In vivo assignment of methylmalonic acid in breast tissue using 2D MRS and relationship with breast density, menopausal status and cancer risk

BACKGROUND

Methylmalonic acid (MMA) is linked to progression and aggressiveness of tumours. A recent study showed that high levels of circulatory MMA directed genetic programs promoting cancer progression.

PURPOSE

To evaluate in vivo two-dimensional correlated spectroscopy (2D COSY) data from women at elevated risk of breast cancer to determine if resonances consistent with MMA are present, and if so to correlate levels with breast density, menopausal status and risk categories.

MATERIALS AND METHODS

With institutional review board approval, 106 women at elevated risk (mean age 47), including 46 participants at medium risk, 43 at high risk with no known mutation and 17 BRCA-mutation carriers, were recruited. Breast density was assessed using a T₂ sequence. A T₁ sequence was used to place the voxel for the 2D COSY data. Peak volumes were normalized to the methylene peak at (1.30, 1.30) ppm. Chi-squared and Mann-Whitney tests were used.

RESULTS

Two resonances are assigned on the diagonal at 3.15 ppm and 3.19 ppm consistent with and denoted MMA1 and MMA2 respectively. MMA1 and MMA2 increased in parallel with increased risk. BRCA-mutation carriers recorded an increase in mean MMA1 of 120% (p = 0.033) and MMA2 of 127% (p = 0.020) in comparison with participants with no known mutation. BRCA-mutation carriers with dense breasts recorded a significant increase in mean MMA1 of 137% (p = 0.002) and in mean MMA2 of 143% (p = 0.004) compared with BRCA-mutation participants with low-density breast tissue. MMA1 and MMA2 were higher in premenopausal women with dense breasts compared with those with low-density tissue. The highest values of MMA were recorded in BRCA-mutation carriers.

CONCLUSION

Two tentative assignments are made for MMA in breast tissue of women at elevated risk for cancer. BRCA-mutation carriers exhibited higher values of MMA than those with no known mutation. Premenopausal women with BRCA mutation and dense breasts recorded the highest levels of MMA compared with other categories.

Technique of intraoperative ultrasound-guided excision of impalpable breast lesions

The introduction of breast screening programs has led to the increased detection of occult breast lesions requiring diagnostic surgical biopsy or breast-conserving surgery for early-stage breast cancer. Excision of impalpable breast lesions can be challenging. Whilst a variety of techniques have now been described including the use of adjuncts such as hook wires, radioactive seeds, magnetic seeds or radiofrequency devices, many of these modalities are expensive and can be logistically problematic. The technique of surgeon-performed ultrasound-guided excision is a straightforward technique which is safe, cost-efficient and avoids a painful preoperative procedure for patients such as hook wire localisation. Whilst the use of intraoperative ultrasound-guided excision of breast lesions has been widely reported, the actual technique itself has been less well described.

Breast Tissue Chemistry Measured In Vivo In Healthy Women Correlate with Breast Density and Breast Cancer Risk

BACKGROUND

The relationship of tissue chemistry to breast density and cancer risk has not been documented despite breast density being a known risk factor.

PURPOSE

To investigate whether distinct chemical profiles associated with breast density and cancer risk are identified in healthy breast tissue using in vivo two-dimensional correlated spectroscopy (2D COSY).

STUDY TYPE

Prospective.

POPULATION

One-hundred-seven participants including 55 at low risk and 52 at high risk of developing breast cancer.

FIELD STRENGTH/SEQUENCE

3 T/ axial/ T1, T2, 2D COSY.

ASSESSMENT

Two radiologists defined breast density on T2. Interobserver variability assessed. Peak volumes normalized to methylene at (1.30, 1.30) ppm as internal shift reference.

STATISTICAL TESTS

Chi-squared/Mann-Whitney/Kappa statistics/Kruskal Wallis/pairwise analyses. Significance level 0.05.

RESULTS

Ten percentage were fatty breasts, 39% scattered fibroglandular, 35% heterogeneously dense, and 16% extremely dense. Interobserver variability was excellent (kappa = 0.817). Sixty percentage (64/107) were premenopausal. Four distinct tissue chemistry categories were identified: low-density (LD)/premenopausal, high-density (HD)/premenopausal, LD/postmenopausal, and HD/postmenopausal. Compared to LD, HD breast chemistry showed significant increases of cholesterol (235%) and lipid unsaturation (33%). In the low-risk category, postmenopausal women with dense breasts recorded the largest significant changes including cholesterol methyl 540%, lipid unsaturation 207%, glutamine/glutamate 900%, and choline/phosphocholine 800%. In the high-risk cohort, premenopausal women with HD recorded a more active chemical profile with significant increases in choline/phosphocholine 1100%, taurine/glucose 550% and cholesterol sterol 250%.

DATA CONCLUSION

Four distinct chemical profiles were identified in healthy breast tissue based on breast density and menopausal status in participants at low and high risk. Gradual increase in neutral lipid content and metabolites was noted in both risk groups across categories in different order. In low risk, the HD postmenopausal category exhibited the highest metabolic activity, while women at high risk exhibited the highest lipid content and metabolic activity in the HD premenopausal category.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY STAGE: 3.

Effect of intervention delivered by frontline maternal care providers to improve outcome and parenting skills among adolescents with perinatal depression in Nigeria (the RAPiD study): A cluster randomized controlled trial

BACKGROUND

Perinatal depression is more common and is associated with greater negative consequences among adolescents than adults. Psychosocial interventions designed for adults may be inadequate at addressing the unique features of adolescent perinatal depression.

METHODS

In a two-arm parallel cluster randomized trial conducted in thirty primary maternal care clinics in Ibadan, Nigeria (15-intervention and 15-control) we compared age-appropriate intervention consisting of problem-solving therapy, behavioral activation, parenting skills training, and parenting support from a self-identified adult to care as usual. Pregnant adolescents (aged <20 years) at fetal gestational age16-36 weeks with moderate to severe depression were recruited. Primary outcomes were depression symptoms (Edinburgh Postnatal Depression Scale, EPDS) and parenting practices (Infant-Toddler version of the Home Inventory for Measurement of the Environment, HOME-IT) at six-months postnatal.

RESULTS

There were 242 participants (intervention arm: 141; Control arm: 101), with a mean age of 18∙0 (SD-1∙2). Baseline mean EPDS score was 14∙2 (SD-2.1); 80∙1 % completed the six-month postnatal follow-up. The intervention group had lower level of depressive symptoms than the control group, mean EPDS scores: 5∙5 (SD-3∙6) versus 7∙2 (SD-4∙0) (adjusted mean difference -1∙84 (95%CI- 3∙06 to -0∙62; p = 0∙003) and better parenting practices, mean total HOME-IT scores: 29∙8 (SD-4∙4) versus 26∙4 (SD-4∙2) (adjusted mean difference 3∙4 (95%Cl- 2∙12 to 4∙69, p = 0∙001).

LIMITATIONS

This study explored the effect of complex interventions making it difficult to know precisely what aspects produced the outcomes.

CONCLUSIONS

An age-appropriate psychosocial intervention package holds promise for scaling up care for adolescents with perinatal depression especially in resource-constrained settings.

TRIAL REGISTRATION

ISRCTN16775958. Registered on 30 April 2019.

