Designing and implementing a bundle of care for patients with early-stage breast cancer: lessons from a pilot program.

We present a case study on the design and implementation of a value-based bundled package of care for patients with early-stage breast cancer treated in the private health sector in Australia. Value-based healthcare is an essential change to how we deliver healthcare, shifting the focus from paying for individual services provided to a focus on the health outcomes gained over a full cycle of care. The Australian health system has unintentionally created barriers to value-based cancer care through fragmented care pathways and complex funding arrangements where patients can unexpectedly encounter high out-of-pocket costs. A team of clinicians, service providers, health systems and funding experts, private health insurers and consumers have collaborated to design and pilot a complete bundled package of care for breast cancer patients which aims to address these challenges. With 40 patients recruited to date, early evaluation results show positive patient experience of 'joined-up' care and financial transparency. This case study provides a high-level overview of the approach taken to design and implement the Breast Cancer Bundle and the lessons learned for its expansion in both public and private settings.

Alcohol and other substance use by faculty, staff, and students in a university community during two hurricanes: Lessons for preventing risky misuse.

Communities commonly warn against heavy alcohol and other substance use during natural disasters like hurricanes, because such use may produce risk for individuals and communities, with studies showing deleterious effects persisting months or even years. Examining patterns and emotional correlates of use in the immediate presence of hurricanes may identify useful risk prevention targets. We assessed self-reported substance use and emotions in a university community (faculty, staff, and students) having the unlucky fate of experiencing hurricanes in early September 2 years in a row. Participants (403 in 2018, 76.0% female; M age 28.82; SD = 12.36 and 292 in 2019, 72.6% female; M age 30.63; SD = 13.96) reported typical weekly substance use and emotions and then the same data during each hurricane day. Results showed elevated use of alcohol, caffeine and tobacco before and during each hurricane, but a rapid drop-off of alcohol and caffeine (but not tobacco) use immediately after-although anxiety remained high. Findings are interpreted using both tension-reduction and stress-coping models and suggestions are made for future risk mitigation.

Women's Drinking Decisions in Heterosocial Situations: Development and Validation of Scenarios to Assess Influence of Attraction and Risk-Awareness.

These three related studies created a set of ecologically valid scenarios for assessing relative associations of both attraction and sexual coercion risk-recognition in college women's heterosocial situational drinking decisions. The first study constructed nine scenarios using input from heterosexual drinking women in the age cohort (18-30) most likely to experience alcohol-related sexual coercion. In the second study, 50 female undergraduates (ages 18-25) assessed the salience of three important dimensions (attraction, risk, and realism) in these scenarios. The third study was a factor analysis (and a follow-up confirmatory factor analysis) of the elements of coercion-risk as perceived by the target group with two female samples recruited 1 year apart (Sample 1: N = 157, ages 18-29); Sample 2: N = 157, ages 18-30). Results confirmed that the scenarios could be a useful vehicle for assessing how women balance out risk and attraction to make in-the moment heterosocial drinking decisions. The factor analysis showed participants perceived two types of situations, based on whether the male character was "Familiar" or "Just Met" and perceived themselves as happier and more excited with Familiar males. However, in contrast to HIV risk studies, Familiar males were perceived as higher risk for unwanted sex. Future research will use the six scenarios that emerged from the factor analysis to study how attraction and risk perception differentially affect young adult women's social drinking decisions.

Impact of same day vs day before pre-operative lymphoscintigraphy for sentinel lymph node biopsy for early breast cancer (local Australian experience).

