Can Pharmacists Fill the Primary Care Provider Gap in Recommending Breast Screening?

Background and context: BreastScreen Victoria (BSV) provides free breast screening to women aged 40+, targeting women aged 50-74. The program reduces breast cancer deaths by up to 28%. Primary care is important in improving uptake of breast screening. In particular, a recommendation from a health professional is a strong influencer. Many general practitioners (GPs) recommend screening, however, it is important to expand recruitment to other health professionals given many women do not visit a GP regularly. Community pharmacists and pharmacy staff may be a trusted source of health information, and are potentially an underutilized opportunity to promote breast screening to women. Based on this gap, BSV developed a three month pharmacy-based screening awareness campaign that was trialed in community pharmacies throughout 2017/18. The campaign is based on a UK community pharmacy model that was shown to successfully increase public awareness about cancer screening. Aim: BSV aims to diversify the types of health professionals that recommend screening to reach women who do not visit a GP regularly. The aim of the pharmacy-based breast screening awareness campaign is to: • build capacity of pharmacy staff to deliver breast screening messages to their communities • increase awareness of breast screening in women aged 50-74 • increase awareness of breast screening among family and friends of women Strategy/Tactics: BSV's pharmacy-based breast screening awareness campaign was trialed in 4 community pharmacies in 2017. Each pharmacy received a grant of up to $1550 which enabled them to: • allow pharmacy staff to attend training to increase their knowledge of breast screening and the campaign • display BreastScreen collateral throughout the store to provide information and prompt queries • initiate conversations and answer questions about breast screening • monitor campaign activity via a number of methods Outcomes: • Posttraining, 100% of staff were confident in promoting breast screening to customers • Staff across 4 pharmacies had 638 conversations about breast screening with customers (average 160/pharmacy). The majority were with women in the target age group • Most pharmacies suggested shortening the campaign to 2 months • All pharmacies said the funding was a critical motivator to participation • All pharmacies stated that the campaign was worthwhile, and allowed them to participate in health promotion Two additional trials are scheduled to test a reduced campaign duration and funding model. Results will be available later in 2018 What was learned: • Many women do not visit their GP regularly • Community pharmacists and pharmacy staff are an underutilized opportunity to promote breast screening • Delivering cancer screening messages through community pharmacies is an effective way to reach women aged 50-74 • Pharmacy funding and training are critical in enabling pharmacies to deliver a breast screening awareness campaign

Can Cross-Sector Partnerships Increase Breast Cancer Screening in Hard-to-Reach Migrant Populations?

Background and context: BreastScreen Victoria (BSV) provides free breast screening to women aged 40+; targeting women aged 50-74. The program reduces breast cancer-related deaths by up to 28%. BSV aims to ensure equitable participation for all women in the target age; however there are large disparities in screening rates for different subpopulations. Emerging migrant women participate in breast screening at lower rates than the general population. These women face complex barriers including cultural factors, low health literacy, and access. BSV identified cross-sector partnerships, with local trusted organizations who engage with emerging migrant women, as an approach to tackle the multidimensional problems in screening inequalities. Aim: Through cross-sector partnerships BSV aims to bring together diverse skills, knowledge and resources for more effective health promotion outcomes, including: 1. Increasing awareness of breast screening in emerging migrant communities, 2. Providing a culturally safe environment for women to access breast screening. Strategy/Tactics: BSV partnered with organizations beyond the traditional health sector. One key partnership is with AMES Australia, who provide settlement services for refugees and migrants. The main approach of this model is two-way capacity building between organizations. BSV built the capacity of AMES to deliver BreastScreen's key messages, and promote screening to eligible women accessing their service. This included training for staff, resource development/sharing, and support. AMES built the capacity of BSV by providing insight into barriers for women they engage, and guidance adapting traditionally clinical environments ensuring cultural safety. To date BSV has undertaken screening initiatives with AMES in 2 Melbourne locations. Outcomes: - Migrant women are introduced to breast screening by a trusted organization - BSV's key messages are delivered in a culturally appropriate manner - Development of sustainable skills, structures and resources in both organizations - Utilization of AMES relationship with their clients to engage women who BSV may not reach -not on the Victorian Electoral Roll - 6 group bookings with specific languages groups - Familiar case worker and in person translator supporting group bookings - Engaging mainly first time screeners who may not have accessed a breast screen - Overcoming cultural, language, and health literacy barriers - Tailored appointments for groups and walk-ins. What was learned: A lack of tailored strategies to engage women in breast screening compounds barriers for migrant women. Cross-sector partnerships increase the efficiency of systems that impact health by making the best use of different but complementary resources. Collaborations, joint resourcing and planned action should be considered ongoing practice, particularly for disengaged populations, to address the many determinants of health that lie outside the reach of the health system.

