Regulating antimicrobial use within hospitals: A qualitative study

OBJECTIVES

To examine how regulatory structures and processes focused on antimicrobial stewardship and antimicrobial resistance are experienced by hospital managers and clinicians.

METHODS

Forty-two hospital managers and clinicians working within accreditation and antimicrobial stewardship teams in three Australian hospitals participated in individual in-depth interviews. Thematic analysis was performed.

RESULTS

Thematic analysis revealed participants' experiences of hospital antimicrobial regulation and their perceptions of what would be required for meaningful antimicrobial optimisation. Theme 1: Experience of regulation of antimicrobials within hospitals: Participants described an increased profile of antimicrobial resistance with inclusion in regulatory requirements, but also the risks of bureaucratic manoeuvring to meet standards rather than governance-inducing systemic changes. Theme 2: Growth of accreditation processes and hospitals over time: Both regulatory requirements and hospitals were described as evolving over time, each manoeuvring in response to each other (e.g. development of short notice accreditation). Theme 3: Perceived requirements for change: Participants perceived a need for top-down buy-in, resource prioritisation, complex understanding of power and influence on clinician behaviour, and a critical need for medical engagement.

CONCLUSIONS

This study around antimicrobials shows the tension and dynamic relationship between regulatory processes and hospital responses, bringing to light the enduring balance of a system that positions itself to meet regulatory requirements and emerging "demands", without necessarily addressing the key underlying concerns. Antimicrobial resistance-related solutions are perceived as likely to require further resourcing and buy-in across multiple levels, engagement across professional streams and require strategies that consider complex systems change in order for regulatory structures to have potency.

The incurable self: Negotiating social bonds and dis/connection with metastatic breast cancer

As the culture of silence that once surrounded cancer has gradually given way to greater public awareness, normative visions of what cancer survivorship should entail have proliferated. These visions emphasise positivity and perseverance in pursuit of cure. While these visions provide comfort to many, for people with metastatic cancer, the emphasis on cure can undermine their sense of belonging to the broader collective of people living with cancer. Drawing on semi-structured interviews with 38 Australian women living with metastatic breast cancer, we explore how incurable cancer inflects understandings of self and transforms interpersonal relationships. Extending ideas around biosociality and belonging, we explore the tenuousness of social bonds, revealing how (in)visibility, (in)authenticity and (in)validation circulate within the daily lives of women with metastatic breast cancer. We conceptualise accounts according to four social bonds: (1) threatened bonds where a relationship is strained by misunderstanding, (2) severed bonds where a relationship is ruptured due to misunderstanding, (3) attuned bonds whereby a relationship is based on shared identification and (4) flexible social bonds when a relationship is based on mutual understanding. More broadly, we illustrate the persistence of normative visions of cancer survivorship and their enduring effects on those whom such visions exclude.

Multidisciplinary team meetings in prosthetic joint infection management: A qualitative study

BACKGROUND

Prosthetic joint infections (PJIs) cause substantial morbidity to patients and are extremely challenging for clinicians. Their management can include multiple operations, antibiotics, and prolonged hospital admissions. Multidisciplinary team meetings (MDTM) are increasingly used for collaborative decision-making around the management of PJIs, but thus far there has been no examination of the role of MDTM in decisions and management. This study aimed to examine interactions in a PJI MDTM to identify the dynamics in decision-making, and inter-specialty relationships more broadly.

METHODS

Twelve MDTMs over 7 months at an Australian tertiary referral hospital were video recorded, transcribed, and thematic analysis was performed.

RESULTS

Thematic analysis revealed four key areas of collaborative discussion 1. Achieving Inter-specialty Balance: The role of the multidisciplinary team discussion in providing balance between specialty views, and traversing the barriers between specialty interactions. 2. Negotiating Grey zones: there was frequent discussion of the limits of tests, interpretation of symptoms, and the limits of proposed operative strategies, and the resultant tensions of balancing ideal care vs pragmatic decision-making, and divergent goals of care. 3. Tailoring Treatment: identification of individual patient factors (both physiological and behavioural) and risks into collaborative decision-making. 4. Affording Failure: creating affordances in communication to openly discuss 'failure' to eliminate infection and likely negative outcomes.

CONCLUSIONS

MDTM in the management of prosthetic joint infections serve multiple functions including: achieving interdisciplinary balance; effective grey zone management, tailoring reconfigured care; and most critically, recognition of 'failure' to eliminate infection, a communicative affordance most likely leading to better care.

Hope in the era of precision oncology: a qualitative study of informal caregivers' experiences

OBJECTIVES

To explore informal caregivers' perspectives on precision medicine in cancer care.

DESIGN

Semi-structured interviews with the informal caregivers of people living with cancer and receiving targeted/immunotherapies. Interview transcripts were analysed thematically using a framework approach.

SETTING

Recruitment was facilitated by two hospitals and five Australian cancer community groups.

PARTICIPANTS

Informal caregivers (n=28; 16 men, 12 women; aged 18-80) of people living with cancer and receiving targeted/immunotherapies.

RESULTS

Thematic analysis identified three findings, centred largely on the pervasive theme of hope in relation to precision therapies including: (1) precision as a key component of caregivers' hope; (2) hope as a collective practice between patients, caregivers, clinicians and others, which entailed work and obligation for caregivers; and (3) hope as linked to expectations of further scientific progress, even if there may be no personal, immediate benefit.

CONCLUSIONS

Innovation and change in precision oncology are rapidly reconfiguring the parameters of hope for patients and caregivers, creating new and difficult relational moments and experiences in everyday life and in clinical encounters. In the context of a shifting therapeutic landscape, caregivers' experiences illustrate the need to understand hope as collectively produced, as emotional and moral labour, and as entangled in broader cultural expectations of medical advances. Such understandings may help clinicians as they guide patients and caregivers through the complexities of diagnosis, treatment, emerging evidence and possible futures in the precision era. Developing a better understanding of informal caregivers' experiences of caring for patients receiving precision therapies is important for improving support to patients and their caregivers.