INTRODUCTION: To assess the impact of delayed vs immediate pre-operative lymphoscintigraphy (LSG) for sentinel lymph node biopsy in a single Australian tertiary breast cancer centre. METHODS: Retrospective cohort study analysing patients with breast cancer or DCIS who underwent lumpectomy or mastectomy with pre-operative LSG and intra-operative sentinel lymph node biopsy from January 2015 to June 2016. RESULTS: A total of 182 LSG were performed. Group A patients had day before pre-operative LSG mapping (n = 79) and Group B had LSG mapping on the day of surgery (n = 103). The overall LSG localisation rate was 97.3% and no statistical difference was detected between the two groups. The overall sentinel lymph node biopsies (SLN) were identified in 99.6% of patients. The number of nodes excised was slightly higher in Group A (1.90 vs 1.72); however, this was not statistically significant. In addition, the number of nodes on histopathology and the incidence of second echelon nodal detection were also similar between the two groups without statistical significance. CONCLUSION: In conclusion, the 2-day LSG protocol had no impact on overall SLNB and LSG detection rates although slightly higher second tier nodes but this did not translate to any difference between the number of harvest nodes between the two groups. The 2-day LSG allows for greater flexibility in theatre planning and more efficient use of theatre time. We recommend a dose of 40 Mbq of Tc99 m pertechnetate-labelled colloid be given day prior to surgery within a 24-hour timeframe.

Mandating influenza vaccinations for health care workers: analysing opportunities for policy change using Kingdon's agenda setting framework.

BACKGROUND: The consequences of annual influenza outbreaks are often underestimated by the general public. Influenza poses a serious public health threat around the world, particularly for the most vulnerable populations. Fortunately, vaccination can mitigate the negative effects of this common infectious disease. Although inoculating frontline health care workers (HCWs) helps minimize disease transmission, some HCWs continue to resist participating in voluntary immunization programs. A potential solution to this problem is government-mandated vaccination for HCWs; however, in practice, there are substantial barriers to the adoption of such policies. The purpose of this paper is to identify the likelihood of adopting a policy for mandatory immunization of HCWs in Ontario based on a historical review of barriers to the agenda setting process. METHODS: Documents from secondary data sources were analysed using Kingdon's agenda setting framework of three converging streams leading to windows of opportunity for possible policy adoption. RESULTS: The problems, politics, and policies streams of Kingdon's framework have converged and diverged repeatedly over an extended period (policy windows have opened and closed several times). In each instance, a technically feasible solution was available. However, despite the evidence supporting the value of HCW immunization, alignment of the three agenda setting streams occurred for very short periods of time, during which, opposition lobby groups reacted, making the proposed solution less politically acceptable. CONCLUSIONS: Prior to the adoption of any new policies, issues must reach a government's decision agenda. Based on Kingdon's agenda setting framework, this only occurs when there is alignment of the problems, politics, and policies streams. Understanding this process makes it easier to predict the likelihood of a policy being adopted, and ultimately implemented. Such learning may be applied to policy issues in other jurisdictions. In the case of mandatory influenza vaccinations for HCWs in Ontario, it seems highly unlikely that a new policy will be adopted until perception of the problem's importance is sufficient to overcome the political opposition to implementing a solution and thus, create a window of opportunity that is open long enough to support change.

Florid pustular dermatitis of breast: A case report on a unusual complication from acellular dermal matrix use.

INTRODUCTION: Idiopathic erythematous reaction of the breast (Red breast syndrome) is a known complication following breast reconstruction with acellular dermal matrix. However pustular dermatitis like presentation is not previously known. PRESENTATION OF CASE: We present a 42-year-old lady who developed bilateral pustular dermatitis like appearance following breast reconstruction with acellular dermal matrix slings. Though surgical washout was done, both expanders and flex HD could be preserved. DISCUSSION: Acellular dermal matrix use is the only possible explanation for such a presentation and this can be considered a variant of red breast syndrome. CONCLUSION: Pustular dermatitis like presentation can be associated with acelluar dermal matrix use and should be considered in similar clinical presentations, since this can avoid unnecessary surgical procedures.

What Do Women Want? A Qualitative Study of Dating.

Many approaches to decrease unwanted sex for women emphasize enhanced risk recognition. However, women often remain in risky situations despite recognition; so we need to understand the attractions of normative dating and sex. In this focus group study, 45 young adult women discussed their attractions to men, dating, and sex. Themes emerged describing conflicts between what they wanted, dating realities, desire for "traditional" behavior from the man, alcohol use, sexual arousal (hers and his), indirect communication about sex, feeling "obligated," and enhanced self-esteem. Results suggest improving risk-recognition programs by examining and clarifying women's goals for dating and putting positive emphasis on "have fun, achieve your goals, but try to avoid harm in the process."