Breast Screening Reminder Letters and Phone Calls to Women in Their Language

Background: BreastScreen Victoria (BSV) provides free breast screening to women aged 40+; targeting women aged 50-74. The program reduces breast cancer-related deaths by up to 28%. BSV aims to ensure equitable participation by all women in the target population. However, women from Arabic and Italian speaking backgrounds have lower breast screening participation compared with English-speaking women. A needs analysis involving consultation with Arabic and Italian speaking women found that invitation letters and calls are important enablers to breast screening, however language is a barrier. Women suggested sending reminder letters and making outbound reminder calls in their language. Aim: The aim of this study was to determine whether, and to what extent, reminder letters and phone calls in language resulted in increased screening rates in Arabic and Italian women. Methods: Two randomized control trials ran in 2017. TRIAL 1: Women due for a routine breast screen who speak Italian or Arabic at home were randomized into one of two trial arms: women in the intervention arm received a reminder letter in language (with the English version enclosed also), and women in the control arm received a reminder letter in English only. 1032 women were included in the study; comprising 322 Arabic and 710 Italian women. TRIAL 2: Lapsed women (had not had a breast screen within 27 months) who speak Italian or Arabic at home were randomized into one of two trial arms: women in the intervention arm received an outbound call in language inviting them to book an appointment; women in the control arm did not receive a call. 219 lapsed screeners were included; comprising 93 Arabic and 126 Italian women Results: TRIAL 1: • Women in the intervention arm more frequently booked (61.2%) compared with the control group (59.8%). However, this difference was not statistically significant. • For Italian women, 64.5% in the intervention group and 66.2% in the control group booked a screening appointment within 30 days of the mail out. Among Arabic women, the rates were 53.1% and 47.5% respectively. TRIAL 2: • Women in the intervention group were 10.7 times more likely to make a booking (42.9%) compared with the control group (4%). The effect was larger for Arabic than for Italian women. Conclusion: Sending reminder letters to Italian and Arabic women in their own language did not result in a statistically significant increase in bookings. Making reminder phone calls to Italian and Arabic women in their own language did result in a large, statistically significant increase in bookings and attendance.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Regional anesthesia decreases complications and resource utilization in shoulder arthroplasty patients

BACKGROUND

Regional anesthesia can be used as part of the anesthetic to optimize anesthesia and analgesia during shoulder arthroplasty, but little is known about the overall effect that regional anesthesia has on perioperative outcomes and resource utilization. We hypothesized that regional anesthesia may decrease complication rates and resource utilization in shoulder arthroplasty patients.

METHODS

We examined administrative data from 588 US hospitals from 2010 to 2015. Logistic regression was used to examine the relationship between type of anesthesia and perioperative complications.

RESULTS

Among patients who underwent shoulder arthroplasty, 79.1% (53,243) had general anesthesia alone, 17.8% (12,011) had general anesthesia and a nerve block, and 3.1% (2062) had a nerve block alone. Overall, the complication rate was 13.3% and 30-day mortality was 1.2 per 1000 (95% CI 0.9, 1.4). In adjusted analyses, patients who had general anesthesia alone (compared to general anesthesia and nerve block) had a 16% increase in all cause infectious complications (OR 1.16, 95% CI: 1.03, 1.31) and were 2.6 times more likely to develop pulmonary complications (OR 2.6, 95% CI: 1.14, 5.78). General anesthesia alone (relative to either block only or general anesthesia and block) was associated with substantial increases in the likelihood of blood transfusions, intensive care unit transfers, and prolonged length of stay.

CONCLUSION

Patients receiving regional anesthesia for shoulder arthroplasty may have a reduction in perioperative complications, the need for intensive care unit transfers, blood transfusions, and prolonged hospital stays.

Long-Term Ingestion of Paracetamol and Liver Disease1

Of 45 patients with chronic active hepatitis, 17 had taken paracetamol before the onset of symptoms. There were no significant differences, however, between the two groups in abnormalities of liver function tests, nor in ease of control after paracetamol withdrawal and institution of immunosuppressive therapy. The patient who had taken more than 5 g/week was studied in greater detail, but after a challenge dose of 1 g paracetamol there was no rise in serum aminotransferases and the pattern of excretion of paracetamol metabolites was normal. A critical review of the previously published reports failed to uncover any convincing evidence that paracetamol is an initiating factor in the development of chronic active hepatitis, although it may, at therapeutic levels, cause a toxic hepatitis in those individuals at risk.