The Enduring Effects of COVID for Cancer Care: Learning from Real-Life Clinical Practice

For three years, COVID-19 has circulated among our communities and around the world, fundamentally changing social interactions, health care systems, and service delivery. For people living with (and receiving treatment for) cancer, pandemic conditions presented significant additional hurdles in an already unstable and shifting environment, including disrupted personal contact with care providers, interrupted access to clinical trials, distanced therapeutic encounters, multiple immune vulnerabilities, and new forms of financial precarity. In a 2020 perspective in this journal, we examined how COVID-19 was reshaping cancer care in the early stages of the pandemic and how these changes might endure into the future. Three years later, and in light of a series of interviews with patients and their caregivers from the United States and Australia conducted during the pandemic, we return to consider the potential legacy effects of the pandemic on cancer care. While some challenges to care provision and survivorship were unforeseen, others accentuated and amplified existing problems experienced by patients, caregivers, and health care providers. Both are likely to have enduring effects in the "post-pandemic" world, raising the importance of focusing on lessons that can be learned for the future.

Characterization of mechanical properties of soft tissues using sub-microscale tensile testing and 3D-Printed sample holder

Obtaining the mechanical properties of soft tissues is critical in many medical fields, such as regenerative medicine and surgical simulation training. Although various tissue-characterization methods have been developed, such as AFM, indentation, and elastography, there remain some limitations on their accuracy and validity for measuring small and fragile soft tissues. This paper presents a tensile testing technique to measure the mechanical properties of soft tissues directly and accurately. Tensile testing was chosen as the primary method because of its simple procedure and ability to derive mechanical properties without requiring many assumptions or complicated models. However, tensile testing on soft tissues presents challenges related to gripping the tissue sample without affecting its inherent properties, applying minuscule forces to the sample, and measuring the cross-section area and strain of the sample. To solve these issues, this study presents a sub-micro scale tensile testing system that uses a flexure mechanism and a novel 3D-printed sample holder for gripping the tissue samples. The system also measures tested samples' cross-section area and strain using two high-resolution cameras. The system was validated by testing standard materials and used to characterize the elastic modulus, yield stress, and yield strain of lung tissue slices from six different mice. The results from the validation tests showed a less than 2.5% error for elastic modulus values measured using the tensile tester. At the same time, results from the mice lung tissue measurements revealed qualitative findings that closely matched those seen in the literature and displayed low coefficient of variation values, demonstrating the high repeatability of the system.

People living with HIV have low trabecular bone mineral density, high bone marrow adiposity, and poor trabecular bone microarchitecture at the proximal femur

People living with HIV (PLWH) have increased risk of osteoporosis and fractures. We assessed the proximal femur of PLWH and age-matched seronegative controls using quantitative computed tomography and magnetic resonance imaging. Results suggest that the trabecular compartment is compromised at fracture-prone regions in the proximal femur of PLWH.

INTRODUCTION

People living with HIV (PLWH) have increased risk of osteoporosis and fractures. However, studies assessing the main determinants of bone strength in the proximal femur exclude this vulnerable population. We assessed the proximal femur of 40 PLWH and 26 age-matched seronegative controls using quantitative computed tomography and magnetic resonance imaging.

METHODS

We examined cortical volumetric bone mineral density (Ct.vBMD), trabecular vBMD (Tb.vBMD), cortical thickness (Ct.Th), bone marrow adiposity (BMA), and trabecular number, separation, and bone volume fraction. Parametric comparisons between the two groups were made for the femoral head, femoral neck, trochanter, and total hip using linear regression adjusting for several covariates, including metrics of body composition. In addition, we investigated the associations of BMA with Tb.vBMD and trabecular microarchitecture with Spearman's rank partial correlations.

RESULTS

PLWH had lower Tb.vBMD and deteriorated trabecular microarchitecture in the femoral neck, trochanter and total hip, and elevated BMA in the femoral head, femoral neck, and total hip. Ct.vBMD and Ct.Th were not significantly different between the two groups. BMA was significantly associated with lower Tb.vBMD and deteriorated trabecular microarchitecture in both groups albeit at different femoral regions.

CONCLUSIONS

Our findings suggest that the trabecular, and not the cortical, compartment is compromised in the proximal femur of PLWH. The observed impairments in fracture-prone regions in PLWH indicate lower femoral strength and suggest higher fracture risk. The inverse associations of BMA with trabecular bone density and microarchitecture quality agree with findings at other anatomic sites and in other populations, suggesting that excess BMA possibly due to a switch from the osteoblast to the adipocyte lineage may be implicated in the pathogenesis of bone fragility at the femur in PLWH.

Experiencing the SARS-CoV-2 Pandemic Whilst Living With Cancer

The SARS-CoV-2 pandemic has resulted in considerable consequences for many cancer patients, exacerbating pre-existing systemic health system limitations as well as creating new challenges. From socially distanced clinics and the widespread introduction of telehealth, to the halting of clinical trials and the reassessment of what constitutes "essential" treatment, care in oncology has abruptly changed. There is currently limited analysis of cancer patients' experiences of the pandemic and its impacts on illness, wellness, and everyday life. Through semi-structured interviews with 54 people living with cancer during the 2020 phase of the SARS-CoV-2 pandemic in Australia, we explore how patients experience illness and care in reflecting upon a range of pandemic challenges, including delay, distance, and vulnerability. We find that in some cases, these pandemic conditions redefined the meaning of essential cancer care, reconfigured expectations around clinical trials, constructed new affective distances, and amplified dread and fear for people living with cancer.

Accuracy of Case-Based Seroprevalence of SARS-CoV-2 Antibodies in Maricopa County, Arizona

We conducted a community seroprevalence survey in Arizona, from September 12 to October 1, 2020, to determine the presence of antibodies to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We used the seroprevalence estimate to predict SARS-CoV-2 infections in the jurisdiction by applying the adjusted seroprevalence to the county's population. The estimated community seroprevalence of SARS-CoV-2 infections was 4.3 times greater (95% confidence interval = 2.2, 7.5) than the number of reported cases. Field surveys with representative sampling provide data that may help fill in gaps in traditional public health reporting. (Am J Public Health. 2022;112(1):38-42. https://doi.org/10.2105/AJPH.2021.306568).