Radioactive seed localisation to guide removal of impalpable lymph nodes (radioguided occult lesion localisation using iodine-125 seeds, "ROLLIS").

Two patients with cancer requiring removal of specific impalpable lymph nodes for full pathological analysis underwent ultrasound-guided lesion localisation and marking with a low-activity I-125 seed. A gamma probe was used in theatre to localise the signal from the seed and guide excision. Successful removal of the lesions was confirmed with the probe and by specimen radiography. Radioguided Occult Lesion Localisation using I-125 Seeds ("ROLLIS") provides a method of precisely marking impalpable lesions for surgical excision.

A framework for assessing cumulative effects in watersheds: an introduction to Canadian case studies.

From 2008 to 2013, a series of studies supported by the Canadian Water Network were conducted in Canadian watersheds in an effort to improve methods to assess cumulative effects. These studies fit under a common framework for watershed cumulative effects assessment (CEA). This article presents an introduction to the Special Series on Watershed CEA in IEAM including the framework and its impetus, a brief introduction to each of the articles in the series, challenges, and a path forward. The framework includes a regional water monitoring program that produces 3 core outputs: an accumulated state assessment, stressor-response relationships, and development of predictive cumulative effects scenario models. The framework considers core values, indicators, thresholds, and use of consistent terminology. It emphasizes that CEA requires 2 components, accumulated state quantification and predictive scenario forecasting. It recognizes both of these components must be supported by a regional, multiscale monitoring program.

Considerations for using bacteriophages for plant disease control.

The use of bacteriophages as an effective phage therapy strategy faces significant challenges for controlling plant diseases in the phyllosphere. A number of factors must be taken into account when considering phage therapy for bacterial plant pathogens. Given that effective mitigation requires high populations of phage be present in close proximity to the pathogen at critical times in the disease cycle, the single biggest impediment that affects the efficacy of bacteriophages is their inability to persist on plant surfaces over time due to environmental factors. Inactivation by UV light is the biggest factor reducing bacteriophage persistence on plant surfaces. Therefore, designing strategies that minimize this effect are critical. For instance, application timing can be altered: instead of morning or afternoon application, phages can be applied late in the day to minimize the adverse effects of UV and extend the time high populations of phage persist on leaf surfaces. Protective formulations have been identified which prolong phage viability on the leaf surface; however, UV inactivation continues to be the major limiting factor in developing more effective bacteriophage treatments for bacterial plant pathogens. Other strategies, which have been developed to potentially increase persistence of phages on leaf surfaces, rely on establishing non-pathogenic or attenuated bacterial strains in the phyllosphere that are sensitive to the phage(s) specific to the target bacterium. We have also learned that selecting the correct phages for disease control is critical. This requires careful monitoring of bacterial strains in the field to minimize development of bacterial strains with resistance to the deployed bacteriophages. We also have data that indicate that selecting the phages based on in vivo assays may also be important when developing use for field application. Although bacteriophages have potential in biological control for plant disease control, there are major obstacles, which must be considered.

Soil-based systemic delivery and phyllosphere in vivo propagation of bacteriophages: Two possible strategies for improving bacteriophage persistence for plant disease control.

Soil-based root applications and attenuated bacterial strains were evaluated as means to enhance bacteriophage persistence on plants for bacterial disease control. In addition, the systemic nature of phage applied to tomato roots was also evaluated. Several experiments were conducted applying either single phages or phage mixtures specific for Ralstonia solanacearum, Xanthomonas perforans or X. euvesicatoria to soil surrounding tomato plants and measuring the persistence and translocation of the phages over time. In general, all phages persisted in the roots of treated plants and were detected in stems and leaves; although phage level varied and persistence in stems and leaves was at a much lower level compared with persistence in roots. Bacterial wilt control was typically best if the phage or phage mixtures were applied to the soil surrounding tomatoes at the time of inoculation, less effective if applied 3 days before inoculation, and ineffective if applied 3 days after inoculation. The use of an attenuated X. perforans strain was also evaluated to improve the persistence of phage populations on tomato leaf surfaces. In greenhouse and field experiments, foliar applications of an attenuated mutant X. perforans 91-118:∆OPGH strain prior to phage applications significantly improved phage persistence on tomato foliage compared with untreated tomato foliage. Both the soil-based bacteriophage delivery and the use of attenuated bacterial strains improved bacteriophage persistence on respective root and foliar tissues, with evidence of translocation with soil-based bacteriophage applications. Both strategies could lead to improved control of bacterial pathogens on plants.