Association of psychiatric consultant characteristics with clinical outcomes of collaborative care for depression

Context: Adult depression treatment in primary care is improved by integrated behavioral health such as the Collaborative Care Model (CoCM) but outcomes vary across health centers. Objective: Identify CoCM team factors associated with variation in clinical outcomes. Study Design: Correlative study of survey with linked clinical data from routine care. Setting or Dataset: Primary care health centers in Washington state participating in two CoCM implementation and sustainment initiatives (MHIP and BHIP). Clinical data from the Care Management Tracking System (CMTS) used as part of routine clinical care in all sites. Population studied: CoCM clinical teams and adults diagnosed with depression and receiving care from 31 distinct clinic sites throughout Washington state. Instrument: A survey for CoCM Care Managers was developed based on qualitative work exploring CoCM team function in eight domains: overall team function (OTF), psychiatric consultant (PsyC), relationship with primary care physicians (RPCP), role in the practice (RP), training experience (TE), thoughts on CoCM (TOC), leadership support (LS), and overall experience with CoCM (EXP). Outcome Measures: Depression symptoms (PHQ-9) measured as part of regular clinical care. Clinically significant improvements were defined as ≥50% improvement, last PHQ-9 measured <10, and a last PHQ-9 measured <5 (remission). Results: Data from 59 Care Manager surveys and 2509 patients from 31 clinics showed psychometric evidence for the 8 survey domains. Unadjusted multilevel mixed-effects logistic regression found the PsyC domain was associated (p<0.05) with >50% change in PHQ-9 (OR=1.32, p=0.046), last PHQ-9 <10 (OR=1.34, p=0.009), and last PHQ-9 <5 (OR=1.25, p=0.029). Adjusting simultaneously for both clinic-level and patient-level variables, the PsyC domain was significantly associated with likelihood of patient remission (last PHQ-9 <5; OR=1.22, p=0.031). Conclusions: An instrument to assess perceived functioning of the CoCM team had psychometric support. Perceived characteristics of psychiatric consultants was associated with likelihood of depression remission. Characteristics included interest in teaching, commitment to the site, making efforts to have weekly meetings, and willingness to assist care managers on adjustment of treatment strategies. This study is the first to quantify variation in CoCM team functioning with patient outcomes and can be used to inform training and the use of the CoCM.

Australian breast surgeons and ultrasound usage: Have practices changed?

BACKGROUND

A recent survey of surgeon performed ultrasound usage was conducted amongst registered members of the Breast Surgeons of Australia and New Zealand Society (BreastSurgANZ) and was compared with a previous survey undertaken in 2010 to determine whether patterns of utilization had changed.

METHODS

From July to September 2019, members of BreastSurgANZ were invited to complete an electronic online survey of personal usage of breast ultrasound focusing on ultrasound equipment access, use of office and intraoperative ultrasound, biopsy interventions and training expectations.

RESULTS

There were 73 respondents to the survey with 45 (61.6%) members indicating access to ultrasound within their practices. Whilst current regular ultrasound usage (68.1%) was only slightly greater than in 2010 (66%), the proportion of respondents not performing any form of needle intervention had increased (62.5% compared to 53% in 2010) and with the proportion of surgeons currently performing >10 biopsies per month decreasing from 10% to only 5.56%. However the percentage of surgeons utilizing intraoperative ultrasound had notably increased since 2010 with 49.3% currently using ultrasound in the operating room compared with only 17% previously. The majority of respondents believed that breast ultrasound training should be conducted through BreastSurgANZ post fellowship training programs.

CONCLUSION

The overall utilization of surgeon-performed ultrasound amongst BreastSurgANZ members has remained similar over the past 9 years with the performance of needle interventions declining slightly, but with the application of intraoperative ultrasound having increased. An ultrasound training curriculum as part of the BreastSurgANZ post fellowship training program is a necessary imperative.

Intrapatient comparisons of efficacy in a single-arm trial of entrectinib in tumour-agnostic indications

Background

Entrectinib is a tropomyosin receptor kinase inhibitor approved for the treatment of neurotrophic tyrosine receptor kinase (NTRK) fusion-positive solid tumours based on single-arm trials. Traditional randomised clinical trials in rare cancers are not feasible; we conducted an intrapatient analysis to evaluate the clinical benefit of entrectinib versus prior standard-of-care systemic therapies.

Methods

Patients with locally advanced/metastatic NTRK fusion-positive tumours enrolled in the global phase II, single-arm STARTRK-2 trial were grouped according to prior systemic therapy and response. The key analysis used growth modulation index [GMI; ratio of progression-free survival (PFS) on entrectinib to time to discontinuation (TTD) on the most recent prior therapy]; ratio ≥1.3 indicated clinically meaningful efficacy. Additional analyses investigated TTD and objective response rate (ORR) for entrectinib and prior therapies.

Results

Seventy-one patients were included; 51 received prior systemic therapy. In 38 patients who progressed on prior therapy, ORR was 60.5% (23/38) with entrectinib and 15.8% (6/38) with the most recent prior therapy. Median PFS [11.2 months; 95% confidence interval (CI) 6.7–not estimable] for entrectinib exceeded median TTD (2.9 months; 95% CI 2.0-4.9) for most recent prior therapy. From the intrapatient analysis of GMI, 65.8% had a ratio ≥1.3 and median GMI was 2.53. Consistent results were observed at more stringent GMI thresholds; 60.5% of patients had GMI ≥1.5 or ≥1.8 and 57.9% had GMI ≥2.0.

Conclusions

ORR was high and PFS was longer on entrectinib versus TTD on prior therapy. Furthermore, 65.8% of patients experienced clinically meaningful benefit based on GMI. This intrapatient analysis demonstrates comparative effectiveness of entrectinib in a rare, heterogeneous adult population.

•

Randomised trials are unfeasible for molecular targeted agents in rare indications because of low patient numbers.

•

Intrapatient comparison with prior therapies can be used to evaluate relative treatment efficacy in rare tumours.

•

Entrectinib is a potent tropomyosin receptor kinase (TRK) inhibitor with proven efficacy in neurotrophic tyrosine receptor kinase (NTRK) fusion-positive tumours from the global STARTRK-2 trial.

•

Median progression-free survival on entrectinib was longer than time to discontinuation on prior therapy (11.2 months versus 2.9 months).

•

About 61% of patients with prior therapy progression responded to entrectinib; 66% had growth modulation index ≥1.3 (clinically meaningful threshold).

Surgeon-Performed Vacuum-Assisted Biopsy of the Breast: Results from a Multicentre Australian Study

BACKGROUND

Image-guided interventional techniques such as vacuum-assisted biopsy are being increasingly utilised in the diagnosis and management of breast conditions. The purpose of this study was to report the outcome of a series of vacuum-assisted biopsies and vacuum-assisted excisions performed by specialist breast surgeons in a largely outpatient setting.

METHODS

An Australian multicentre trial of ultrasound-guided surgeon-performed vacuum-assisted biopsy (VAB) and vacuum-assisted excision (VAE) of breast lesions was conducted involving three surgeons in three participating centres. VAEs were performed for presumed or proven benign breast lesions only.