Institutional governance and responsiveness to antimicrobial resistance: a qualitative study of Australian hospital executives

OBJECTIVES

Despite escalating antimicrobial resistance (AMR), implementing effective antimicrobial optimisation within healthcare settings has been hampered by institutional impediments. This study sought to examine, from a hospital management and governance perspective, why healthcare providers may find it challenging to enact changes needed to address rising AMR.

DESIGN

Semistructured qualitative interviews around their experiences of antimicrobial stewardship (AMS) and responsiveness to the requirement for optimisation. Data were analysed using the framework approach.

SETTING

Two metropolitan tertiary-referral hospitals in Australia.

PARTICIPANTS

Twenty hospital managers and executives from the organisational level of department head and above, spanning a range of professional backgrounds and in both clinical and non-clinical roles, and different professional streams were represented.

RESULTS

Thematic analysis demonstrated three key domains which managers and executives describe, and which might function to delimit institutional responsiveness to present and future AMR solutions. First, the primacy of 'political' priorities. AMR was perceived as a secondary priority, overshadowed by political priorities determined beyond the hospital by state health departments/ministries and election cycles. Second, the limits of accreditation as a mechanism for change. Hospital accreditation processes and regulatory structures were not sufficient to induce efficacious AMS. Third, a culture of acute problem 'solving' rather than future proofing. A culture of reactivity was described across government and healthcare institutions, precluding longer term objectives, like addressing the AMR crisis.

CONCLUSION

There are dynamics between political and health service institutions, as well as enduring governance norms, that may significantly shape capacity to enact AMS and respond to AMR. Until these issues are addressed, and the field moves beyond individual behaviour modification models, antimicrobial misuse will likely continue, and stewardship is likely to have a limited impact.

A sociology of precision-in-practice: The affective and temporal complexities of everyday clinical care

The idea of 'precision medicine', which has gained increasing traction since the early 2000s, is now ubiquitous in health and medicine. Though varied in its implementation across fields, precision medicine has raised hopes of revolutionary treatments and has spurred the proliferation of novel therapeutics, the alteration of professional trajectories and various reconfigurations of health/care. Nowhere is the promise of precision medicine more apparent, nor further institutionalised, than in the field of oncology. While the transformative potential of precision medicine is widely taken for granted, there remains scant attention to how it is being experienced at the coalface of care. Here, drawing on the perspectives of 54 cancer care professionals gleaned through eight focus group discussions in two hospitals in Australia, we explore clinicians' experiences of the day-to-day dynamics of precision-in-practice. We illustrate some of the affective and temporal complexities, analysed here under the rubrics of enchantment, acceleration and distraction that are emerging alongside the uptake of precision medicine in the field of oncology. We argue that these complexities, and their dis/continuities with earlier iterations of cancer care, demonstrate the need for sociological analyses of precision medicine as it is being implemented in practice and its varied effects on 'routine' care.

Entanglements of affect, space, and evidence in pandemic healthcare: An analysis of Australian healthcare workers' experiences of COVID-19

The COVID-19 pandemic continues to highlight both global interconnectedness and schisms across place, context and peoples. While countries such as Australia have securitised their borders in response to the global spread of disease, flows of information and collective affect continue to permeate these boundaries. Drawing on interviews with Australian healthcare workers, we examine how their experiences of the pandemic are shaped by affect and evidence ‘traveling’ across time and space. Our analysis points to the limitations of global health crisis responses that focus solely on material risk and spatial separation. Institutional responses must, we suggest, also consider the affective and discursive dimensions of health-related risk environments.

Interrogating the World Bank's role in global health knowledge production, governance, and finance

Background

In the nearly half century since it began lending for population projects, the World Bank has become one of the largest financiers of global health projects and programs, a powerful voice in shaping health agendas in global governance spaces, and a mass producer of evidentiary knowledge for its preferred global health interventions. How can social scientists interrogate the role of the World Bank in shaping ‘global health’ in the current era?

Main body

As a group of historians, social scientists, and public health officials with experience studying the effects of the institution’s investment in health, we identify three challenges to this research. First, a future research agenda requires recognizing that the Bank is not a monolith, but rather has distinct inter-organizational groups that have shaped investment and discourse in complicated, and sometimes contradictory, ways. Second, we must consider how its influence on health policy and investment has changed significantly over time. Third, we must analyze its modes of engagement with other institutions within the global health landscape, and with the private sector. The unique relationships between Bank entities and countries that shape health policy, and the Bank’s position as a center of research, permit it to have a formative influence on health economics as applied to international development. Addressing these challenges, we propose a future research agenda for the Bank’s influence on global health through three overlapping objects of and domains for study: knowledge-based (shaping health policy knowledge), governance-based (shaping health governance), and finance-based (shaping health financing). We provide a review of case studies in each of these categories to inform this research agenda.

Conclusions

As the COVID-19 pandemic continues to rage, and as state and non-state actors work to build more inclusive and robust health systems around the world, it is more important than ever to consider how to best document and analyze the impacts of Bank’s financial and technical investments in the Global South.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-021-00761-w.

Barriers-enablers-ownership approach: a mixed methods analysis of a social intervention to improve surgical antibiotic prescribing in hospitals

OBJECTIVES

To assess an intervention for surgical antibiotic prophylaxis (SAP) improvement within surgical teams focused on addressing barriers and fostering enablers and ownership of guideline compliance.

DESIGN

The Queensland Surgical Antibiotic Prophylaxis (QSAP) study was a multicentre, mixed methods study designed to address barriers and enablers to SAP compliance and facilitate engagement in self-directed audit/feedback and assess the efficacy of the intervention in improving compliance with SAP guidelines. The implementation was assessed using a 24-month interrupted time series design coupled with a qualitative evaluation.

SETTING

The study was undertaken at three hospitals (one regional, two metropolitan) in Australia.

PARTICIPANTS

SAP-prescribing decisions for 1757 patients undergoing general surgical procedures from three health services were included. Six bimonthly time points, pre-implementation and post implementation of the intervention, were measured. Qualitative interviews were performed with 29 clinical team members. SAP improvements varied across site and time periods.

INTERVENTION

QSAP embedded ownership of quality improvement in SAP within surgical teams and used known social influences to address barriers to and enablers of optimal SAP prescribing.

