Primary-Site Local Therapy for Patients with De Novo Metastatic Breast Cancer: An Educational Review.

BACKGROUND: Until 2001, the paradigm guiding the management of women with de novo metastatic breast cancer (dnMBC) stipulated that primary-site locoregional therapy (PSLT) did not alter the course of metastatic disease and was necessary only for palliation of symptoms. Since 2002, retrospective data have begun questioning this paradigm. However, selection biases driving an observed survival advantage associated with PSLT in dnMBC were quickly recognized and led to several randomized clinical trials (RCTs) addressing this question. METHODS AND RESULTS: Four published RCTs have since tested the value of PSLT added to systemic therapy (ST) or not, with overall survival (OS) as the primary end point. The results of three published trials show no OS benefit for the addition of PSLT: Indian Tata Memorial, U.S./Canada E2108, and Austrian POSYTIVE (although POSYTIVE did not reach full accrual). The fourth RCT (Turkey, MF07-01) shows an OS benefit for PSLT at 5 years (42 % vs 24 % in the ST arm; hazard ratio [HR], 0.66; 95 % confidence interval [CI], 0.49-0.88). However, the 5-year survival in the PSLT arm of MF07-01 is similar to that in both arms of E2108, suggesting that the worse survival in the ST arm of MF07-01 is a result of biologically worse disease (from imbalanced randomization). Locoregional control was improved by PSLT in all trials, but without improvement in quality of life. CONCLUSIONS: The current evidence fails to refute the 20th century paradigm guiding management of de novo metastatic breast cancer. Discussion continues regarding the survival value of PSLT for patients with bone-only disease or oligometastases, but unbiased evidence is lacking.

Cancer fatalism and adherence to national cancer screening guidelines: Results from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

BACKGROUND: Sociocultural factors, such as health insurance status, income, education, and acculturation, predict cancer screening among U.S. Hispanics/Latinos. However, these factors can be difficult to modify. More research is needed to identify individual-level modifiable factors that may improve screening and subsequent cancer outcomes in this population. The aim of this study was to examine cancer fatalism (i.e., the belief that there is little or nothing one can do to lower his/her risk of developing cancer) as a determinant of adherence to national screening guidelines for colorectal, breast, prostate, and cervical cancer among Hispanics/Latinos. METHODS: Participants were from the multi-site Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Sociocultural Ancillary Study (N = 5313). The National Cancer Institute (NCI) Health Interview National Trends Survey was used to assess cancer fatalism and receipt of cancer screening. Adherence was defined as following screening guidelines from United States Preventive Services Task Force and the American Cancer Society during the study period. RESULTS: Adjusting for well-established determinants of cancer screening and covariates (health insurance status, income, education, acculturation, age, Hispanic/Latino background), lower cancer fatalism was marginally associated with greater adherence to screening for colorectal (OR 1.13, 95% CI [.99-1.30], p = .07), breast (OR 1.16, 95% CI [.99-1.36], p = .08) and prostate cancer (OR 1.18, 95% CI [.97-1.43], p = .10), but not cervical cancer. CONCLUSIONS: The associations of cancer fatalism were small and marginal, underlining that sociocultural factors are more robust determinants of cancer screening adherence among Hispanics/Latinos.

The development and implementation of a layperson trauma first responder course in La Paz, Bolivia: A pilot study.

BACKGROUND: Ninety percent of nearly five million annual global injury deaths occur in low- and middle-income countries (LMICs), where prehospital care systems are frequently rudimentary or nonexistent. The World Health Organization considers layperson first-responders as essential for emergency medical services in low-resource settings lacking more formalized systems. This study sought to develop and implement a layperson trauma first responder course (TFRC) in Bolivia. MATERIALS AND METHODS: In March and April 2013 nine sessions of the eight-hour TFRC were held in La Paz, Bolivia. The course charged a nominal fee, and was led by an American surgeon and medical student. The TFRC built upon existing models with local stakeholder input, and included both didactic and practical components. Participants completed a baseline survey, and pre and posttests. The primary outcome was test performance, with secondary outcomes including demographic sub-group test score analyses and exam question validation. Data were assessed using nonparametric and psychometric methods RESULTS: One hundred fifty-nine individuals met study inclusion criteria. Participant median age was 28 (IQR 24, 36), 49.1% were male, 59.1% worked in a medical field, most had secondary (35.2%) or university (56.0%) level educations, and 67.3% had prior first aid training. Median test scores improved after course completion (48% vs. 76%, p <0.001), along with skill confidence (4 vs. 4.5, p <0.001). Most questions had appropriate item difficulty indices, point bi-serial correlation coefficients, and positive Pretest Posttest Difference Indices. Cronbach alpha coefficients for pre and posttest scores were 0.72 and 0.78, respectively. CONCLUSIONS: This study presents data from the first offering of an original TFRC for laypeople in Bolivia. Increased participant knowledge and skill confidence after course completion, and acceptable overall psychometric test properties, indicate this model is valid and effective. Future aims include TFRC revision, and enrollment of more layperson first responders to increase population-level impacts.

Trauma system development in low- and middle-income countries: a review.