RESULTS

A total of 225 surgeon-performed ultrasound-guided vacuum-assisted procedures were undertaken in 197 patients. Of the 225 VAB procedures, 51 (22.7%) were performed as diagnostic cores and 174 (77.3%) were undertaken as core excisions. Of the 174 VAE procedures undertaken with intent of completely excising the lesion, successful excision of the lesion was achieved in 165 of these cases (94.8%), with complete excision being judged by the absence of any lesion seen on ultrasound following the procedure or the absence of the lesion on a subsequent interval ultrasound examination. A total of 199 procedures were performed in the outpatients setting under local anaesthesia, and 26 procedures were performed in an operating theatre setting under neurolept anaesthesia. The average size of lesions was 19.3 mm in the diagnostic core group and 10.6 mm in the core excision group. The average time for either procedure was approximately 14 min.

CONCLUSION

Specialist breast surgeons familiar with ultrasound can be readily upskilled to perform vacuum-assisted procedures safely and expeditiously. VAE represents a minimally invasive method of breast lesion management and is a technique with which breast surgeons should become adept.

Breast cancer screening in women at high risk of hereditary breast cancer: an Australian experience

BACKGROUND

While population-based breast screening is a well-documented health strategy worldwide, very few centres offer breast-screening programmes specifically targeted at women at high risk of hereditary breast cancer. We present our experience with multimodality breast screening in a high-risk population.

METHODS

The outcomes from a familial breast cancer clinic at the North Brisbane BreastScreen Queensland Service providing a multimodality screening programme for high-risk women were reviewed from the prospectively maintained database between 2011 and 2018.

RESULTS

Over the 8 years of study period, a total of 6686 annual screening rounds were performed for 823 asymptomatic women at high risk of hereditary breast cancer. As a result, 40 cancers were diagnosed including 25 invasive ductal cancers, three invasive lobular cancers, two invasive cancers with mixed ductal and lobular features and 10 ductal carcinomas in situ. Ultrasound and mammography detected 72.5% (29/40) and 55% (22/40) of the cancers, respectively. A total of 3672 magnetic resonance imaging studies were performed. Ten (25%) cancers were initially only seen on magnetic resonance imaging including seven invasive ductal cancers, one invasive lobular cancer and two high-grade ductal carcinomas in situ. The cancer detection rate for first-round screening was 13.3 cancers per 1000 women screened, with 4.9 cancers per 1000 women detected on subsequent-round screening. One interval cancer occurred in the study period.

CONCLUSION

Multimodality breast screening of younger women at high risk of hereditary breast cancer is effective with the yield substantially exceeding the results from established breast screening programmes in older women. Co-location of this service within BreastScreen Australia efficiently shares resources.

Scaling Implementation of Collaborative Care for Depression: Adaptation of the Stages of Implementation Completion (SIC)

Tools to monitor implementation progress could facilitate scale-up of effective treatments. Most treatment for depression, a common and disabling condition, is provided in primary care settings. Collaborative Care Management (CoCM) is an evidence-based model for treating common mental health conditions, including depression, in this setting; yet, it is not widely implemented. The Stages of Implementation Completion (SIC) was adapted for CoCM and piloted in eight rural primary care clinics serving adults challenged by low-income status. The CoCM-SIC accurately assessed implementation effectiveness and detected site variations in performance, suggesting key implementation activities to aid future scale-ups of CoCM for diverse populations.

Responding to the challenge of Adolescent Perinatal Depression (RAPiD): protocol for a cluster randomized hybrid trial of psychosocial intervention in primary maternal care

BACKGROUND

Adolescent pregnancy is a pressing public health issue globally, and particularly in low and middle-income countries. Depression occurring in the perinatal period is common among women and more so among adolescent mothers. Effective treatments for the condition have been demonstrated in adults but the needs of adolescents are often unique, making such treatments unlikely to meet those needs.

METHOD/STUDY DESIGN

A hybrid effectiveness-implementation research study is described in which a cluster randomized trial design is used to explore the effectiveness as well as the utility in routine practice of an intervention package specifically designed for adolescents with perinatal depression. Consenting pregnant adolescents (aged less than 20 years) who are newly registered for antenatal care are enrolled into the trial if their fetal gestational age is less than 36 weeks and they score 12 or more on the Edinburgh Postnatal Depression Scale (EPDS). The intervention package consists of structured sessions of behavior activation, problem-solving treatment, and parenting skills training, and is delivered by primary maternal health care providers, complemented by support provided by a "neighborhood mother" identified by the adolescent. Mothers in the control arm receive care as usual. The trial is conducted in clinics where the maternal providers are trained to deliver routine depression care with the use of the WHO Mental Health Gap Action Programme, intervention guide. Assessments are undertaken by trained blinded assessors at baseline, at childbirth, and at 3 and 6 months postpartum. The primary outcome, assessed at 6 months, is the level of maternal depression (measured with the EPDS). The secondary outcome is parenting skills (assessed with the Home Observation Measurement of the Environment, Infant-Toddler version), while tertiary outcomes include measures of disability, quality of life, mother-child bonding, as well as infants' nutritional and growth indices.

DISCUSSION

This, to the best of our knowledge, will be the first fully-powered trial of an intervention package specifically designed to address the unique needs of adolescents with perinatal depression.

TRIAL REGISTRATION

ISRCTN16775958. Registered on 30 April 2019.

Abstract P4-07-07: Establishing whole-exome sequencing for breast cancer patient care

Background. Next-generation sequencing (NGS) technology enables profiling of individual tumours and to measure the increasing number of biomarkers relevant to the management of breast cancer patients. The Australian Translational Genomics Centre (ATGC) is a collaboration between the healthcare sector (Metro South Hospital and Health Service), higher education sector (Queensland University of Technology) and a government-run pathology service (Pathology Queensland) to provide genomic profiling of breast cancer patients at the Princess Alexandra Hospital. The program was developed to integrate the ordering, processing and interpretation of large-scale NGS into clinical practice.

Methods. Patients were consented for somatic testing and ordering was integrated into the hospital’s electronic ordering system. Samples were derived from fresh tissue biopsies after surgeries (47%) or from FFPE histology sections. No selection criteria were applied during the initial phase and the cohort was representative of newly presenting patients at the hospitals breast cancer clinic. Patients were sequenced using a NATA-accredited ISO15189 program using whole-exome sequencing (WES) combined with a high-coverage spike-in panel of known cancer genes. Clinical reports included the calculation of tumour purity, tumour mutational burden (TMB), the assessment of copy number events and somatic mutations down to 3% allele frequency.

Standard molecular testing in Australia includes ER, PR and HER2 status, and additional testing included testing of Tier 1-2 somatic variants in the genes ABCC3, AKT1, CCND1, CCNE1, CDKN2A, ERBB2, ESR1, FGF3, FGFR1, FGFR2, MTOR, NCOA3, NF2, PIK3CA, PIK3R1, PTEN, RB1, RSF1, SF3B1, TP53. Results. Seventy-one patients were tested by WES/panel, and an average of 1.5 clinically significant Tier 1- 2 mutations were detected per patient. In 77% of cases, the molecular profiling could stratify patients to those with either PI3K/Akt/mTOR pathway activation (by PIK3CA activating mutations, AKT, MTOR mutations or PTEN loss) or CDK4/6 activation (by CCND1 expansion or CDKN2A loss). The most frequently observed mutations were PIK3CA activation (40%) and CCND1 copy number expansions (24%). A small proportion (n=3) were found to have mTOR or TCS1/2 mutations reported to have association with a durable response to mTOR inhibitors. Additionally, 11 patients (15%) had a high TMB (TMB, &gt;6.8 mutations/megabase) with 6 having &gt;10 mutations/Mb. Within this high-TMB cohort, 3 were found to be ER-PR-HER-, however, the majority (n=7) were ER+PR+HER2- patients. Calculation of the tumour purity indicated that, despite expert resection of the biopsies to isolate the most tumour dense regions, tumour purity was not significantly enriched. In 58% of cases, the tumour purity was less than 50%, and in 13% of samples, it was less than 25%, indicating that in clinical practice the method of sequencing must be robust, as many samples have significant amounts of contaminating stroma.

