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Objective This study examined how well healthcare providers perceive and understand their patients' health beliefs and values compared to patients' actual beliefs, and to determine if communication relationships maybe improved as a result of healthcare providers' understanding of their patients' illness from their perspective. Methods A total of 61 participants (7 healthcare providers and 54 patients) were enrolled in the study. Healthcare providers and patients individually completed survey instruments and each participated in a structured focus group. Results Healthcare provider and patient differences revealed that patients perceived greater meaning of their illness (p = 0.038), and a greater preference for partnership (p = 0.026) compared to providers. The three qualitative themes most important for understanding patients' health beliefs and values as perceived by healthcare providers were education, trust, and culture. Educating patients was perceived as having the greatest impact and also the easiest method to implement to foster providers' understanding, with at least one patient focus group in agreement of same. Likewise, three themes were derived from patients' perspectives as relatively more important in understanding providers' beliefs and values; bidirectional communication, comprehensive treatment, and discipline. Overwhelmingly, bidirectional communication was perceived as a critical factor as having the greatest impact and may also be easiest to implement according to these patients. Conclusion When patients and healthcare providers listen and communicate with each other, they are likely to develop a shared understanding that may improve future decision making and quality of care patients receive.

Background\ud Postmastectomy radiotherapy in patients with four or more positive axillary nodes reduces breast cancer mortality, but its role in patients with one to three involved nodes is controversial. We assessed the effects of postmastectomy radiotherapy on quality of life (QOL) in women with intermediate-risk breast cancer.\ud \ud Methods\ud SUPREMO is an open-label, international, parallel-group, randomised, controlled trial. Women aged 18 years or older with intermediate-risk breast cancer (defined as pT1–2N1; pT3N0; or pT2N0 if also grade III or with lymphovascular invasion) who had undergone mastectomy and, if node positive, axillary surgery, were randomly assigned (1:1) to receive chest wall radiotherapy (50 Gy in 25 fractions or a radiobiologically equivalent dose of 45 Gy in 20 fractions or 40 Gy in 15 fractions) or no radiotherapy. Randomisation was done with permuted blocks of varying block length, and stratified by centre, without masking of patients or investigators. The primary endpoint is 10-year overall survival. Here, we present 2-year results of QOL (a prespecified secondary endpoint). The QOL substudy, open to all UK patients, consists of questionnaires (European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-BR23, Body Image Scale, Hospital Anxiety and Depression Scale [HADS], and EQ-5D-3L) completed before randomisation, and at 1, 2, 5, and 10 years. The prespecified primary outcomes within this QOL substudy were global QOL, fatigue, physical function, chest wall symptoms, shoulder and arm symptoms, body image, and anxiety and depression. Data were analysed by intention to treat, using repeated mixed-effects methods. This trial is registered with the ISRCTN registry, number ISRCTN61145589.\ud \ud Findings\ud Between Aug 4, 2006, and April 29, 2013, 1688 patients were enrolled internationally and randomly assigned to receive chest wall radiotherapy (n=853) or not (n=835). 989 (79%) of 1258 patients from 111 UK centres consented to participate in the QOL substudy (487 in the radiotherapy group and 502 in the no radiotherapy group), of whom 947 (96%) returned the baseline questionnaires and were included in the analysis (radiotherapy, n=471; no radiotherapy, n=476). At up to 2 years, chest wall symptoms were worse in the radiotherapy group than in the no radiotherapy group (mean score 14·1 [SD 15·8] in the radiotherapy group vs 11·6 [14·6] in the no radiotherapy group; effect estimate 2·17, 95% CI 0·40–3·94; p=0·016); however, there was an improvement in both groups between years 1 and 2 (visit effect −1·34, 95% CI −2·36 to −0·31; p=0·010). No differences were seen between treatment groups in arm and shoulder symptoms, body image, fatigue, overall QOL, physical function, or anxiety or depression scores.\ud \ud Interpretation\ud Postmastectomy radiotherapy led to more local (chest wall) symptoms up to 2 years postrandomisation compared with no radiotherapy, but the difference between groups was small. These data will inform shared decision making while we await survival (trial primary endpoint) results.\ud \ud Funding\ud Medical Research Council, European Organisation for Research and Treatment of Cancer, Cancer Australia, Dutch Cancer Society, Trustees of Hong Kong and Shanghai Banking Corporation.

