Treatment and survival of patients diagnosed with high-risk HR+/HER2- breast cancer in the Netherlands: a population-based retrospective cohort study.

BACKGROUND: Several factors may increase the risk of recurrence of patients diagnosed with hormone receptor-positive human epidermal growth factor receptor 2-negative (HR+/HER2-) breast cancer (BC). We aim to determine the proportion of patients with high-risk HR+/HER2- BC within the total HR+/HER2- BC cohort and compare their systemic treatments and survival rates with those of patients with low- and intermediate-risk HR+/HER2- BC and triple-negative (TN) BC. PATIENTS AND METHODS: Women diagnosed with nonmetastatic invasive HR+/HER2- BC and TNBC in the Netherlands between 2011 and 2019 were identified from the Netherlands Cancer Registry. Patients with HR+/HER2- BC were categorised according to risk profile, defined by nodal status, tumour size, and histological grade. High-risk HR+/HER2- BC was defined by either four or more positive lymph nodes or one to three positive lymph nodes with a tumour size of ≥5 cm or a histological grade 3 tumour. Overall survival (OS) and relative survival (RS) were calculated using the Kaplan-Meier and Pohar-Perme method. RESULTS: In this study of 87 455 patients with HR+/HER2- BC, 44 078 (50%) patients were diagnosed with low risk, 28 452 (33%) with intermediate risk, and 11 285 (13%) with high-risk HR+/HER2- BC. In 3640 (4%) patients, the risk profile could not be defined. Endocrine therapy and chemotherapy were used in 38% and 7% of low-risk, 90% and 47% of intermediate-risk, and 94% and 73% of high-risk patients, respectively. The 10-year OS and RS rates were 84.1% [95% confidence interval (95% CI) 83.5% to 84.7%] and 98.7% (95% CI 97.3% to 99.4%) in low-risk, 75.1% (95% CI 74.2% to 76.0%) and 91.7% (95% CI 89.7% to 93.3%) in intermediate-risk, and 63.4% (95% CI 62.0% to 64.7%) and 72.3% (70.1% to 74.3%) in high-risk patients. The 10-year OS and RS rates of 12 689 patients with TNBC were 69.7% (95% CI 68.6% to 70.8%) and 79.1% (95% CI 77.0% to 80.9%), respectively. CONCLUSION: The poor prognosis of patients with high-risk HR+/HER2- BC highlights the need for a better acknowledgement of this subgroup and supports ongoing clinical trials aimed at optimising systemic therapy.

[(Too) long in tbs? A study on patients receiving forensic psychiatric tbs-treatment for 15 years or longer]. / (Te) lang in tbs? Een onderzoek naar patiënten die meer dan 15 jaar in tbs-behandeling zijn.

BACKGROUND: In 2013 in the Netherlands about 100 forensic psychiatric patients were treated in tbs-hospitals for 15 years or more.
AIM: To investigate the variables that characterise patients who have been receiving forensic psychiatric treatment (tbs) for 15 years or more, and to obtain insight in which actions might be helpful to facilitate discharge or transfer of such patients to other (mental health care) facilities, according to their caregivers and experts.
METHOD: The group of long-term tbs-patients (n = 97) was compared with regard to diagnostic characteristics, 'basic historical risks' (as assessed by risk assessment instruments), and behaviour  to three other groups of forensic patients: a. a group who had received treatment for 5 to 10 years, b. a group of patients who had been recently discharged, and c. a group of long-stay tbs-patients.
RESULTS: Long-term tbs-patients relatively often had been sex offenders (50% compared to about 20% of recently discharged tbs-patients), and had been admitted in a tbs-hospital at a relatively young age (on average they had been five years younger on admission). The professional clinicians of the long-term tbs-patients considered that the psychopathology of the long term tbs-patients was more severe than the psychopathology of the average tbs-patient. The clinicians also indicated that the long-term tbs-patients all need long-term supervision; however, they considered that only a minority of these patients (17%) required a maximum level of security and very restricted possibilities for temporary leave.
CONCLUSION: Patient related factors and organisational factors within the tbs-hospital and the general mental health care system seem to play a role in the lengthy period of tbs-treatment of the long-term tbs-patients. According to tbs-clinicians, these patients require prolonged and intensive supervision which the general mental health care system is often not equipped to deliver.

[Substance use and criminality: a review]. / Middelengebruik en criminaliteit: een overzicht.

BACKGROUND: Substance use regularly co-occurs with many types of criminality, including violent behaviour. AIM: To review the relationships between substance abuse and criminality, which can involve violent behaviour. METHOD: We searched the literature for meta-analyses, reviews and empirical articles about relationships between the problematic use of and addiction to psychoactive substances on the one hand and antisocial and aggressive behaviour and recidivism on the other hand. RESULTS: In the case of both men and women there are significant relationships between substance abuse and criminal behavior. The majority of substance users, however, are not criminals and most of the offences they commit can be termed 'acquisitive offences'. The relationship between alcohol and violence is stronger than the relationship between substance abuse and violence. Furthermore, it is only in cocaine users that we find indications that psychopharmacological effects stimulate violent behaviour. A number of factors, particularly interactions, determine whether substance abusers are criminal and are violent. Violent behaviour can result from interactions between the severity of illness caused by substance abuse, individual psychological, social and neurobiological characteristics, situational factors and expectancies regarding the psychopharmacological effects of a particular substance. CONCLUSION: Substance abuse, particularly the combination of alcohol and drugs, is a predictor of criminality and criminal recidivism.