Conclusion. We demonstrate that integration of WES/panel testing into clinical practice is practical and provides multiplexed testing of current and emerging biomarkers in a significant number of tested patients. While a high proportion of patients had mutations that could stratify them to targeted therapies in the event of metastatic disease, the somatic molecular profiles did not modify first line therapy decision-making. Training of clinical staff for patient consent and the dissemination of findings, the development of a dedicated molecular tumour board, and decision protocols to identify patients of metastatic risk were identified as key developments in this clinical program. The program identified previously unidentified subsets of patients including a subset of ER+ patients with high TMB for which for there are no effective treatments option in Australia.

Citation Format: Kate Roberts, Paul J Leo, Jeremy Khoo, Alice Febery, Jonathan Ellis, Mhairi Clout, Lawrie Wheeler, Lisa Anderson, Matthew Brown, Ian Bennett. Establishing whole-exome sequencing for breast cancer patient care [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-07-07.

Sonographic features of inflammatory conditions of the breast

Inflammatory conditions of the breast can be a diagnostic challenge, and ultrasound is a proven valuable tool in this setting. In acute infective conditions, ultrasound is often a superior tool to mammography due to the impracticality of applying compression to the breast and the increased parenchymal density of these often younger patients. Although infective processes comprise the majority of inflammatory conditions in the breast, not infrequently other various disease processes can masquerade as infections. In particular, inflammatory breast cancer can be easily misdiagnosed as an infective process and sonography can play an important role in expediting the correct diagnosis. Furthermore, aspiration, drainage and biopsy are frequently required in managing breast inflammation and breast disease generally, and ultrasound is the most practical imaging modality facilitating such interventions. This article provides a review of the ultrasound characteristics of some of the more frequently encountered inflammatory disorders of the breast which span a spectrum of acute to chronic conditions. The various conditions in this report are described in terms of their specific sonographic imaging features as well as pathogenesis, common clinical presentations, and aspects of management are outlined where appropriate.

Trends in non-lactation breast abscesses in a tertiary hospital setting

BACKGROUND

The aim of this paper was to retrospectively review non-lactation breast abscesses treated in Princess Alexandra Hospital over a 10-year period and to illustrate the trends in size, risk factors, microbiological profile and management.

METHODS

A computerized search of the medical records was undertaken to identify all adult patients with a diagnosis of breast abscesses during June 2005-June 2015. Patients concurrently breastfeeding were excluded. A retrospectively review of the clinical records was performed.

RESULTS

Eighty-five abscesses were identified in 77 patients. The median patient age was 45 years and 93.7% were females. Smoking and diabetes mellitus were associated with a longer inpatient hospital stay. There was a significant difference in microbiology of abscesses in relation to size. Smaller abscesses (≤3.0 cm) predominantly had mixed anaerobes (54%), whereas larger abscesses had a dominance of Staphylococcus aureus (29%) and other aerobic microbes (33%) (P < 0.05). Seven percent of all abscesses had methicillin-resistant S. aureus. Flucloxacillin was prescribed solely in majority of the cases (45%) with addition of suitable mixed anaerobic cover in 12% cases. Of the 85 abscesses, 58.8% were managed non-operatively with antibiotics ± percutaneous drainage. Percutaneous aspiration had a shorter inpatient stay compared with patients who underwent operative management.

CONCLUSION

This represents the first Australian study solely analysing non-lactation breast abscess. Size was correlated significantly to characteristic bacteriology and empiric therapy should include both aerobic and anaerobic cover. The majority of non-lactation breast abscesses can be managed non-operatively with a combination of antibiotics and percutaneous aspiration.

Self-assembly of gradient copolymers synthesized in semi-batch mode by nitroxide mediated polymerization

The effect of diffuse compositional interfaces on copolymer self-assembly was studied via gradient copolymers (GCP). Poly(methyl methacrylate)-grad-(styrene) (PMMA-grad-PSt) copolymers were synthesized in semi-batch mode using nitroxide-mediated polymerization (NMP) with varied monomer injection protocols to produce varied diffuse interfaces (number average molecular weights (M_n) ranged from 62 000 g mol^-1 to 94 000 g mol^-1 with dispersities (Đ) between 1.35 and 1.59). The GCPs were spun into thin films on substrates made neutral by (St-ran-MMA-ran-hydroxyethyl methacrylate) terpolymers and annealed at elevated temperature to produce vertically oriented microphase-separated domains. The GCPs were found to have domain spacing larger than equivalent monodisperse BCPs, due to their polydisperse nature. This effect was partially offset by the decrease in χ due to the gradient. GCPs synthesized with a single-injection protocol (i.e. less diffuse interfaces) were found to self-assemble into ordered domains. However, GCPs synthesized with long injection times (i.e. more diffuse interfaces) exhibited poor self-assembly attributed to their predicted statistical-copolymer-like middle sequence, which caused a reduction of the effective enthalpic interaction parameter.

Proceedings of the 8th Annual Conference on the Science of Dissemination and Implementation : Washington, DC, USA. 14-15 December 2015

A1 Introduction to the 8^th Annual Conference on the Science of Dissemination and Implementation: Optimizing Personal and Population Health

David Chambers, Lisa Simpson

D1 Discussion forum: Population health D&I research

Felicia Hill-Briggs

D2 Discussion forum: Global health D&I research

Gila Neta, Cynthia Vinson

D3 Discussion forum: Precision medicine and D&I research

David Chambers

S1 Predictors of community therapists’ use of therapy techniques in a large public mental health system

Rinad Beidas, Steven Marcus, Gregory Aarons, Kimberly Hoagwood, Sonja Schoenwald, Arthur Evans, Matthew Hurford, Ronnie Rubin, Trevor Hadley, Frances Barg, Lucia Walsh, Danielle Adams, David Mandell

S2 Implementing brief cognitive behavioral therapy (CBT) in primary care: Clinicians' experiences from the field

Lindsey Martin, Joseph Mignogna, Juliette Mott, Natalie Hundt, Michael Kauth, Mark Kunik, Aanand Naik, Jeffrey Cully

S3 Clinician competence: Natural variation, factors affecting, and effect on patient outcomes

Alan McGuire, Dominique White, Tom Bartholomew, John McGrew, Lauren Luther, Angie Rollins, Michelle Salyers

S4 Exploring the multifaceted nature of sustainability in community-based prevention: A mixed-method approach

Brittany Cooper, Angie Funaiole

S5 Theory informed behavioral health integration in primary care: Mixed methods evaluation of the implementation of routine depression and alcohol screening and assessment

Julie Richards, Amy Lee, Gwen Lapham, Ryan Caldeiro, Paula Lozano, Tory Gildred, Carol Achtmeyer, Evette Ludman, Megan Addis, Larry Marx, Katharine Bradley