Effect of reduced protein intake on endurance performance and water turnover during low intensity long duration exercise in Alaskan sled dogs

Increased nutritional demands for endurance exercise of dogs are typically met through increased amounts of their current food. As a result, protein intake is also increased, and excessive nitrogen may affect the dog’s water balance. Sixteen unconditioned Alaskan sled dogs underwent a 6-week exercise training protocol, wherein 8 dogs were fed increasing amounts of their normal kibble to maintain body weight, while the other 8 were fed the same amount of kibble, with increasing calorie needs met by equal amounts of sugar and oil. The diets resulted in similar calorie intakes (181.3±20.0 and 205.7±36.3 kcal/kg0.75, for the control and low protein dogs respectively) but control dogs had higher protein intakes (32.2±0.0 and 19.4±2.4% of metabolic energy intake). After 6 weeks of training the dogs completed a 5 day exercise test in which they travelled 24 km per day, where total energy expenditure was determined using doubly-labelled water technique. Dogs expended an average of 1,491±264 kcal/day (145±25 kcal/kg0.75/day), with no difference between the dietary treatments and no negative performance indicators. Following the exercise test the dogs underwent a 24 hour dehydration test (water withheld) followed by an 8 hour rehydration test (with ad libitum water intake recorded) where total body water was determined using deuterium oxide. Blood and urinary samples were also collected. Following exercise conditioning, control dogs had higher serum urea nitrogen than low protein dogs, and this as well as albumin decreased further during the 5 day exercise test. Low-protein dogs had lower overall total body water and higher fractional excretion of Na+, suggesting some renal adaptation. These findings suggest that reduced protein intake did not negatively affect athletic performance, though some facets of body chemistry were altered.

Flexural and Torsional Analysis of Five Acrylics for Use in External Skeletal Fixation

Mechanical testing of five acrylics was performed to evaluate material property differences that might affect their use as support rods in external skeletal fixation (ESF). Flexural and torsional analysis demonstrated that differences existed in the stiffness of the acrylics with polyethyl/polymethylmethacrylate products being the stiffest and a polyethylmethacrylate product being least stiff. Increasing the amount of inert filler also increased the stiffness. The inherent porosity of the individual acrylics did not have an effect on their mechanical properties. These differences in stiffness might affect fracture healing by affecting the amount of primary or secondary osteosynthesis that occurs.

Different polymeric forms of acrylic possess mechanical properties that influence their stiffness. Based on flexural and torsional analysis, these properties may differ significantly and affect external skeletal fixator stiffness.

Presented at the twenty-fourth annual meeting of the Veterinary Orthopedic Society, Big Sky, MT March 2-8, 1997.

Towards global consensus on core outcomes for hidradenitis suppurativa research: an update from the HISTORIC consensus meetings I and II

BACKGROUND

A core outcomes set (COS) is an agreed minimum set of outcomes that should be measured and reported in all clinical trials for a specific condition. Hidradenitis suppurativa (HS) has no agreed-upon COS. A central aspect in the COS development process is to identify a set of candidate outcome domains from a long list of items. Our long list had been developed from patient interviews, a systematic review of the literature and a healthcare professional survey, and initial votes had been cast in two e-Delphi surveys. In this manuscript, we describe two in-person consensus meetings of Delphi participants designed to ensure an inclusive approach to generation of domains from related items.

OBJECTIVES

To consider which items from a long list of candidate items to exclude and which to cluster into outcome domains.

METHODS

The study used an international and multistakeholder approach, involving patients, dermatologists, surgeons, the pharmaceutical industry and medical regulators. The study format was a combination of formal presentations, small group work based on nominal group theory and a subsequent online confirmation survey.

RESULTS

Forty-one individuals from 13 countries and four continents participated. Nine items were excluded and there was consensus to propose seven domains: disease course, physical signs, HS-specific quality of life, satisfaction, symptoms, pain and global assessments.

CONCLUSIONS

The HISTORIC consensus meetings I and II will be followed by further e-Delphi rounds to finalize the core domain set, building on the work of the in-person consensus meetings.

A suspected case of intermediate syndrome in a dog with carbamate toxicosis

CASE REPORT

A 7-year-old female spayed Labrador Retriever was managed for suspected carbamate toxicosis after confirmed ingestion of a large amount of methiocarb. Therapy included decontamination, supportive care and management for aspiration pneumonia. On the third day of hospitalisation, after an initial clinical improvement, the dog developed respiratory muscle weakness, inspiratory dyspnoea and pronounced cervical muscle weakness. These delayed clinical signs were consistent with the 'intermediate syndrome' described in some cases of organophosphate and carbamate toxicoses in humans and also described in one case of organophosphate toxicosis in the dog. Intermediate syndrome has not been reported in carbamate toxicosis in the dog.

CONCLUSION

This case report highlights the necessity for veterinarians to monitor for additional complications not commonly considered in acute carbamate toxicoses.

Trace elements have beneficial, as well as detrimental effects on bone homeostasis

The protective role of nutrition factors such as calcium, vitamin D and vitamin K for the integrity of the skeleton is well understood. In addition, integrity of the skeleton is positively influenced by certain trace elements (e.g. zinc, copper, manganese, magnesium, iron, selenium, boron and fluoride) and negatively by others (lead, cadmium, cobalt). Deficiency or excess of these elements influence bone mass and bone quality in adulthood as well as in childhood and adolescence. However, some protective elements may become toxic under certain conditions, depending on dosage (serum concentration), duration of treatment and interactions among individual elements. We review the beneficial and toxic effects of key elements on bone homeostasis.