[Behavioural changes during forensic psychiatric treatment: a multicenter study]. / Gedragsveranderingen tijdens tbs-behandeling: een multicenteronderzoek.

BACKGROUND: In forensic psychiatry it is essential that patients' risks of reoffending are assessed as reliably as possible. The risk assessment instrument hkt-30 assesses both static and dynamic risk factors. It is assumed that dynamic risk factors should change when a patient receives treatment. AIM: To find out whether dynamic risk factors changed during the course of forensic psychiatric treatment. METHOD: The hkt-30 was administered 984 times for forensic psychiatric patients in 3 different forensic psychiatric centres, in the period June 2003-November 2006. For 513 patients the instrument was administered at least once, for 313 this was done at least twice and for 158 patients for three years in succession. By subdividing the research group into 'new', 'old' and 'transferred' patients we were able to examine in which phase of treatment the largest changes in hkt-30 scores occurred. RESULTS: More than half the scores for dynamic risk factors, as well as the total score, declined significantly as treatment progressed, but the differences were small in absolute terms. The three subgroups of patients hardly differed from each other with regard to the degree of change. CONCLUSION: The scores for the risk factors, assumed in theory to be changeable, seemed to become lower as the treatment progressed. However, it is not yet certain whether these lower scores were in fact directly linked to a reduction on the risk of reoffending.

[Proposal for a treatment law based on the Scottish model]. / Voorstel voor een behandelwet naar Schots model.

Even after recent amendments and proposed modifications, the Dutch law on special admissions to psychiatric hospitals ('Bopz') is still primarily a law on admissions, whereas what psychiatry and society in general urgently require is a law on treatment. In October, 2005, in Scotland a new law concerning the care and treatment of psychiatric patients came into force: the Mental Health (Care and treatment) Act 2003 ('Act'). This new law can in fact be designated a treatment law. In this article the Scottish Act is compared to the Bopz. The comparison shows that Scotland has in fact developed a law which may provide an answer to the inadequacies of the Bopz.

[On the way to a treatment law?]. / Op weg naar een behandelwet?

Under the current Dutch law on special admissions to psychiatric hospitals (Bopz) it is possible to detain a patient who is a danger to himself and others. The Bopz, however, makes hardly any provisionfor compulsory treatment. Many psychiatrists regard this as an inherent shortcoming of the law. Members of the public, too, are becoming increasingly concerned by the fact that a seriously ill patient can, subject to strict criteria, be detained compulsorily but cannot thereafter be compelled to undergo treatment. The legislature has recently made some amendments to the Bopz law. The main goals is to widen its scope, making the law more flexible with regard to compulsory admission and compulsory treatment. In this article we discuss these amendments and new developments and by referring to case law we investigate whether these changes increase the possibilitiesfor compulsory treatment. We conclude that at the moment they do not.

Compulsive smoking: the development of a Rasch homogeneous scale of nicotine dependence.

The unidimensionality of nicotine dependence has not been established firmly yet. The aim of this study was to assess the dimensionality of nicotine dependence, preferably meeting the strict assumptions of the Rasch model. First, we examined the validity of the Fagerström Test for Nicotine Dependence (FTND) [Br. J. Addict. 86 (1991) 1119.] in 1525 smokers who participated in a national survey considering smoking behavior. Two factors were found, suggesting that the FTND does not measure a unidimensional construct. Factor analysis of 19 other dependence items in 512 smokers resulted in four factors of which three were interpretable: compulsive smoking, social problems due to smoking, and physical dependence. We focused on smoking compulsivity. This factor turned out to consist of a four-item Rasch homogeneous scale. Two items of the FTND with face validity of smoking compulsivity were found to fit into the scale. The results of Rasch analysis were in support of a continuum of compulsivity. Difficulty refraining from smoking in places where it is forbidden was found to indicate highest compulsivity. Several correlates with smoking compulsivity were found. We conclude that compulsive smoking is one important dimension of nicotine dependence, which may account for the considerable relapse of this disorder.

Caring for women living with ovarian cancer: recommendations for advanced practice nurses.

This article summarizes advice for advanced practice nurses (APNs) that grew out of research with women living with premenopausal ovarian cancer. We claim that the process of diagnosis and being told, battle metaphors, treatment expectations, the patient's sense of normalcy, her sense of being heard, her ability to make sense of her new world, her inability to have children, issues of sexuality, and the irrelevance of most support groups are important considerations in the treatment of such women. The APN's major role in caring for these women is understanding the experience as it informs the APN's practice and serving as advocates for the women.