S6 Enhancing the evidence for specialty mental health probation through a hybrid efficacy and implementation study

Tonya VanDeinse, Amy Blank Wilson, Burgin Stacey, Byron Powell, Alicia Bunger, Gary Cuddeback

S7 Personalizing evidence-based child mental health care within a fiscally mandated policy reform

Miya Barnett, Nicole Stadnick, Lauren Brookman-Frazee, Anna Lau

S8 Leveraging an existing resource for technical assistance: Community-based supervisors in public mental health

Shannon Dorsey, Michael Pullmann

S9 SBIRT implementation for adolescents in urban federally qualified health centers: Implementation outcomes

Shannon Mitchell, Robert Schwartz, Arethusa Kirk, Kristi Dusek, Marla Oros, Colleen Hosler, Jan Gryczynski, Carolina Barbosa, Laura Dunlap, David Lounsbury, Kevin O'Grady, Barry Brown

S10 PANEL: Tailoring Implementation Strategies to Context - Expert recommendations for tailoring strategies to context

Laura Damschroder, Thomas Waltz, Byron Powell

S11 PANEL: Tailoring Implementation Strategies to Context - Extreme facilitation: Helping challenged healthcare settings implement complex programs

Mona Ritchie

S12 PANEL: Tailoring Implementation Strategies to Context - Using menu-based choice tasks to obtain expert recommendations for implementing three high-priority practices in the VA

Thomas Waltz

S13 PANEL: The Use of Technology to Improve Efficient Monitoring of Implementation of Evidence-based Programs - Siri, rate my therapist: Using technology to automate fidelity ratings of motivational interviewing

David Atkins, Zac E. Imel, Bo Xiao, Doğan Can, Panayiotis Georgiou, Shrikanth Narayanan

S14 PANEL: The Use of Technology to Improve Efficient Monitoring of Implementation of Evidence-based Programs - Identifying indicators of implementation quality for computer-based ratings

Cady Berkel, Carlos Gallo, Irwin Sandler, C. Hendricks Brown, Sharlene Wolchik, Anne Marie Mauricio

S15 PANEL: The Use of Technology to Improve Efficient Monitoring of Implementation of Evidence-based Programs - Improving implementation of behavioral interventions by monitoring emotion in spoken speech

Carlos Gallo, C. Hendricks Brown, Sanjay Mehrotra

S16 Scorecards and dashboards to assure data quality of health management information system (HMIS) using R

Dharmendra Chandurkar, Siddhartha Bora, Arup Das, Anand Tripathi, Niranjan Saggurti, Anita Raj

S17 A big data approach for discovering and implementing patient safety insights

Eric Hughes, Brian Jacobs, Eric Kirkendall

S18 Improving the efficacy of a depression registry for use in a collaborative care model

Danielle Loeb, Katy Trinkley, Michael Yang, Andrew Sprowell, Donald Nease

S19 Measurement feedback systems as a strategy to support implementation of measurement-based care in behavioral health

Aaron Lyon, Cara Lewis, Meredith Boyd, Abigail Melvin, Semret Nicodimos, Freda Liu, Nathanial Jungbluth

S20 PANEL: Implementation Science and Learning Health Systems: Intersections and Commonalities - Common loop assay: Methods of supporting learning collaboratives

Allen Flynn

S21 PANEL: Implementation Science and Learning Health Systems: Intersections and Commonalities - Innovating audit and feedback using message tailoring models for learning health systems

Zach Landis-Lewis

S22 PANEL: Implementation Science and Learning Health Systems: Intersections and Commonalities - Implementation science and learning health systems: Connecting the dots

Anne Sales

S23 Facilitation activities of Critical Access Hospitals during TeamSTEPPS implementation

Jure Baloh, Marcia Ward, Xi Zhu

S24 Organizational and social context of federally qualified health centers and variation in maternal depression outcomes

Ian Bennett, Jurgen Unutzer, Johnny Mao, Enola Proctor, Mindy Vredevoogd, Ya-Fen Chan, Nathaniel Williams, Phillip Green

S25 Decision support to enhance treatment of hospitalized smokers: A randomized trial

Steven Bernstein, June-Marie Rosner, Michelle DeWitt, Jeanette Tetrault, James Dziura, Allen Hsiao, Scott Sussman, Patrick O’Connor, Benjamin Toll

S26 PANEL: Developing Sustainable Strategies for the Implementation of Patient-Centered Care across Diverse US Healthcare Systems - A patient-centered approach to successful community transition after catastrophic injury

Michael Jones, Julie Gassaway

S27 PANEL: Developing Sustainable Strategies for the Implementation of Patient-Centered Care across Diverse US Healthcare Systems - Conducting PCOR to integrate mental health and cancer screening services in primary care

Jonathan Tobin

S28 PANEL: Developing Sustainable Strategies for the Implementation of Patient-Centered Care across Diverse US Healthcare Systems - A comparative effectiveness trial of optimal patient-centered care for US trauma care systems

Douglas Zatzick

S29 Preferences for in-person communication among patients in a multi-center randomized study of in-person versus telephone communication of genetic test results for cancer susceptibility

Angela R Bradbury, Linda Patrick-Miller, Brian Egleston, Olufunmilayo I Olopade, Michael J Hall, Mary B Daly, Linda Fleisher, Generosa Grana, Pamela Ganschow, Dominique Fetzer, Amanda Brandt, Dana Farengo-Clark, Andrea Forman, Rikki S Gaber, Cassandra Gulden, Janice Horte, Jessica Long, Rachelle Lorenz Chambers, Terra Lucas, Shreshtha Madaan, Kristin Mattie, Danielle McKenna, Susan Montgomery, Sarah Nielsen, Jacquelyn Powers, Kim Rainey, Christina Rybak, Michelle Savage, Christina Seelaus, Jessica Stoll, Jill Stopfer, Shirley Yao and Susan Domchek

S30 Working towards de-implementation: A mixed methods study in breast cancer surveillance care

Erin Hahn, Corrine Munoz-Plaza, Jianjin Wang, Jazmine Garcia Delgadillo, Brian Mittman Michael Gould

S31Integrating evidence-based practices for increasing cancer screenings in safety-net primary care systems: A multiple case study using the consolidated framework for implementation research

Shuting (Lily) Liang, Michelle C. Kegler, Megan Cotter, Emily Phillips, April Hermstad, Rentonia Morton, Derrick Beasley, Jeremy Martinez, Kara Riehman

S32 Observations from implementing an mHealth intervention in an FQHC

David Gustafson, Lisa Marsch, Louise Mares, Andrew Quanbeck, Fiona McTavish, Helene McDowell, Randall Brown, Chantelle Thomas, Joseph Glass, Joseph Isham, Dhavan Shah

S33 A multicomponent intervention to improve primary care provider adherence to chronic opioid therapy guidelines and reduce opioid misuse: A cluster randomized controlled trial protocol

Jane Liebschutz, Karen Lasser

S34 Implementing collaborative care for substance use disorders in primary care: Preliminary findings from the summit study

Katherine Watkins, Allison Ober, Sarah Hunter, Karen Lamp, Brett Ewing

S35 Sustaining a task-shifting strategy for blood pressure control in Ghana: A stakeholder analysis