BACKGROUND: Trauma systems in resource-rich countries have decreased mortality for trauma patients through centralizing resources and standardizing treatment. Rapid industrialization and urbanization have increased the demand for formalized emergency medical services and trauma services (EMS and TS) in low- and middle-income countries (LMICs). This systematic review examines initiatives to develop EMS and TS systems in LMICs to inform the development of comprehensive prehospital care systems in resource-poor settings. MATERIALS AND METHODS: EMS and TS system development publications were identified using MEDLINE, PubMed, and Scopus databases. Articles addressing subspecialty skill sets, public policy, or physicians were excluded. Two independent reviewers assessed titles, abstracts, and full texts in a hierarchical manner. RESULTS: A total of 12 publications met inclusion criteria, and 10 unique LMIC EMS and TS programs were identified. Common initiatives included the integration of existing EMS and TS services and provision of standardized training and formalized certification processes for prehospital care providers, as well as the construction of a conceptual framework for system development through the public health model. CONCLUSIONS: There is no single model of EMS and TS systems, and successful programs are heterogeneous across regions. Successful EMS and TS systems share common characteristics. A predevelopment needs assessment is critical in identifying existing EMS and TS resources as a foundation for further development. Implementation requires coordination of preexisting resources with cost-effective initiatives that involve local stakeholders. High-impact priority areas are identified to focus improvements. Financial stresses and mismatching of resources in LMICs are common and are more commonly encountered when implementing a high-income model EMS and TS in an LMIC. Preimplementation and postimplementation evaluations can determine the efficacy of initiatives to strengthen EMS and TS systems.

Layperson trauma training in low- and middle-income countries: a review.

BACKGROUND: Prehospital trauma systems are rudimentary in many low- and middle-income countries (LMICs) and require laypersons to stabilize and transport injured patients. The World Health Organization recommends educating layperson first responders as an essential step in the development of Emergency Medical Services systems in LMICs. This systematic review examines trauma educational initiatives for layperson first responders in resource-poor settings. MATERIALS AND METHODS: Layperson first-responder training and education program publications were identified using PubMed MEDLINE and Scopus databases. Articles addressing physicians, professional Emergency Medical Services training, or epidemiologic descriptions were excluded. Publications were assessed by independent reviewers, and those included underwent thematic analysis. RESULTS: Thirteen publications met inclusion criteria. Four themes emerged regarding the development of layperson first-responder training programs: (1) An initial needs assessment of a region's existing trauma system of care and laypersons' baseline emergency care knowledge focuses subsequent educational interventions; (2) effective programs adapt to and leverage existing resources; (3) training methods should anticipate participants with low levels of education and literacy; and (4) postimplementation evaluation allows for curriculum improvement. Technology, such as online and remote learning platforms, can be used to operationalize each theme. CONCLUSIONS: Successful training programs for layperson first responders in LMICs identify and maximize existing resources are adaptable to learners with little formal education and are responsive to postimplementation evaluation. Educational platforms that leverage technology to deliver content may facilitate first-responder trauma education in underresourced areas. Themes identified can inform the development of trauma systems of care to decrease mortality and physiological severity scores in trauma patients in LMICs.

Mononuclear, five-coordinate lanthanide amido and aryloxide complexes bearing tetradentate (N2O2) Schiff bases.

Two monomeric, five-coordinate lanthanide complexes, [bis-5,5'-(1,3-propanediyldiimino)-2,2-dimethyl-4-hexene-3-onato]samarium[2,6-bis(tert-butyl)-4-methylphenoxide] and [bis-5,5'-(1,3-propanediyldiimino)-2,2-dimethyl-4-hexene-3-onato]erbium[2,6-bis(tert-butyl)-4-methylphenoxide], were isolated from the reactions of 2,6-bis(tert-butyl)-4-methylphenol with [bis-5,5'-(1,3-propanediyldiimino)-2,2-dimethyl-4-hexene-3-onato]lanthanide[bis(trimethylsilyl)amido] (lanthanide = Er(3+) and Sm(3+)). The purified phenoxides were recovered in excellent yields and analytical purity, and the reactions proceeded cleanly without Schiff-base degradation or cluster formation. Analogously, [bis-3,3'-(1,3-propanediyldiimino)-1-phenyl-2-butene-1-onato]erbium[bis(trimethylsilyl)amido] was also directly converted to [bis-3,3'-(1,3-propanediyldiimino)-1-phenyl-2-butene-1-onato]erbium[2,6-bis(tert-butyl)-4-methylphenoxide]; however, a less sterically demanding alcohol (i.e., ethanol) yielded a neutral trinuclear oxo alkoxide species with each dianionic Schiff base asymmetrically bridging through micro-oxo interactions. In this polynuclear cluster, each symmetry-related, seven-coordinate erbium(III) ion exhibits monocapped trigonal prismatic geometry, which assembles by sharing triangular capped faces. Single-crystal X-ray diffraction revealed square-pyramidal metal coordination in each five-coordinate lanthanide ion with varied S(4) ruffling of the "square base" donor atoms and the six-membered propylene diamine chelate ring adopting the boat conformation. To contrast the effect of subtle ligand changes, we also report the synthesis and characterization of [bis-5,5'-(2,2-dimethyl-1,3-propanediyldiimino)-2,2-dimethyl-4-hexene-3-onato]samarium[bis(trimethylsilyl)amido], having gem-dimethyl substituents appended to the propylene bridge central carbon. The six-membered diamine chelate ring in this compound adopts the chair conformation without metal-hydrocarbon interaction. Also presented are qualitative activity observations and polymerization data for the polymerization of rac-lactide and epsilon-caprolactone using the five-coordinate lanthanide amidos and phenoxides.