A comparison of African-American versus Caucasian men screened for an alcohol administration laboratory study: recruitment and representation implications.

African-Americans are under-represented in alcohol research, especially alcohol administration laboratory studies. Specific recruitment of African-Americans into laboratory studies, however, may also inadvertently affect the generalizability of the findings. In the current study, we compared all African-American young adult men (n=53) who volunteered and met criteria for an alcohol administration study to a sample (n=50) of Caucasian men recruited for the same study. Groups were compared on variables including demographics, quantity and frequency of alcohol consumption and other substance use, consequences of use and psychopathology. Compared to their Caucasian counterparts, African-American men reported less drinking frequency and quantity, less use of other substances and fewer negative consequences, but their alcohol and drug use was more likely to be associated with various measures of psychopathology. Results suggest that even when recruiting participants using criteria that should minimize differences (i.e. all participants were "social drinkers"), differences on key variables were evident. These differences may have important implications for alcohol research.

Incidence, sources, and self-management of depression in persons attending a rural health clinic in southeastern North Carolina.

The purpose of this study was to determine the incidence, sources, and self-management strategies of depression in a sample of 48 persons visiting a primary care clinic in rural Southeastern North Carolina. Forty percent of the participants met the criteria of clinical depression on the Center for Epidemiological Studies Depression Scale (CES-D). Highest rates of depression found in single, African American men who were employed with adequate health insurance were attributed primarily to work related stressors in dealing with overwhelming social problems of other rural residents, as well as economic stressors. Critical incident interviews identified depression self-management strategies and sources of social support.

The effects of alcohol and cue salience on young men's acceptance of sexual aggression.

Research suggests that alcohol intoxication may increase a young man's likelihood of sexual aggression. This laboratory analogue experiment tested a disinhibition versus alcohol myopia explanation of alcohol's role by investigating effects of acute alcohol administration, expectations and individual differences drawn from Malamuth's Confluence Model of Sexual Aggression (i.e., Acceptance of Interpersonal Violence: AIV, Need for Sexual Dominance: NSD) on young men's acceptance of sexual aggression. Young adult heterosexual men (n=334) attended two laboratory sessions each. In the first, they completed screening and individual differences measures. In the second, they were assigned randomly to consume one of four beverages: Control, Placebo, Low Dose Alcohol (0.33 ml alcohol/kg body weight) or Moderate Dose Alcohol (0.75 ml/kg) and view one of two video-delivered scenario conditions: "Anti-Force Cues" (scenario of a couple on a date with embedded explicit cues mitigating against forced sex) or "No Cues" (Identical scenario with no Anti-Force cues). Participants then judged 1) should the man continue to force the woman to have sex? 2) would they force the woman? and 3) who was responsible for the outcome? Results supported a disinhibition versus alcohol myopia model. Consuming alcohol increased acceptance of sexual aggression. Further, higher NSD and AIV scores were associated with acceptance of forced sex, but only after alcohol consumption. Overall, findings showed that key individual difference factors from Malamuth's Confluence Model enhance precision of predicting sexual aggression risk by young men under the influence of alcohol.

Laparoscopic oophorectomy in the management of breast disease.