RESULTS

The site that reported senior surgeon engagement showed steady and consistent improvement in prescribing over 24 months (prestudy and poststudy). Multiple factors, including resource issues, influenced engagement and sites/time points where these were present had no improvement in guideline compliance.

CONCLUSIONS

The barriers-enablers-ownership model shows promise in its ability to facilitate prescribing improvements and could be expanded into other areas of antimicrobial stewardship. Senior ownership was a predictor of success (or failure) of the intervention across sites and time periods. The key role of senior leaders in change leadership indicates the critical need to engage other specialties in the stewardship agenda. The influence of contextual factors in limiting engagement clearly identifies issues of resource distributions/inequalities within health systems as limiting antimicrobial optimisation potential.

Mycobacterium bovis BCG Danish Strain 1331 isolated from a periarticular lesion in a domestic cat

A 7-year-old male neutered domestic shorthair outdoor cat was referred for chronic left forelimb lameness, which had been treated with intra-articular injections of triamcinolone acetonide. A soft tissue swelling around the elbow joint, extending from the distal humerus to the proximal ulna, was surgically explored and biopsy samples obtained. Mycobacterium bovis was cultured from samples from the soft tissue and bone. The mycobacteria from the media were killed and the DNA extracted and tested on a multiplex real-time PCR for the absence of specific genes and the presence of mycobacterial genus markers. The PCR revealed bacillus Calmette-Guérin Danish Strain 1331; this was also isolated from the prescapular lymph node, muscle and bone, obtained at post mortem examination. Badgers had been vaccinated with the bacillus Calmette-Guérin vaccine SSI (Statens Serum Institute) in the area where the cat lived, in the spring and autumn of the previous year. To the authors' knowledge, this is the first report of infection with M. bovis bacillus Calmette-Guérin Danish Strain 1331 in a domestic cat, potentially associated with annual vaccination of badgers in the proximity of the cat's home.

Antimicrobial overuse in India: A symptom of broader societal issues including resource limitations and financial pressures

India and the global community are facing a critical crisis of antimicrobial resistance (AMR), significantly contributed to by on-going and increasing antimicrobial misuse. Information as to what drives misuse of antimicrobials within India is essential to inform strategies to address the crisis. This papers aims to identify perceived influences on antimicrobial use in Hyderabad, India. We conducted semi-structured qualitative interviews conducted with thirty participants (15 doctors, 15 pharmacists) around their experiences of antimicrobials in Hyderabad, India. Thematic analysis was performed and four themes identified around (1) Perceptions of the problem of resistance and antimicrobial use; (2) Social pressures to prescribe/dispense; (3) Financial pressures driving antimicrobial over-use; and (4) Lack of regulation around training and qualifications. We conclude that antimicrobial use within India is embedded with, and occurs as a result of, complex social and economic factors including issues of resource limitation, structural/governance limitations and social relationships. Strategies to address misuse without acknowledging and addressing the critical driving forces of use will be unlikely to induce significant change.

COVD-25. THE PARADOXICAL EFFECTS OF COVID-19 ON CANCER CARE IN THE NEURO-ONCOLOGY SETTING

COVID-19 has caused ongoing interruptions to healthcare systems worldwide, shifting care to virtual platforms, and placing significant economic and logistical burdens on clinical practice. The pandemic has created uncertainty in delivering the standard of care, both in areas of cancer diagnosis and treatment, especially within neuro-oncology. Due to the pandemic, care and operational planning goals have shifted to infection prevention, modifying recommendations to decrease viral transmission and increasing telemedicine use, potentially creating a burden on implementing evidence-based medicine. These dynamics have since begun to redefine traditional practice and research regimens, impacting the comprehensive care that cancer patients can and should receive; and the enduring consequences for the delivery of healthcare. The impact of COVID-19 on oncology practice and trials might endure well beyond the short- to mid-term of the active pandemic. Therefore, these shifts must be accompanied by improved training and awareness, enhanced infrastructure, and evidence-based support to harness the positives and offset the potential negative consequences of the impacts of COVID-19 on cancer care. To address these paradoxical effects, we will conduct iterative, qualitative (face-to-face/video conference) interviews with neuro-oncology clinical and research professionals and adult brain tumor patients receiving care during the pandemic. We will capture unique aspects of oncology care: the lived, subjective, situated, and contingent accounts of patients and medical professionals, especially during a pandemic. We will also specifically compare the impact of telehealth during the pandemic on delivery of care to complex neuro-oncology patients. A summary of this in-depth, qualitative approach will result in a sophisticated understanding of neuro-oncology care on the frontline at a time of crisis, as experienced during a pandemic, to articulate best practices for future implementation.

Reconsidering the nursing role in antimicrobial stewardship: a multisite qualitative interview study

OBJECTIVES

This study responds to calls for greater focus on nursing roles, and the need for nursing integration within the antimicrobial optimisation agenda. The objective of this study was to explore Australian hospital nurses' views on antimicrobial resistance and antimicrobial stewardship (AMS) in a hospital setting, in order to better understand the opportunities for and challenges to integration of nursing staff in antimicrobial optimisation within hospital settings.

DESIGN

Qualitative one-on-one, semistructured interviews. Interview transcripts were digitally audio-recorded and transcribed verbatim. Data were subject to thematic analysis supported by the framework approach and informed by sociological methods and theory.

SETTING

Four hospitals (three public and one private), across metropolitan, regional and remote areas, in two Australian states.

PARTICIPANTS

86 nurses (77 females, 9 males), from a range of hospital departments, at a range of career stages.

RESULTS

Findings were organised into three thematic domains: (1) the current peripheral role of nurses in AMS; (2) the importance of AMS as a collaborative effort, and current tensions around interprofessional roles and (3) how nurses can bolster antimicrobial optimisation within AMS and beyond.

CONCLUSION

Nursing staff are central to infection management within the hospital and are thus ideally located to enhance antibiotic optimisation and contribute to AMS governance. However, without increased interprofessional cooperation, education and integration in the AMS agenda, as well as addressing organisational/resource constraints in the hospital, the nursing role in stewardship will remain limited.