Juliet Iwelunmor, Joyce Gyamfi, Sarah Blackstone, Nana Kofi Quakyi, Jacob Plange-Rhule, Gbenga Ogedegbe

S36 Contextual adaptation of the consolidated framework for implementation research (CFIR) in a tobacco cessation study in Vietnam

Pritika Kumar, Nancy Van Devanter, Nam Nguyen, Linh Nguyen, Trang Nguyen, Nguyet Phuong, Donna Shelley

S37 Evidence check: A knowledge brokering approach to systematic reviews for policy

Sian Rudge

S38 Using Evidence Synthesis to Strengthen Complex Health Systems in Low- and Middle-Income Countries

Etienne Langlois

S39 Does it matter: timeliness or accuracy of results? The choice of rapid reviews or systematic reviews to inform decision-making

Andrea Tricco

S40 Evaluation of the veterans choice program using lean six sigma at a VA medical center to identify benefits and overcome obstacles

Sherry Ball, Anne Lambert-Kerzner, Christine Sulc, Carol Simmons, Jeneen Shell-Boyd, Taryn Oestreich, Ashley O'Connor, Emily Neely, Marina McCreight, Amy Labebue, Doreen DiFiore, Diana Brostow, P. Michael Ho, David Aron

S41 The influence of local context on multi-stakeholder alliance quality improvement activities: A multiple case study

Jillian Harvey, Megan McHugh, Dennis Scanlon

S42 Increasing physical activity in early care and education: Sustainability via active garden education (SAGE)

Rebecca Lee, Erica Soltero, Nathan Parker, Lorna McNeill, Tracey Ledoux

S43 Marking a decade of policy implementation: The successes and continuing challenges of a provincial school food and nutrition policy in Canada

Jessie-Lee McIsaac, Kate MacLeod, Nicole Ata, Sherry Jarvis, Sara Kirk

S44 Use of research evidence among state legislators who prioritize mental health and substance abuse issues

Jonathan Purtle, Elizabeth Dodson, Ross Brownson

S45 PANEL: Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid type 1 designs

Brian Mittman, Geoffrey Curran

S46 PANEL: Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid type 2 designs

Geoffrey Curran

S47 PANEL: Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid type 3 designs

Jeffrey Pyne

S48 Linking team level implementation leadership and implementation climate to individual level attitudes, behaviors, and implementation outcomes

Gregory Aarons, Mark Ehrhart, Elisa Torres

S49 Pinpointing the specific elements of local context that matter most to implementation outcomes: Findings from qualitative comparative analysis in the RE-inspire study of VA acute stroke care

Edward Miech

S50 The GO score: A new context-sensitive instrument to measure group organization level for providing and improving care

Edward Miech

S51 A research network approach for boosting implementation and improvement

Kathleen Stevens, I.S.R.N. Steering Council

S52 PANEL: Qualitative methods in D&I Research: Value, rigor and challenge - The value of qualitative methods in implementation research

Alison Hamilton

S53 PANEL: Qualitative methods in D&I Research: Value, rigor and challenge - Learning evaluation: The role of qualitative methods in dissemination and implementation research

Deborah Cohen

S54 PANEL: Qualitative methods in D&I Research: Value, rigor and challenge - Qualitative methods in D&I research

Deborah Padgett

S55 PANEL: Maps & models: The promise of network science for clinical D&I - Hospital network of sharing patients with acute and chronic diseases in California

Alexandra Morshed

S56 PANEL: Maps & models: The promise of network science for clinical D&I - The use of social network analysis to identify dissemination targets and enhance D&I research study recruitment for pre-exposure prophylaxis for HIV (PrEP) among men who have sex with men

Rupa Patel

S57 PANEL: Maps & models: The promise of network science for clinical D&I - Network and organizational factors related to the adoption of patient navigation services among rural breast cancer care providers

Beth Prusaczyk

S58 A theory of de-implementation based on the theory of healthcare professionals’ behavior and intention (THPBI) and the becker model of unlearning

David C. Aron, Divya Gupta, Sherry Ball

S59 Observation of registered dietitian nutritionist-patient encounters by dietetic interns highlights low awareness and implementation of evidence-based nutrition practice guidelines

Rosa Hand, Jenica Abram, Taylor Wolfram

S60 Program sustainability action planning: Building capacity for program sustainability using the program sustainability assessment tool

Molly Hastings, Sarah Moreland-Russell

S61 A review of D&I study designs in published study protocols

Rachel Tabak, Alex Ramsey, Ana Baumann, Emily Kryzer, Katherine Montgomery, Ericka Lewis, Margaret Padek, Byron Powell, Ross Brownson

S62 PANEL: Geographic variation in the implementation of public health services: Economic, organizational, and network determinants - Model simulation techniques to estimate the cost of implementing foundational public health services

Cezar Brian Mamaril, Glen Mays, Keith Branham, Lava Timsina

S63 PANEL: Geographic variation in the implementation of public health services: Economic, organizational, and network determinants - Inter-organizational network effects on the implementation of public health services

Glen Mays, Rachel Hogg

S64 PANEL: Building capacity for implementation and dissemination of the communities that care prevention system at scale to promote evidence-based practices in behavioral health - Implementation fidelity, coalition functioning, and community prevention system transformation using communities that care

Abigail Fagan, Valerie Shapiro, Eric Brown

S65 PANEL: Building capacity for implementation and dissemination of the communities that care prevention system at scale to promote evidence-based practices in behavioral health - Expanding capacity for implementation of communities that care at scale using a web-based, video-assisted training system

Kevin Haggerty, David Hawkins

S66 PANEL: Building capacity for implementation and dissemination of the communities that care prevention system at scale to promote evidence-based practices in behavioral health - Effects of communities that care on reducing youth behavioral health problems

Sabrina Oesterle, David Hawkins, Richard Catalano

S68 When interventions end: the dynamics of intervention de-adoption and replacement

Virginia McKay, M. Margaret Dolcini, Lee Hoffer

S69 Results from next-d: can a disease specific health plan reduce incident diabetes development among a national sample of working-age adults with pre-diabetes?

Tannaz Moin, Jinnan Li, O. Kenrik Duru, Susan Ettner, Norman Turk, Charles Chan, Abigail Keckhafer, Robert Luchs, Sam Ho, Carol Mangione

S70 Implementing smoking cessation interventions in primary care settings (STOP): using the interactive systems framework

Peter Selby, Laurie Zawertailo, Nadia Minian, Dolly Balliunas, Rosa Dragonetti, Sarwar Hussain, Julia Lecce

S71 Testing the Getting To Outcomes implementation support intervention in prevention-oriented, community-based settings

Matthew Chinman, Joie Acosta, Patricia Ebener, Patrick S Malone, Mary Slaughter

S72 Examining the reach of a multi-component farmers’ market implementation approach among low-income consumers in an urban context

Darcy Freedman, Susan Flocke, Eunlye Lee, Kristen Matlack, Erika Trapl, Punam Ohri-Vachaspati, Morgan Taggart, Elaine Borawski

S73 Increasing implementation of evidence-based health promotion practices at large workplaces: The CEOs Challenge

Amanda Parrish, Jeffrey Harris, Marlana Kohn, Kristen Hammerback, Becca McMillan, Peggy Hannon

S74 A qualitative assessment of barriers to nutrition promotion and obesity prevention in childcare