This article explores whether deregulation of the Australian retail banking sector in the 1980s delivered the enhanced consumer choice that had been promised. Using new data on banking products and their usage, it analyses consumers' ability to select optimal ‘frontier’ products. It concludes that following deregulation of retail banking, product offerings underwent such tumultuous change that the scope for effective consumer choice was severely constrained. While there were improvements towards the end of the period, progress was not assisted by the banks' strategy of proliferating and re-bundling products. Consequently, the anticipated improvements to consumer choice were slow to arrive.

Anecdotal reports suggest that application of a cool device to the back of the neck at the onset of a hot flush can afford symptomatic relief. The effects of a novel handheld mechanical cooling device in a population of perimenopausal women with moderate-to-severe vasomotor symptoms were evaluated.In this randomized, double-blind, sham-controlled pilot study, 40 perimenopausal women experiencing ≥ 7 moderate-to-severe hot flushes per day were recruited at a single university site. Women were randomized to the active (n = 20) or sham (n = 20) device, which was applied to the back of the neck with each hot flush over the 4-week treatment period. Hot flush scores were calculated based on frequency and severity of symptoms. The Carpenter Hot Flash Related Daily Interference Scale and Zung Anxiety Scale were used to evaluate impact on quality of life. At study end, participants completed an open-ended questionnaire to assess the degree of unblinding and overall subjective improvement in symptoms with use of the device.No statistically significant differences were observed between the effects of the active and sham device. However, thematic analysis of the open-ended questionnaire revealed that 12/17 women (70.6%) in the active group, compared to 4/18 (22.2%) women in the sham group felt the device provided some symptomatic relief.Although the majority of women using the active device acknowledged that its cooling effect afforded a degree of symptomatic relief, the symptom scores chosen for this pilot study did not reflect a beneficial effect.

Poor patenting performance is often taken as a sign of low inventiveness. This article explores this belief by looking at the case of 19th-century Victoria, where the level of foreign patenting consistently grew at a much faster rate than that of local patenting. By mapping movements in both foreign and Australian revealed technological advantage in Victoria in this period, this article demonstrates that this faster rate of foreign patenting was due not to the technological weaknesses of the Australian colonies, but rather to the nature and timing of their economic development.

This paper uses patent data from Victoria to examine the roles played by skill and experience in Australian invention during the colonial era. In addition to identifying a broadening involvement of Australians in inventive activity in the second half of the nineteenth century, this paper also provides evidence which indicates that technological creativity in Australia in this period did not depend on either the existence of a body of highly skilled workers or major advances in the stock of knowledge of which only they were cognizant. Rather, common sense and the acquisition of basic practical skills appear to have been the only prerequisites for inventiveness. Given the widespread availability of such skills in the colonies, the article concludes that the supply of patentable ideas in nineteenth-century Australia must have been fairly elastic.

Tifblue rabbiteye blueberries {Vacciniwn ashei, Reade) were harvested twice daily (09:00, 14:30) and held under one of two conditions (cooled room, outside in shade) for six holding times (0, 1.5, 3, 6, 12, 24 hours after harvest) before refrigeration. Blueberries rejected when sorted were affected by harvest time (more rejected from 14:30 harvest), holding condition (more rejected from shade treatments) and holding time (more rejected as holding time increased). Storage defects after 21 days at 4.4°C (40°F) were affected by holding time (% defects increased with holding time). Treatments were intended to simulate the conditions of a small grower with limited facilities.

Presenting a blend of economics and law, this book provides unique insights as well as practical guidance for negotiators considering major issues on the agendas of bilateral and regional preferential trading agreements (PTAs).

Trastuzumab is an effective treatment for patients with metastatic breast cancer (MBC) that overexpresses HER-2. A high incidence of brain metastases (BM) has been noted in patients receiving trastuzumab. A retrospective chart review was conducted of 100 patients commencing trastuzumab for metastatic breast cancer from July 1999 to December 2002, at the Christie Hospital. Seven patients were excluded; five patients developed central nervous system metastases prior to starting trastuzumab, and inadequate data were available for two. Out of the remaining 93 patients, 23 (25%) have developed BM to date. In all, 46 patients have died, and of these 18 (39%) have been diagnosed with BM prior to death. Of the 23 patients developing BM, 18 (78%) were hormone receptor negative and 18 (78%) had visceral disease. Univariate analysis showed a significant association between the development of cerebral disease and both hormone receptor status and the presence of visceral disease. In conclusion, a high proportion of patients with MBC treated with trastuzumab develop symptomatic cerebral metastases. HER-2-positive breast cancer may have a predilection for the brain, or trastuzumab therapy may change the disease pattern by prolonging survival. New strategies to address this problem require investigation in this group of patients.