The Paradoxical Effects of COVID-19 on Cancer Care: Current Context and Potential Lasting Impacts

Coronavirus disease 2019 (COVID-19) has fundamentally disrupted the practice of oncology, shifting care onto virtual platforms, rearranging the logistics and economics of running a successful clinical practice and research, and in some contexts, redefining what treatments patients with cancer should and can receive. Since the start of the pandemic in early 2020, there has been considerable emphasis placed on the implications for patients with cancer in terms of their vulnerability to the virus and potential exposure in healthcare settings. But little emphasis has been placed on the significant, and potentially enduring, consequences of COVID-19 for how cancer care is delivered. In this article, we outline the importance of a focus on the effects of COVID-19 for oncology practice during and potentially after the pandemic, focusing on key shifts that are already evident, including: the pivot to online consultations, shifts in access to clinical trial and definitions of "essential care," the changing economics of practice, and the potential legacy effects of rapidly implemented changes in cancer care. COVID-19 is reshaping oncology practice, clinical trials, and delivery of cancer care broadly, and these changes might endure well beyond the short- to mid-term of the active pandemic. Therefore, shifts in practice brought about by the pandemic must be accompanied by improved training and awareness, enhanced infrastructure, and evidence-based support if they are to harness the positives and offset the potential negative consequences of the impacts of COVID-19 on cancer care.

Reciprocity, Autonomy, and Vulnerability in Men's Experiences of Informal Cancer Care

Men are increasingly participating, and acknowledging their roles, as informal carers. Yet, there has been comparatively little exploration of their experiences therein, especially within the context of cancer care. Here, drawing on semi-structured qualitative interviews with 16 Australian male carers for a relative with cancer, and using constructivist grounded theory, we explore their experiences of informal caring. Our analysis highlights a series of tensions, including the following: the meanings and practicalities of care provision including notions of reciprocity, duty, autonomy, and interdependence; the discomforts of dependency and vulnerability; and the complicated moralities that inflect "caring well." Given the shifting dynamics around informal care, we argue for increased attention to the affective tensions that arise at the nexus of moralities and masculinities in informal caring relations, especially as they are articulated in the context of illness, affliction, and dependency.

Cancer caregivers' experiences of prognosis in Australia: a qualitative interview study

OBJECTIVES

Forecasting survival in cancer is a particularly challenging facet of oncological work and can involve complex interactions with patients and their families. While there is considerable research on patient experiences of being provided with, or becoming aware of, their prognosis, there has been much less emphasis placed on the experiences of caregivers. The aim of this paper was to examine caregivers' experiences of prognosis.

DESIGN

This study used semistructured interviews; transcripts were analysed thematically using the framework approach. These data are part of a larger research project focused on experiences of cancer survivorship.

SETTING

Recruitment was from two metropolitan hospitals in Queensland, Australia.

PARTICIPANTS

50 caregivers of patients living with cancer and receiving treatment at two metropolitan hospitals (32% male, 68% female) participated in this study.

RESULTS

Four main themes were identified: (1) caregivers' uncertainty around the meaning and implications of prognosis, (2) caregivers' sense of exclusion in prognostic conversations, (3) the practice of situating prognosis within a context of hope and (4) the precarious balance between realism, optimism and strategic 'ignorance'.

CONCLUSIONS

Caregivers are in many respects the unseen third party of prognostic communication. Developing a better understanding of caregivers' perceptions of prognosis, including how this may be challenged, accepted or otherwise, is important in engaging caregivers in the process of communicating prognostic information. Facilitating greater participation by caregivers in prognostic conversations could potentially address evident complexities and even improve the experiences of all stakeholders in cancer care settings.

The collective/affective practice of cancer survivorship

Whether within an atmosphere of hope, or amidst relations of fear, the emotions of cancer are unavoidably collectively produced. Yet persistent individualistic paradigms continue to obscure how the emotions of cancer operate relationally - between bodies, subjects, discourses, and practices - and are intertwined with circulating beliefs, cultural desires, and various forms of normativity. Drawing on interviews with 80 people living with cancer in Australia, this paper illustrates why recognition of the collective enterprise of survivorship - and the collective production of emotion, more generally - is important in light of persistent, culturally dominant conceptions of the individual patient as the primary 'afflicted', 'feeling', and 'treated' subject. Building on previous work on affective relations and moral framings, we posit that the collective affects of survivorship inflect what people living with cancer can, and should, feel. We highlight how such things as hope, resignation, optimism, and dread are 'products' of the collective affects of cancer, with implications for how survivorship is lived, felt, and done.

In one’s own time: Contesting the temporality and linearity of bereavement

This article explores the experience and meaning of time from the perspective of caregivers who have recently been bereaved following the death of a family member. The study is situated within the broader cultural tendency to understand bereavement within the logic of stages, including the perception of bereavement as a somewhat predictable and certainly time-delimited ascent from a nadir in death to a ‘new normal’ once loss is accepted. Drawing on qualitative data from interviews with 15 bereaved family caregivers we challenge bereavement as a linear, temporally bound process, examining the multiple ways bereavement is experienced and how it variously resists ideas about the timeliness, desirability and even possibility of ‘recovery’. We posit, on the basis of these accounts, that the lived experience of bereavement offers considerable challenges to normative understandings of the social ties between the living and the dead and requires a broader reconceptualization of bereavement as an enduring affective state.

A prospective clinical study of regenerative endodontic treatment of traumatized immature teeth with necrotic pulps using bi-antibiotic paste

AIM

To evaluate the treatment outcomes of a revitalization endodontic technique (RET) for the management of traumatized immature teeth with necrotic pulps in children.

METHODOLOGY

Fifteen healthy children (age range = 7-10 years) with traumatized immature maxillary incisors with necrotic pulps treated with bi-antibiotic revitalization endodontic technique were prospectively assessed over approximately two years (mean = 22 months). One operator undertook all treatments, clinical reviews and standardized radiographic exposures with radiographic analysis being carried out by two calibrated experienced clinicians. Crown colour change was assessed using an objective published methodology. Wilcoxon signed-rank test was used to compare root lengths, root dentinal widths and apical foramen widths over time.