Taren Swindle, Geoffrey Curran, Leanne Whiteside-Mansell, Wendy Ward

S75 Documenting institutionalization of a health communication intervention in African American churches

Cheryl Holt, Sheri Lou Santos, Erin Tagai, Mary Ann Scheirer, Roxanne Carter, Janice Bowie, Muhiuddin Haider, Jimmie Slade, Min Qi Wang

S76 Reduction in hospital utilization by underserved patients through use of a community-medical home

Andrew Masica, Gerald Ogola, Candice Berryman, Kathleen Richter

S77 Sustainability of evidence-based lay health advisor programs in African American communities: A mixed methods investigation of the National Witness Project

Rachel Shelton, Lina Jandorf, Deborah Erwin

S78 Predicting the long-term uninsured population and analyzing their gaps in physical access to healthcare in South Carolina

Khoa Truong

S79 Using an evidence-based parenting intervention in churches to prevent behavioral problems among Filipino youth: A randomized pilot study

Joyce R. Javier, Dean Coffey, Sheree M. Schrager, Lawrence Palinkas, Jeanne Miranda

S80 Sustainability of elementary school-based health centers in three health-disparate southern communities

Veda Johnson, Valerie Hutcherson, Ruth Ellis

S81 Childhood obesity prevention partnership in Louisville: creative opportunities to engage families in a multifaceted approach to obesity prevention

Anna Kharmats, Sandra Marshall-King, Monica LaPradd, Fannie Fonseca-Becker

S82 Improvements in cervical cancer prevention found after implementation of evidence-based Latina prevention care management program

Deanna Kepka, Julia Bodson, Echo Warner, Brynn Fowler

S83 The OneFlorida data trust: Achieving health equity through research & training capacity building

Elizabeth Shenkman, William Hogan, Folakami Odedina, Jessica De Leon, Monica Hooper, Olveen Carrasquillo, Renee Reams, Myra Hurt, Steven Smith, Jose Szapocznik, David Nelson, Prabir Mandal

S84 Disseminating and sustaining medical-legal partnerships: Shared value and social return on investment

James Teufel

Practice-based learning and improvement in family medicine student clerkships: a CERA study

BACKGROUND

Practice-based learning and improvement (PBLI) has been promoted as a key component of competency-based training in medical student education, but little is known about its implementation.

METHODS

This project is part of a larger CERA omnibus survey of family medicine medical student clerkship directors carried out from July to September 2012. Analyses were conducted to assess clerkship infrastructure, learner assessment and feedback, and clerkship director perceptions of PBLI curricula.

RESULTS

The majority (69.0%, 58/82) of family medicine clerkship directors reported that PBLI is not included in their clerkship. Significant predictors of PBLI in the curriculum include: regularly scheduled centralized teaching (weekly or more versus less than weekly, OR=1.14, 95% CI=1.01--1.29) and clerkship director belief that students should achieve PBLI competency (agree in competency versus disagree in competency, OR=1.19, 95% CI=1.08--1.30). Few (20.5%, 16/78) family medicine clerkship directors reported that the amount of PBLI in their curriculum is likely to increase in the next 12 months. The duration of the clerkship was a significant predictor of reported likelihood of increasing PBLI over the next 12 months (3 weeks versus 8 weeks, OR=1.23, 95% CI=1.00--1.51).

CONCLUSIONS

Despite increased emphasis on quality improvement activities in practice, most family medicine clerkships do not currently offer PBLI curricula. Additionally, less than one in four family medicine clerkships plan on increasing the amount of PBLI curricula in the next 12 months. Continued research in this area is needed to identify successful models for PBLI curricular offerings.

Evaluation of office ultrasound usage among Australian and New Zealand breast surgeons

BACKGROUND

Surgeon performed ultrasound (US) is being increasingly embraced by breast surgeons worldwide as an integral part of patient assessment. The extent of its application within Australia and New Zealand is not well documented. The present study aimed to evaluate its current usage patterns and to determine suitable future training models.

METHODS

An online survey was sent to members of Breast Surgeons of Australia and New Zealand (BreastSurgANZ) between July and September 2010, with emphases on practice demographics, access to US equipment, usage, biopsy patterns, and training.

RESULTS

Of the 126 surveys sent, 59 were returned. The majority of respondents were metropolitan based (64 %), worked in both public and private sectors (71 %), and practiced endocrine or general surgery (85 %), as well as breast surgery. A preponderance of surgeons had access to equipment (63 %), performed at least 1 US monthly (63 %), but did not perform regular guided biopsies. Rural practice did not affect access or usage patterns. Most respondents underwent structured US training (73 %), which was associated with greater US and biopsy usage, biopsy complexity, intraoperative applications, and cross discipline applications (p < 0.03). Most surgeons favored a structured training program for future trainees (83 %).

CONCLUSIONS

The majority of breast surgeons from Australia and New Zealand have adopted office US to varying degrees. Geographic variation did not lead to access inequity and variation in scanning patterns. Formal US training may result in a wider scope of clinical applications by increasing operator confidence and is the preferred model within a specialist breast surgical curriculum.

The active management of risk in multiparous pregnancy at term: association between a higher preventive labor induction rate and improved birth outcomes

OBJECTIVE

To determine whether exposure of multiparous women to a high rate of preventive labor induction was associated with a significantly lower cesarean delivery rate.

STUDY DESIGN

Retrospective cohort study involving 123 multiparous women, who were exposed to the frequent use of preventive labor induction, and 304 multiparous women, who received standard management. Rates of cesarean delivery and other adverse birth outcomes were compared in the 2 groups. Logistic regression controlled for confounding covariates.

RESULTS

The exposed group had a lower cesarean delivery rate (adjusted odds ratio, 0.09; 0.8% vs 9.9%; P = .02) and a higher uncomplicated vaginal delivery rate (odds ratio, 0.53; 78.9% vs 66.4%; P = .01). Exposure was not associated with higher rates of other adverse birth outcomes.

CONCLUSION

Exposure of multiparous women to a high rate of preventive labor induction was significantly associated with improved birth outcomes, including a very low cesarean delivery rate. A prospective randomized trial is needed to determine causality.

A family medicine training collaborative in early abortion

OBJECTIVES

This study's objective was to assess participation and perceived benefits of abortion training among residents at programs with integrated early abortion care.

INTERVENTION

We developed a collaborative early abortion training network.

RESULTS

Residents at training sites had high participation (71%) and were more likely to report familiarity and comfort with providing early abortion care than comparison sites. Residents reported benefits to overall training (78%), satisfaction (55%), and plans to provide abortion care (40%).

CONCLUSIONS

This collaborative abortion training program was valued by residents and was associated with greater self-assessed skills and positive attitudes toward providing early abortion care than at comparison sites.

'Breaking it down': patient-clinician communication and prenatal care among African American women of low and higher literacy

PURPOSE

Low literacy has been associated with poor medical adherence, but its role in maternal care utilization has not been explored.

METHODS

We undertook a concurrent mixed methods study among 202 African American women of low (< or = 6th grade) and higher literacy receiving Medicaid. Poor use of prenatal care was defined by (1) starting care after the first trimester and (2) inadequate care utilization according to the Adequacy of Prenatal Care Utilization Index (APNCU). Participant-derived themes regarding prenatal care and care utilization were identified and explored through individual interviews (free listing and cultural consensus analysis; n = 40), and 4 confirmatory focus groups stratified by literacy.