Medulloblastoma is an uncommon tumour in the adult population. Maximum surgical resection followed by craniospinal irradiation with a posterior fossa boost is the standard treatment. We report the case history of an adult with medulloblastoma and severe kyphoscoliosis. The unusual anatomy of the patient posed a technical challenge to the oncologist and the physicist in planning the craniospinal radiotherapy. A shaped spinal field matched to a parallel opposed pair of shaped head fields was used. The technique used in treating this patient was made possible with the use of a multileaf collimation and verification with an electronic portal imaging device. The patient remains well with no sign of relapse 4 years after treatment.

Background International standard adjuvant radiotherapy regimens following primary surgery for early breast cancer have historically delivered a high total dose (50Gy) in 25 small daily doses (fractions) over 5 weeks, however randomised trials, including START, indicate that a lower total dose delivered in fewer, larger fractions (Fr) is likely to be at least as safe and effective (START Trialists' Group, Lancet 2008 & Lancet Oncol 2008). With patients remaining at risk of local relapse for many years, information on long-term outcomes is needed to provide confidence in clinical practice. Here, we report 10-year follow-up of the UK START Trials testing 13- and 15-Fr regimens in terms of local cancer control and late adverse effects. Methods Between 1999 and 2002, 4451 women with completely excised invasive breast cancer (T1-3, N0-1, M0) were randomised after primary surgery to comparisons of 50Gy in 25Fr over 5 weeks vs 41·6Gy or 39Gy in 13Fr over 5 weeks (START A), or 50Gy in 25Fr over 5 weeks vs 40Gy in 15Fr over 3 weeks (START B). Women were eligible if aged over 18 years and did not have an immediate surgical reconstruction. Protocol-specified principal endpoints were local-regional (LR) tumour relapse and late normal tissue effects. Analysis was by intention to treat. Findings Median follow-up in survivors is now 9.3 years in START A and 9.9 years in START B, with 139 LR relapses in START A and 95 in START B. In START A, the 10-year rate of LR relapse was 7.4% (95%CI 5.5–10.0) after 50Gy, 6.3% (95%CI 4.7–8.5) after 41·6Gy and 8.8% (95%CI 6.7–11.4) after 39Gy. In START B, the 10-year rate of LR relapse was 5.5% (95%CI 4.2–7.2) after 50Gy and 4.3% (95%CI 3.2–5.9) after 40Gy. Clinician assessments suggested lower 10-year rates of any moderate/marked late normal tissue effects after 39Gy (43.9%; 95%CI 39.3–48.7) and similar rates after 41.6Gy (49.5%; 95%CI 44.9–54.3) compared with 50Gy (50.4%; 95%CI 45.8–55.3) in START A and lower rates after 40Gy in START B (37.9%; 95%CI 34.5–41.5) compared with 50Gy (45.3%; 95%CI 41.7–49.0). From a planned meta-analysis of START A and the START pilot trial (Owen et al, Lancet Oncol 2006), the adjusted estimate of α/β value for tumour control was 3.5Gy (95% CI 1.2–5.7) and for late change in photographic breast appearance was 3.1Gy (95% CI 2.0–4.2). Interpretation Long-term follow-up confirms that breast cancer and the surrounding dose-limiting healthy tissues respond similarly to radiotherapy fraction size and thus that appropriately-dosed hypofractionated radiotherapy is safe and effective in treatment of patients with early breast cancer. 41·6Gy in 13Fr and 40Gy in 15Fr each appear comparable to 50Gy in 25Fr in terms of local-regional tumour control and late normal tissue effects. These results support the continued use of 40Gy in 15Fr as standard of care (UK NICE Guidance 2009) for women requiring adjuvant radiotherapy for early breast cancer. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr S4-1.

11504 Background: Following interim results of the HERA study (2005) trastuzumab (T) was introduced as standard clinical practice three weekly for 18 cycles postchemotherapy (CT). Cardiac dysfuncti...