RESULTS

Interoperator measurement reliability was consistently strong for all measurements. There was no significant difference in root lengths or root dentinal wall widths following RET. A significant difference in apical foramen widths was observed after 2 years (P = 0.013) with resolution of clinical signs of infection in all cases. Despite omitting minocycline and using Portland cement (nonbismuth containing cement), a noticeable crown colour change (yellower, redder and lighter), as measured by an objective colour measurement system with ΔE = 7.39, was recorded. Most patients, however, were satisfied with the aesthetic outcome.

CONCLUSION

Traumatized immature teeth with necrotic pulps treated with revitalization endodontic technique did not demonstrate continuation of root development or dentine formation when assessed by periapical radiographs. However, apical closure and periodontal healing were observed. A measurable change in crown colour (yellower, redder and lighter), with mostly no aesthetic concern to the patients/parents, was also observed.

Evaluation of testing strategies to identify infected animals at a single round of testing within dairy herds known to be infected with Mycobacterium avium ssp. paratuberculosis

As part of a broader control strategy within herds known to be infected with Mycobacterium avium ssp. paratuberculosis (MAP), individual animal testing is generally conducted to identify infected animals for action, usually culling. Opportunities are now available to quantitatively compare different testing strategies (combinations of tests) in known infected herds. This study evaluates the effectiveness, cost, and cost-effectiveness of different testing strategies to identify infected animals at a single round of testing within dairy herds known to be MAP infected. A model was developed, taking account of both within-herd infection dynamics and test performance, to simulate the use of different tests at a single round of testing in a known infected herd. Model inputs included the number of animals at different stages of infection, the sensitivity and specificity of each test, and the costs of testing and culling. Testing strategies included either milk or serum ELISA alone or with fecal culture in series. Model outputs included effectiveness (detection fraction, the proportion of truly infected animals in the herd that are successfully detected by the testing strategy), cost, and cost-effectiveness (testing cost per true positive detected, total cost per true positive detected). Several assumptions were made: MAP was introduced with a single animal and no management interventions were implemented to limit within-herd transmission of MAP before this test. In medium herds, between 7 and 26% of infected animals are detected at a single round of testing, the former using the milk ELISA and fecal culture in series 5 yr after MAP introduction and the latter using fecal culture alone 15 yr after MAP introduction. The combined costs of testing and culling at a single round of testing increases with time since introduction of MAP infection, with culling costs being much greater than testing costs. The cost-effectiveness of testing varied by testing strategy. It was also greater at 5 yr, compared with 10 or 15 yr, since MAP introduction, highlighting the importance of early detection. Future work is needed to evaluate these testing strategies in subsequent rounds of testing as well as accounting for different herd dynamics and different levels of herd biocontainment.

Exercise for fatigue management in hematopoietic stem cell transplantation recipients

Fatigue is a commonly reported symptom of patients who have undergone hematopoietic stem cell transplantation (HSCT). Fatigue in the HSCT recipient has multiple possible causes, including deconditioning, anemia, and medications. Regardless of the cause, fatigue impacts patients' well-being, ability to reintegrate into their normal lifestyle, physical recovery from transplantation, and overall symptom management. The authors discuss the current evidence regarding exercise for the management of fatigue in this population and lay the groundwork for developing an evidence-based intervention.

Abstract P3-05-05: HER2 Expression and Gene copy analysis by Immunofluorescence and Fluorescence in situ Hybridization, on a Single formalin-fixed paraffin-embedded tissue section

Introduction: Breast cancer is the most common cancer for women worldwide. HER2 expression and gene copy number are important when determining eligibility for adjuvant therapy and/or chemotherapy medications. One challenging issue for breast cancer testing is intratumoral heterogeneity of HER2 gene amplification. Intratumoral heterogeneity can make it difficult to localize target cells of interest. Serial tissue sections used for independent H&E, IHC and FISH stains also increase the difficulty to localize targets due to cellular truncation. We have developed a system to assess both HER2 expression and gene copy number on the same cell.

Method: Immunofluorescence (IF) and Fluorescence in situ Hybridization (FISH) were performed on tissue sections from 19 patients with invasive ductal breast carcinoma. Cases were selected based on prior HER2 FISH results (HER2:Chromosome 17 = ratio) representing unamplified (<2.0), amplified (≥2.0) and equivocal (1.8–2.2). Samples were collected from June 2011 – February 2012. Tissue sections were cut at 4uM from formalin-fixed paraffin-embedded tissue blocks. Slides were stained with antibodies for HER2 (Clone #D8F12, Cell Signaling, Danvers, MA), cytokeratin (Clone #AE1, eBioscience, San Diego, CA) and Pan cytokeratin (Clone #PCK-26, Sigma-Aldrich, St. Louis, MO). The whole tissue imaging was performed on the In-Cell (GE Healthcare, Chalfont St. Giles, UK) at 10X. Proprietary software developed by GRC (GE Global Research, Niskayuna, NY) controlled the hardware and performed numerous algorithmic functions. Regions of Interest (ROI) were selected by a pathologist on a whole tissue image and coordinates were recorded by the software. The slides were then imaged at 40x using the previously recorded ROI's. The same slides were stained with the PathVysion HER2/CEP17 FISH kit (Abbott Molecular, Des Plaines, IL). Slides were registered to the previous IF scan using recorded coordinates and tissue morphology recognition algorithms. The sections were imaged for FISH at 40X using the previous ROI selections. Cases were assessed for successful protein and genetic expression using proprietary visualization tools for combined analysis.

Results: We evaluated a total of 22 breast cancer cases with 19 cases detecting both protein and gene expression. Of the three cases that could not be evaluated the rationale is as follows: tissue damage incurred during imaging, insufficient focus during the FISH imaging portion, and poor signal to noise of the FISH dots.

Conclusion: The reported incidence of intratumoral HER2 amplification heterogeneity is as high as 30%. The challenges associated with tumor heterogeneity may benefit from a standardize analysis method. Using integrated images generated by this system, pathologist is able to select the appropriate cells for HER2 copy number enumeration based on the expression level of HER2 protein, in the same cell, allowing rapid identification of intratumoral heterogeneity.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-05-05.

The use of psychotherapeutic interventions by primary care GPs in Ireland in the treatment of their methadone patients: a grounded theory study

BACKGROUND

The methadone protocol placed responsibility on general practitioners (GPs) for the methadone treatment of stabilised drug-addicted patients. The protocol emphasised a medico-pharmacological model with minor reference to psychotherapeutic treatment.