Io as a source of the jovian dust streams

Streams of dust emerging from the direction of Jupiter were discovered in 1992 during the flyby of the Ulysses spacecraft, but their precise origin within the jovian system remained unclear. Further data collected by the Galileo spacecraft, which has been orbiting Jupiter since December 1995, identified the possible sources of dust as Jupiter's main ring, its gossamer ring, comet Shoemaker-Levy 9 (ref. 8) and Io. All but Jupiter's gossamer ring and Io have since been ruled out. Here we find that the dominant source of the jovian dust streams is Io, on the basis of periodicities in the dust impact signal. Io's volcanoes, rather than impact ejecta, are the dust sources.

In your skin you are different: women living with ovarian cancer during childbearing years.

The purpose of this study was to understand what it is like to live with ovarian cancer during childbearing years. The primary researcher (PR) conducted three to four in-depth interviews, lasting 60 to 90 minutes each, with five women living with ovarian cancer for 1 to 10 years. Van Manen's method of reflection and writing guided the inquiry. The process of existential investigation expanded the inquiry. Trustworthiness was assured through member checking, reflective journaling, coinvestigators checking the logic of the PR's analysis, and the achievement of consensus through dialogue. Analysis of the data revealed the themes of serendipitous diagnosis, managing treatment, horrible hair experience, hysterectomy violating one's sense of being, unfairness of menopause, body changes, intimate dreaming, being with others, being normal/different, being vigilant, being heard, and trying to make sense of it. The stories revealed provide us with a window into the experience of women with ovarian cancer.

New classes for office staff. MSMS Educational Program focuses on improving your practice.

Have you ever wondered how your practice could benefit from a highly trained and specialized office staff? It could improve how patients are treated and enhance the day-to-day tasks required to run an office. Medical office personnel are essential, and their continued education can directly affect the operation and perception of your practice.

Submission and rebellion: excessive drinking of women in problematic heterosexual partner relationships.

Functionality of alcohol use for coping with partner relationship problems was explored in a group of 45 alcohol-dependent women with semistructured interviews. Six functions were categorized, three of them referring to adjustment and three to opposition to the partner. Respondents who had started excessive drinking mainly in response to problems with the partner reported more partner-related functions than respondents for whom a problematic partner relationship was not an important factor in the development of excessive drinking. Respondents of the first group also reported other characteristics of their relationship, notably they said more often that their partner was dominant. It was concluded that for a subgroup of women with alcohol problems, alcohol use may be a way of coping with a situation of powerlessness toward the partner.

Do alcohol pharmacokinetics in women vary due to the menstrual cycle?

Many authors in the alcohol field believe that the physiological responsiveness of women to alcohol varies during the menstrual cycle, due to changes in levels of sex steroid hormones. Statements about this issue are very contradictory, however. The aim of this review was to decide what valid evidence was available on this issue. Three criteria were set to assess the validity of the reviewed studies: (1) was a within-subjects design used with normally cycling subjects, (2) were the time points selected for testing characterized by significant variations in sex steroid activity, and (3) was it verified whether ovulation occurred in the subjects by measuring levels of sex steroids? Two of the 11 studies we examined met these criteria. These studies, emanating from the same laboratory, found that alcohol elimination increased, by about 14%, during the luteal phase compared to other phases of the cycle. The results were discussed in relation to other research regarding effects of sex steroids on alcohol metabolism. It is concluded that there is no evidence that menstrual cycle causes significant instability in alcohol pharmacokinetics in women.

A cardiac arrest and a second-hand report.

KIE: A resident was ordered to discontinue resuscitation procedures on a 65-year-old man who had suffered cardiac arrest. A chaplain's assistant and a nurse had alerted the primary physician to the spouse's statements that her husband did not want his life prolonged by extraordinary means. A lack of communication among all the parties aggravated the conflicts in this case in which the patient was unable to state his desires, the resident and physician found out about his wishes second-hand, and only the chaplain's assistant spoke about the issue with the wife. Physicians are urged to take the initiative in discussing resuscitation with patients and/or family members as soon as potentially terminal situations arise. Other health personnel should participate in decisions about emergency care. In cases where such communication has not occurred, a resident should not stop resuscitative efforts without more information about the patient's wishes.^ieng

Issues for informed consent.

Informed consent from a cytapheresis donor is the culmination of a complex decision making process during which the blood collecting agency presents sufficient information to enable the donor to make a free choice whether or not to donate. The institution bears the responsibility for providing all information relevant to the donor's decision, whether favorable or unfavorable. At no other stage of its contact with the donor can a collecting agency discharge its public trust more meaningfully. Thus, informed consent is not only the greatest altruistic expression from the unrelated volunteer donor, or the expression of deepest commitment to the family for the related donor, it is also the fullest expression of the value which the institute places on the autonomy of the donor. The foundation upon which the concept of informed consent rests has been laid by law, medicine, government, ethics, and religion. Although the procedures accompanying the informed consent process appear bureaucratic, they should be viewed as the components of a remarkable, dynamic process. The consent of a donor to undergo cytapheresis is an eloquent statement of the value he or she places on the importance of another human being's life.