LBA518 Background: The START Trials (ST-A and ST-B) test the hypothesis that breast cancer is as sensitive to fraction (Fr) size as late reacting normal tissues, with an a/β value of about 4Gy. Methods: The phase III randomised START Trials tested hypofractionated post-operative RT in women with completely excised invasive breast cancer (T1–3, N0–1, M0). Centres opted for either ST-A or ST-B. ST-A tested 50Gy in 25Fr (5 wks) vs 41.6Gy vs 39Gy, both in 13Fr (5 wks). ST-B tested 50Gy in 25Fr (5 wks) vs 40Gy in 15Fr (3 wks). Stratification was by centre, surgery and boost. The primary endpoint was local-regional (LR) relapse. Late normal tissue effects (NTE) were assessed by breast photographs, clinical examination and quality of life (QL) questionnaires. Survival analysis methods were used to estimate rates of relapse and NTEs, and hazard ratios (HR) (with 95%CI). Smoothed estimates of absolute differences in relapse rates were obtained from the rates in the 50Gy control arms and the HR. Results: 2236 (ST-A) and 2215 (ST-B) patients were recruited from 35 UK centres during 1999–2002. Median follow-up is 5.1 years (ST-A) and 6.0 years (ST-B). There were 93 LR relapses in ST-A (4.1% at 5 years, 3.2- 5.0%), with absolute differences in LR relapse rates at 5 years compared with 50Gy of 0.2% (−1.3%−2.6%) for 41.6Gy and 0.9% (−0.8%−3.7%) for 39Gy. The a/β estimate for tumour control was 5.0Gy (−2.7–12.7). In ST-B, there were 65 LR relapses (2.8% at 5 years, 2.1–3.5%), with an absolute difference in LR relapse rates at 5 years of −0.6% (−1.7%−0.9%) for 40Gy vs 50Gy. In ST-A the rate of mild/marked change in photographic breast appearance was lower in 39Gy vs 50Gy (HR 0.69, 0.52–0.91), and similarly for 40Gy vs 50Gy in ST-B (HR 0.83, 0.66–1.04). The a/β estimate for change in breast appearance was 3.1Gy (1.6–4.6). Rates of induration, telangiectasia and breast oedema were lower in 39Gy (ST-A) and 40Gy (ST-B) compared with the 50Gy arms. QL results were consistent with the clinical findings. Conclusions: The fractionation sensitivity of breast cancer is comparable to that of late reacting normal tissues, confirming the results of a recent pilot trial. These results support the use of hypofractionated RT schedules for early breast cancer. No significant financial relationships to disclose.

Many concepts of the nutritional value of fruit and vegetables generally accepted in the past, in the light of more knowledge, today are considered “misconceptions.” For example, the tomato, once considered poisonous, then shown edible, later proved to be a “good” food and a valuable source of minerals and vitamin C, today shows the potential for significant anti-cancer activity. Results of a 6-year study of the dietary habits of 47,000 men reported up to a 45% reduction in the incidence of prostate cancer of those who ate 10 or more servings per week of tomato-based products. Other misconceptions to be discussed include nightshade vegetables and arthritis, apples after meals to clean the teeth and gums, and “if a little is good for you, a lot must be better.” Today's nutritional ideas about many fruits and vegetables may become tomorrow's misconceptions as our knowledge of the composition (e.g., phytochemicals) of fruits and vegetables increases. Examples of this are include the use of muscadine pomace and the nutritive value of strawberries.

The delivery of radiotherapy to the young child can be a challenging process, particularly where the primary disease is well advanced, involves the central nervous system or requires involuntary immobilisation. Radiotherapy units often sedate children to overcome these problems, which may lead to suboptimal nutrition and sleep disruption. We have reviewed our own practice in preparing young children for radiotherapy and factors influencing use of sedation. Our practice encompasses providing radiotherapy from a paediatric unit, encouraging parents and children to stay until radiotherapy is accepted by the child, structured and unstructured play therapy, and timing radiotherapy to reflect the child's natural sleep pattern.

I wish to comment on the paper by Plowman & Doughty (1991). The authors describe an interesting method for cranio-spinal radiation using a PTB technique. They “believe such techniques will become standard practice”.