AIM

This qualitative study investigated how primary care GPs in Ireland use psychotherapeutic interventions in the treatment of methadone patients.

METHOD

A grounded theory methodology was used.

FINDINGS

There is a wide variation in the beliefs and knowledge of methadone-prescribing GPs regarding the efficacy of psychotherapeutic interventions for patients on methadone maintenance. GPs do not formally integrate psychotherapeutic interventions into methadone patient treatment. Accessing psychotherapeutic services raises concerns for GPs in terms of availability, location and quality. Primary care GPs who offer methadone maintenance view opiate abuse as a health issue similar to other such issues within their community. They take a holistic view of their methadone patient and, without formal guidelines, develop individual approaches to the use of psychotherapeutic interventions. The absence of a framework for the use of psychotherapeutic interventions in primary care methadone treatment in Ireland militates against the development of a basis for improving practice.

Rare Bilateral Lipoma of the Internal Auditory Canals

About 10% of all intracranial tumors are localized in the cerebellopontine angle and in the internal auditory canal. Less than 2% of these are lipomas. Furthermore, it can be expected that lipomas in this position with a bilateral localization are exceedingly rare. We describe a 70-year-old-woman with lipomas in both internal auditory canals presented in the literature for the first time and include a detailed literature research.

Antibody response to various single-factor o antigens of salmonella

The relative agglutinin responses to various single O-antigenic (Kauffmann-White) factors were measured after immunization of rabbits with several strains of heat-killed salmonella organisms. As expected, the relative strength of the responses to the various O factors was quite varied and in some cases depended on the presence or absence of other single factors. For example, antibodies to factor 12(2) were formed rapidly and to extremely high levels in rabbits immunized with either Salmonella typhi (O 9,12(1),12(2),12(3)) or S. paratyphi B (O 1,4,5,12(1),12(2)), whereas factor 12(3) in S. typhi and factor 1 in S. paratyphi B induced only minimal responses. However, rabbits immunized with S. paratyphi A var. durazzo (O 2,12(1),12(3)), which lacks factor 12(2), produced high levels of agglutinins to the 12(3) antigenic determinant. In general, most of the agglutinin responses to the various single factors measured were formed in parallel, but there were several exceptions. For instance, the responses to factors 4 and 5 were relatively strong in rabbits receiving three graded doses of S. paratyphi B. However, agglutinins to factor 4 did not appear until after the second injection, and not at all in rabbits given the full amount of antigen in one injection. In contrast, antibodies to factor 4 were formed rapidly in rabbits receiving three graded doses of a strain of S. typhimurium (O 1,4,12) lacking factor 5. Good overall agreement was obtained between agglutination and hemagglutination assays of antibodies, as demonstrated by the responses to the various O factors of S. friedenau. It was concluded that measurement of the antibody responses to the various single-factor O antigens throughout the immunization program was necessary for effective evaluation of the relative significance of these factors in antibody formation against intact bacteria.

An evaluation of Irish cattle herds with inconclusive serological evidence of bovine brucellosis

Since 1998, there has been a steady decline in herd restrictions and de-populations in Ireland due to bovine brucellosis. There is concern that the interpretation of laboratory results may become increasingly problematic, as brucellosis prevalence falls in Ireland. Therefore, the purpose of the current study was to evaluate the infection status of Irish herds and animals with inconclusive serological evidence of bovine brucellosis. During 12 months from September 1, 2004, laboratory and observational epidemiological data were collected from all Irish herds where animal testing identified at least one animal with a complement fixation test (CFT) reading greater than zero and/or a positive result to the indirect enzyme-linked immunosorbent assay (iELISA). Due to the observational nature of the study, we have robust estimates of the relative, but not the absolute, performance of the CFT, iELISA and brucellin skin test (BST). Herds were divided into three categories (Group A, B or C) on the basis of test results at initial assessment. A total of 639 herds were enrolled into the study, and observed for at least two years following enrolment. A rising CFT titre, with a CFT reading of 111 International CFT Units (IU) or greater at the subsequent blood test, was generally associated with herds where other evidence of infection was also available. Knowledge of the CFT reading at the initial and a subsequent blood test proved useful in distinguishing false-positive and true-positive brucellosis results. There was poor correlation between the CFT and iELISA results, and between the CFT and BST results. As a result of this study, national policy has been modified to include re-sampling of all animals with CFT readings of 20 IU or greater. This project has also led to a reduction in the number of herds restricted, as well as restriction duration. It has also contributed to a reduction in the number of herds listed for contiguous tests, and therefore the potential for contiguity testing of false positive results.

Enzyme immunoassay for the diagnosis of brucellosis: chimeric Protein A–Protein G as a common enzyme labeled detection reagent for sera for different animal species

A recombinant protein combining the immunoglobulin binding sites of Proteins A and G, conjugated with horseradish peroxidase was used as a universal detection reagent for the assessment of antibodies against Brucella spp. The reagent was applied in an indirect enzyme immunoassay for detection of antibodies to smooth lipopolysaccharide antigen in sera from Brucella spp. exposed and non-exposed cattle, sheep, goats and pigs and to antibodies to rough lipopolysaccharide in sheep, dogs and cattle. The results were similar to those obtained when murine monoclonal antibody-enzyme conjugates were used. An added advantage was that a universal cut-off for all tests using the proteins A and G detection reagent could be established, simplifying diagnostic interpretation of the data.

