article describes a case of necrotizing fasciitis in a 52-year-old man with previously undiagnosed diabetes. Treatment involved massive debridement and subsequent dressing of the open surgical wound. A modern hydrofibre dressing (Aquacel) was inserted intraoperatively and subsequently continued postoperatively. Wound healing occurred over 3 months and the patient was discharged with no disability. The dressing managed the exudate level and kept the wound moist. It also was well tolerated by the patient, was comfortable and easy for the nurses to remove and apply.

The adult attachment interview: rating and classification problems posed by non-normative samples.

Non-normative samples can pose major procedural and coding challenges to interviewers and raters of the Adult Attachment Interview (AAI). With reference to interview transcripts drawn from a population of personality disordered offenders detained in a high-security hospital, specific difficulties are identified and discussed. These difficulties have their roots in three separate but overlapping areas: extreme attachment-related experience; interviewees' psychological or psychiatric state; and factors relating to the context in which the interview is conducted. They raise questions about whether and when the use of the interview should be restricted, the rating rules elaborated and/or the rating system expanded. Suggestions are made as to how some of the difficulties might be addressed.

Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting "same day" consultations in primary care.

OBJECTIVE: To ascertain any differences between care from nurse practitioners and that from general practitioners for patients seeking "same day" consultations in primary care. DESIGN: Randomised controlled trial with patients allocated by one of two randomisation schemes (by day or within day). SETTING: 10 general practices in south Wales and south west England. SUBJECTS: 1368 patients requesting same day consultations. MAIN OUTCOME MEASURES: Patient satisfaction, resolution of symptoms and concerns, care provided (prescriptions, investigations, referrals, recall, and length of consultation), information provided to patients, and patients' intentions for seeking care in the future. RESULTS: Generally patients consulting nurse practitioners were significantly more satisfied with their care, although for adults this difference was not observed in all practices. For children, the mean difference between general and nurse practitioner in percentage satisfaction score was -4.8 (95% confidence interval -6.8 to -2.8), and for adults the differences ranged from -8.8 (-13.6 to -3.9) to 3.8 (-3.3 to 10.8) across the practices. Resolution of symptoms and concerns did not differ between the two groups (odds ratio 1.2 (95% confidence interval 0.8 to 1.8) for symptoms and 1.03 (0.8 to 1.4) for concerns). The number of prescriptions issued, investigations ordered, referrals to secondary care, and reattendances were similar between the two groups. However, patients managed by nurse practitioners reported receiving significantly more information about their illnesses and, in all but one practice, their consultations were significantly longer. CONCLUSION: This study supports the wider acceptance of the role of nurse practitioners in providing care to patients requesting same day consultations.

Meeting the needs of people with cancer for support and self-management.

Health professionals tend to consider that they are in the best position to decide treatment options for cancer patients despite research evidence that a feeling of powerlessness can affect health outcomes and the inclusion of patient empowerment within government policy. This article describes a focus group study, carried out in collaboration with the University of Warwick, aiming to elicit the needs of people with cancer and their carers/supporters, the reactions to these needs and the strategies adopted to obtain support and self-management skills. The methodology was II two-stage focus groups carried out in four English cities in 1998, involving 54 people with cancer and 14 supporters. The main study findings identified a parallel 'journey' to the previously described emotional and medical cancer journey in the form of an epistemological journey of 'identity shifts' as people progressed through their disease. People required additional emotional and psychological support when these shifts were taking place and used a variety of strategies to obtain this, including the use of complementary therapies and other strategies designed to increase their sense of control. The article concludes by describing a 'holistic' approach to cancer care which supports patient empowerment and recommendations for implementing the research findings into practice.