BACKGROUND: Oophorectomy is being increasingly carried out in the management of breast disease, as either adjuvant treatment for breast cancer or for prevention of ovarian and fallopian tube cancer in BRCA gene mutation carriers. The aims of this study were to determine the surgical outcome of laparoscopic oophorectomy when carried out by breast surgeons and whether laparoscopic oophorectomy can be safely carried out during the same anaesthesia as breast surgery. METHODS: Patients who had laparoscopic oophorectomy carried out by two breast surgeons were reviewed with regard to the indication, surgical outcome and concurrent procedures. Salpingectomy was also carried out when the indication was prevention. RESULTS: Seventy patients with breast disease had laparoscopic oophorectomy between January 2000 and June 2007. Forty-three patients had laparoscopic oophorectomy for adjuvant endocrine treatment of early breast cancer, 13 for prophylaxis, 7 for endocrine and prophylactic reasons and 7 for treatment of metastatic breast cancer. Sixteen patients had laparoscopic oophorectomy and breast surgery at the same time, without complication. Of note, four BRCA mutation carriers had prophylactic mastectomies, bilateral breast reconstruction and bilateral laparoscopic salpingo-oophorectomy. No patient required conversion to an open procedure, including 29 patients with previous abdominal surgery. There were no significant complications. Three patients had ovarian cancer or breast cancer detected in an ovary. CONCLUSION: Laparoscopic oophorectomy can be safely and efficiently carried out by breast surgeons with expertise in laparoscopic surgery. Previous abdominal surgery did not prevent a successful laparoscopic approach. Breast oncological and/or reconstructive surgery and laparoscopic oophorectomy can be reliably carried out as a combined procedure.

Development and validation of videotaped scenarios: a method for targeting specific participant groups.

Researchers using scenarios often neglect to validate perceived content and salience of embedded stimuli specifically with intended participants, even when such meaning is integral to the study. For example, sex and aggression stimuli are heavily influenced by culture, so participants may not perceive what researchers intended in sexual aggression scenarios. Using four studies, the authors describe the method of scenario validation to produce two videos assessing alcohol-related sexual aggression. Both videos are identical except for the presence in one video of antiforce cues that are extremely salient to the young heterosexual men. Focus groups and questionnaires validate these men's perceptions that (a) the woman was sexually interested, (b) the sexual cues were salient, (c) the antiforce cues were salient (antiaggression video only), and (e) these antiforce cues inhibited acceptance of forced sex. Results show the value of carefully selecting and validating content when assessing socially volatile variables and provide a useful template for developing culturally valid scenarios.

Arzoxifene: the evidence for its development in the management of breast cancer.

INTRODUCTION: Endocrine therapy is an important and integral part of breast cancer management. Selective estrogen receptor modulators (SERMs), such as tamoxifen, remain a vital component in the endocrine therapy armamentarium. However the "ideal SERM", which has antagonist effects on the breast and endometrium but beneficial agonistic effects on bone and lipid profile, remains to be found. AIM: The aim of this review is to examine the evidence for arzoxifene as the "ideal SERM." EVIDENCE REVIEW: Arzoxifene showed initial promise as the "ideal SERM" in preclinical, phase I, and phase II clinical studies. It appeared to have powerful antiestrogenic effects on breast cancer and endometrium, with equally strong favorable estrogenic effects on bone and lipid profile, minimal side effects, and good oral bioavailability. However, phase III trial data found it to be inferior to tamoxifen, bringing an apparent end to its investigation as a breast cancer treatment. CLINICAL POTENTIAL: Despite early promise as the "ideal SERM", results from a phase III trial have relegated arzoxifene to research in breast cancer prevention and osteoporosis treatment.

Multiple papillomas of the breast: is current management adequate?

Multiple papillomas (MP) are subject to debate in terms of their clinical and pathological significance and management. To date the ideal management is still not well established. The Royal Perth Hospital Multidisciplinary Breast Service has prospectively accrued clinical and pathological data on over 9000 patients since 1994. The database was interrogated and all pathology reports retrospectively reviewed. A total of 23 cases with the diagnosis of MP were retrieved from the database between 1994 and 2004. Of these 23 cases, 13 (56.5%) were diagnosed by core biopsy, nine (39.1%) on excision biopsy, and one (4.4%) on a mastectomy specimen. The average age of patients was 56.4 years (range 44-74 years). The average duration of follow up is 4.1 years (range 1-10 years). In our series a close association with malignancy was noted for MP, which was also associated with a spectrum of proliferative breast disease. Contemporary guidelines should be developed for this controversial condition. We recommend that all patients with MP, especially when associated with atypia, undergo wide excision of the lesion with clear margins of at least 10mm and that these patients be monitored closely with annual imaging.