Rough Lipopolysaccharide ofBrucella abortusRB51 as a Common Antigen for Serological Detection ofB. ovis,B. canis, andB. abortusRB51 Exposure Using Indirect Enzyme Immunoassay and Fluorescence Polarization Assay

Rough lipopolysaccharide (RLPS) antigens were prepared from cultures of Brucella abortus RB51, B. ovis, and B. canis. The preparations were standardized by weight and tested with sera from cattle immunized with B. abortus RB51, sheep infected with B. ovis, and dogs infected with B. canis. Populations of unexposed animals of each species were also tested. The tests used were the indirect enzyme immunoassay (IELISA) using RLPS and the fluorescence polarization assay (FPA) using RLPS core fractions, labeled with fluorescein isothiocyanate. The IELISA using B. abortus RB51 RLPS antigen resulted in sensitivity and specificity values of 94.8% and 97.3%, respectively, when testing bovine sera, 98.5% and 97.8% when testing ovine sera, and 95.8% and 100% when testing dog sera. The IELISA using B. ovis RLPS antigen gave sensitivity and specificity values of 80.5% and 91.7%, respectively with bovine sera, 98.9% and 93.8% with sheep sera, and 70.8% and 79.8% with dog sera. The IELISA using B. canis RLPS antigen resulted in sensitivity and specificity values of 97.0% and 97.4%, respectively, with bovine sera, 96.2% and 96.3% with sheep sera, and 95.8% and 98.8% with dog sera. Labeling RLPS core from B. ovis and B. canis with fluorescein was not successful. B. abortus RB51 core labeled with fluorescein resulted in sensitivity and specificity values of 93.5% and 99.8%, respectively, with bovine sera and 78.1% and 99.0% with sheep sera. It was not possible to test the dog sera in the FPA.

Staphylococcus aureus capsular polysaccharide type 5 conjugate and whole cell vaccines stimulate antibody responses in cattle

Dairy heifers were immunized subcutaneously with one of four different vaccines which contained preparations of Staphylococcus aureus capsular polysaccharide type 5 (CP5) and a mineral oil adjuvant, or received a placebo containing saline and adjuvant. The vaccine containing a CP5-human serum albumin conjugate (CP5-HSA) and the vaccine with formaldehyde inactivated whole cells expressing CP5, both elicited strong anti-CP5 antibody responses. After two injections three weeks apart and a third injection 10 months later, the mean level and duration of the anti-CP5 antibody response was significantly higher in the whole cell group. No differences were found between the two groups with regard to the relative proportion of IgG subclasses, and the antibody responses to the polysaccharide were composed of both the IgG1 and IgG2. Vaccines containing only free CP5 or CP5 mixed with HSA produced weak and transient humoral immune responses. Only animals vaccinated with the whole cell vaccine or the conjugate vaccine showed responses to CP5 in a lymphocyte proliferation assay conducted one year after the third vaccination. This study indicates that CP5 expressed on the surface of formaldehyde inactivated whole cells, emulsified in an oil adjuvant, gives a strong and long lasting immune response in cattle. The use of conjugation technology, although effective, might not be necessary in order to achieve an immune response against S. aureus CP5 in cattle.

Fluorescence polarization assay for the diagnosis of bovine brucellosis: adaptation to field use

A fluorescence polarization assay (FPA) was used to test whole blood samples prepared by mixing blood cells from cattle without exposure to Brucella abortus (B. abortus) with sera from animals with confirmed (bacteriologically) infection. A cut-off value between negative and positive values was initially established to be 87.2mP. This value was changed to 95mP to increase assay specificity without loss of sensitivity when testing blood samples from negative animals. The FPA technology was applied to whole blood samples in the field and to stored whole blood samples using two diluent buffers. Relative sensitivity and specificity values for the FPA performed in the field, based on buffered antigen plate agglutination test and competitive enzyme immunoassay results were 95.3 and 97.3%, respectively. However, to obtain maximum sensitivity and specificity, a cut-off value of 105mP was determined for fresh whole blood samples. The relative sensitivity and specificity values of the FPA when testing stored whole blood samples were 100% each using a 95mP cut-off.The usefulness of the FPA for testing whole blood samples in the field was demonstrated.

Characterisation of isolates of Staphylococcus aureus from acute, chronic and subclinical mastitis in cows in Norway

Eighty-six Staphylococcus aureus isolates from cases of bovine mastitis were characterised biochemically and with respect to serotype, multilocus enzyme electrophoresis genotypes, antibiotic sensitivity, and production of enterotoxins A through D (SEA-D) and toxic shock syndrome toxin-1 (TSST-1). The samples were obtained from 81 different cows from 79 Norwegian dairy herds in 10 different counties in southern Norway. There was an equal representation of isolates from cases of acute, chronic and subclinical mastitis. Multilocus enzyme electrophoresis using 13 genetic loci showed that 69 of 86 isolates had the same electrophoretic type. This common electrophoretic type comprised isolates that differed in the expression of other phenotypical characteristics studied. Fifty-eight percent of the isolates produced one or more enterotoxins, predominantly a combination of SEC and TSST-1. Capsular serotyping revealed that 95% of the isolates belonged to serotype 8. No correlation was found between the factors studied and the clinical classification of mastitis. It appears that the majority of S. aureus isolates recovered from cases of bovine mastitis in Norway are genetically closely related and express common phenotypical characteristics.

Genetic and serologic evaluation of capsule production by bovine mammary isolates of Staphylococcus aureus and other Staphylococcus spp. from Europe and the United States

Bovine mastitis caused by Staphylococcus aureus is responsible for major economic losses to the dairy industry, and more-effective therapeutic or preventive approaches are sorely needed. The predominance of staphylococcal capsular polysaccharide types 5 and 8 among human isolates from many sources is well documented, but there seems to be a greater variation in the distribution of capsular serotypes among isolates from cows. A total of 636 isolates of S. aureus from cases of bovine mastitis in Sweden, Denmark, Finland, Iceland, Ireland, and the United States were investigated for production of capsular polysaccharide types 5 and 8. Approximately half of all the European isolates tested were of serotype 8, although variation among countries and among isolates of clinical and subclinical origin was observed. Sweden had the highest frequency (87%) of serotypeable isolates, and Finland had the lowest (48%). Capsule types 5 and 8 accounted for only 42% of the U.S. isolates tested. A few isolates showed weak reactivity with CP5 antiserum in a colony blot assay, and an enzyme-linked immunosorbent assay inhibition method confirmed that the levels of capsule produced by these strains were <10% of those produced by control strains. Fifty isolates that failed to react with capsular antisera all possessed the genes for production of capsular polysaccharide type 5 or 8. These results underscore the variability in capsule production by bovine isolates of S. aureus from different geographic regions. This information is important for the rational design of a capsule-based vaccine to prevent S. aureus bovine mastitis.