The thermionic work functions of five different beryllium samples were studied as a function of the degree of surface oxidation. The state of oxidation of each sample was determined by visual observation and by analysis of x-ray diffraction patterns. The data were analyzed by the Schottky plot-Richardson plot method. One wire was completely oxidized to BeO and its Richardson work function was found to be 3.80±0.06 e V and the thermionic constant was 31 amps/cm2-∮K2. From visual and x-ray analyses of the various samples, it is concluded that the lowest work function determined for any of the beryllium samples, 3.22±0.08 eV, is the closest to the work function of pure polycrystalline beryllium metal.

This paper describes a rapid response microwave hygrometer for continuously recording the water vapor pressure of atmospheric air over a wide ambient range. The principle employed involves the measurement by means of a cavity resonator of the contribution of water vapor to the refractive index of atmospheric air. The device described also has potential application to the continuous measurement of the degree of contamination of one gas (or of gas mixtures) by another gas (or gases).

A patient presented with mild hyperthyroidism, elevated serum T4 and T3, and an inappropriately raised serum thyrotrophin (TSH). There was no evidence of pituitary tumour (alpha-subunit secretion and CT scan of the pituitary were normal). The TSH response to TRH was greater than normal. The elevated TSH was suppressed by oral triiodothyronine (100 micrograms daily for 10 d). The normal diurnal variation of TSH was preserved. Intravenous injection of the dopamine receptor blocking agent domperidone led to a greater than normal elevation in TSH (maximum increments 18-20 mU/l). This increased dopaminergic tone was similar in studies carried out in the morning and late evening. The dopamine agonist bromocriptine (2.5 mg twice daily) failed to suppress serum TSH either acutely or over 6 weeks. The circadian rhythm was unaltered by this treatment. Basal serum prolactin levels were normal, and responded appropriately to TRH, domperidone and bromocriptine. These observations indicate that dopamine does not control the diurnal variation of TSH in nontumoral TSH-mediated hyperthyroidism. The increased dopaminergic tone demonstrated may be secondary to the primary failure of pituitary-thyroid feedback in the condition.

A study of mortality following major emergency abdominal operations in a community hospital from 1955 to 1960 is presented. An analysis of the charts of the twenty-four deaths in this series seems to indicate that eleven were unavoidable while thirteen might have been prevented. The difficulties which caused death in decreasing order of frequency were: (1) inadequate preoperative evaluation and diagnosis, (2) presence of additional disease, (3) patient delay in seeking medical care and (4) physician delay in seeking surgical consultation. In the group of cases studied, the causes of mortality in twenty-four patients in decreasing order of frequency are: (1) age and general debility, eleven, (2) inadequate preoperative evaluation and misdiagnosis, five; (3) additional disease, three; (4) patient delay and failure to cooperate, three; (5) physician delay, two.

We studied the charts of 42 consecutive patients in whom blunt trauma had ruptured the spleen. The diagnosis was established by operation. Purpose We hoped to discover a consistent clinical pattern for patients suffering from acute traumatic rupture of the nondiseased spleen, secondary to blunt trauma. Material The 42 charts were analyzed to correlate consistent clinical findings in the "pure splenic-rupture syndrome." Cases of "delayed rupture" and those having severe trauma to organs other than the spleen were not included. History There is some type of rather severe trauma to the left upper abdomen and/or left lower chest in cases of rupture of the nondiseased spleen. The leading cause is auto accidents, 1-4 and the incidence is increasing. Table 1 lists the types of trauma in the present series. The age range is from 2 to 67 years, averaging 21 years. Thirty-one of the 42 patients (74%) are 26 years

WE HAVE made a retrospective study of the records of one thousand patients who had undergone cholecystectomy. The surgical procedures were carried out in a community hospital of 350 beds by five general surgeons from 1955 through 1966. This study seeks important factors involving diagnosis as contained in the history, physical examination, laboratory and x-ray examinations. An analysis is made of the operative procedures, subsequent histological examination of the surgical specimen, the postoperative complications, and mortality. Factors in the History Age and Sex. —The age range is from 15 to 81 years, with the mean age of 52 years. The greatest incidence is in the fourth and fifth decades. Only 21% of the patients are men. The number of cases each year gradually increased from 56 in 1955 to 142 in 1966. This is probably due to hospital and medical staff expansion, but an actual increase in incidence cannot be