RESULTS

Thirty-three women (16%) had low-literacy levels, 120 (61%) women started prenatal care after the first trimester, and 101 (50%) had inadequate utilization of prenatal care. Neither measure varied by literacy (P >.05). Cultural consensus analysis identified a single prenatal care factor that was comprised of 9 items, shared by women of low and higher literacy (eigenvalue 0.881, SD 0.058). Focus groups confirmed these items among participants from both literacy groups. Communication with clinicians was a central theme linking all of the factor items. Effective communication, exemplified by "breaking it down," was described as encouraging, whereas ineffective communication discouraged use of care.

CONCLUSION

Women who had both low- and higher-literacy skills had high rates of poor prenatal care utilization and reported that communication with clinicians influenced their use of prenatal care. Improving the clarity of communication by breaking down information into simple parts should be a priority for prenatal clinicians.

Leiomyoma of the Nipple

Leiomyoma is a rare, benign neoplasm of the nipple. We report the case of a patient with a leiomyoma arising from her left nipple who presented with persistent nipple pain and tenderness which led to the eventual complete excision of her left nipple and areola complex. The clinical characteristics, gross and microscopic pathologic findings, and management of this lesion are discussed. Surgical management should be tailored primarily to the control of symptoms. Clinicians should be aware that this is a rare, but potential cause of chronic persistent pain and swelling in the region of the nipple-areola complex of the breast.

The effect of a simple educational intervention on interest in early abortion training among family medicine residents

OBJECTIVES

We aimed to assess the effect of an educational intervention on the interest in and support for abortion training among family medicine residents.

METHODS

We conducted a cross-sectional survey before and after an educational lecture on medical and surgical abortion in primary care among 89 residents in 10 New Jersey family medicine programs.

RESULTS

Before the lecture, there was more interest in medical abortion training than surgical abortion. Resident interest in surgical abortion and overall support for abortion training increased after the educational intervention (p<.01).

CONCLUSIONS

Efforts to develop educational programs on early abortion care may facilitate the integration of abortion training in family medicine.

Initiating abortion training in residency programs: issues and obstacles

OBJECTIVES

Early abortion is a common outpatient procedure, but few family medicine residencies provide abortion training. We wished to assess experiences and obstacles among residency programs that have worked to establish early abortion services.

METHODS

From 2001-2004, 14 faculty participated in a collaborative program to initiate abortion training at seven family medicine residencies. Ten focus groups with all trainees were followed by individual semi-structured interviews with a smaller group (n=9) that explored the progress and obstacles they experienced. Individual interviews were recorded and analyzed to identify major themes and sub-themes related to initiating abortion training.

RESULTS

Five of seven sites established abortion training. Five major themes were identified: (1) establishing support, (2) administration, (3) finance, (4) legal matters, and (5) security/demonstrators. Faculty from sites where training was ultimately established rated the sub-themes of billing/reimbursement, obtaining staff support, and state/hospital regulations as most difficult. Gaining support from within the department and institution was most difficult for the two sites that could not establish training. None experienced difficulty with security/demonstrators.

CONCLUSIONS

Developing the clinical and administrative capacity to provide early abortion services in family medicine residency programs is feasible. Support from leadership within departments and from the wider institution is important for implementation.

Smoking in pregnancy: patient and provider risk reduction behavior

OBJECTIVE

To describe the range of risk reduction behaviors among women who continue to smoke after learning of their pregnancy, including reduced tobacco use, eventual cessation, and sustained abstinence as well as the patient-reported smoking cessation-promoting behaviors of prenatal care providers.

METHODS

This research is part of a larger prospective, community-based study conducted to assess the association between maternal stress and birth outcomes and infant health and development. Over a 2-year period, from February 2000 to November 2001, women receiving prenatal care at a consortium of public health centers in Philadelphia, Pennsylvania, were consecutively recruited (n = 1,451) completing interviews at their initial prenatal visit and again 3 to 4 months following their delivery. Smoking rates during pregnancy were determined from responses given during the first postpartum interview, at 3 to 4 months postpartum.

RESULTS

Of the 1,451 women interviewed at 3 to 4 months postpartum, 24.9 percent indicated smoking during their pregnancy. Of these antenatal smokers, 89.0 percent reported reducing their cigarette consumption during pregnancy. However, only 25.4 percent attained abstinence during their pregnancy. Among women who achieved abstinence during their pregnancy, 21.7 percent were still not smoking at the time of the postpartum interview. Antenatal smokers reported that prenatal care providers asked about their smoking (90.6%) and advised about quitting (76.5%). However, only 27.9 percent were given referrals to smoking cessation programs.

CONCLUSION

While cessation was achieved by only a quarter of antenatal smokers, almost 90 percent reduced their cigarette consumption. Prenatal care providers identified and provided cessation advice to the majority of women who were smoking but they did not follow through with material assistance in the form of referrals to smoking cessation programs.

Ultrasonic specimen radiography for non-palpable breast lesions

A retrospective review of ultrasound guided breast excisional biopsies performed in a Surgical Unit of Princess Alexandra Hospital in 1998-99 was undertaken to assess the use of ultrasound specimen radiography. In this series a total of 55 localization biopsies were performed for impalpable lesions in 53 women. In 21 patients (38%), specimen ultrasound was used to confirm that the lesion in question had been excised, whereas for 34 lesions (62%), specimen X-ray was undertaken. In a total of six cases (10.9% overall) the radiographic abnormality was seen on ultrasound only. Real-time specimen sonography is a technique which is very appropriately utilized in conjunction with ultrasound guided excisions and can be easily performed either in the radiology department or the operative suite with minimal time delay. It could have particular application for lesions that are detected in younger women with dense breast parenchyma. The results of this review confirm specimen sonography to be a reliable technique.

Parathyroid hormone venous sampling prior to reoperation forprimary hyperparathyroidism

BACKGROUND

The surgical cure rate for primary hyperparathyroidismis greater than 95%. For those who have recurrent or persistent disease, preoperative localization improves reoperation success rates. Selective parathyroid venous sampling (SPVS) for intact parathyroid hormone is particularly useful when non-invasive localization techniques are negative or inconclusive.

METHODS

We present all known cases (n = 13)between 1994 and 2002 who had venous sampling for localization a tour institution prior to reoperation for recurrent or persistent primary hyperparathyroidism. Comparison was made with non-invasive localization procedures. Results of invasive and non-invasive localization were correlated with surgical findings.

RESULTS

Of the nine reoperated cases, eight had positive correlations between SPVS and operative findings and histopathology. SPVS did not reveal the parathyroid hormone source in one case with negative non-invasive localization procedures. Comparisons between SPVS,computerized tomography (CT), and parathyroid scintigraphy (MIBI)as expressed in terms of true positive (TP), false positive (FP)and false negative (FN) were: SPVS - TP88.8%, FP 0%, FN 11.1%; CT - TP22.2%, FP 22.2%, FN 55.5%; and MIBI - TP33.3%, FP 0%, FN 66.6%. At least seven of the nine operated cases have been cured; another remained normocalcaemic 2 weeks after subtotal parathyroidectomy.

CONCLUSION

In our institution SPVS has proven to be a valuable tool in cases with recurrent or persistent primary hyperparathyroidism and negative non-invasive localization procedures.