Exercise and secondary lymphedema : safety, potential benefits, and research issues

Participating in regular physical activity is encouraged following breast cancer (BC) treatment, except for those who have subsequently developed lymphoedema. We designed a randomised controlled trial to investigate the effect of participating in a supervised, mixed-type, moderate-intensity exercise program among women with lymphoedema following breast cancer. Women <76 years who had completed BC treatment at least six months prior and subsequently developed unilateral, upper-limb lymphoedema were randomly allocated to an intervention (n=16) or control (n=16) group. The intervention group (IG) participated in 20 supervised group exercise sessions over 12 weeks, while the control group (CG) was instructed to continue habitual activities. Lymphoedema status was assessed by bioimpedance spectroscopy (impedance ratio between limbs) and perometry (volume difference between limbs). Mean baseline measures were similar for the IG (1.13+0.15 and 337+307ml, respectively) and CG (1.13+0.15 and 377+416ml, respectively) and no changes were observed over time. However, 2 women in the IG no longer had evidence of lymphoedema by study end. Average attendance was over 70% of supervised sessions, and there were no withdrawals. The results indicate that, at worst, exercise does not exacerbate secondary lymphoedema. Women with secondary lymphoedema should be encouraged to be physically active, optimising their physical and psychosocial recovery.

Developing a best practice framework for implementing public private partnerships (PPP) in Hong Kong

Public Private Partnership (PPP) is a well established methodology for procuring public works projects. By incorporating the private sector’s expertise, efficiency, innovation, business sense, risk sharing, financing etc. into public works projects, the quality of public services and facilities can be uplifted. Like many jurisdictions, Hong Kong is also keen to take aboard this methodology which is so familiar but yet so distant. Although they have been one of the first jurisdictions to utilise the private sector in public works projects, their comfortable financial reserves has meant that there has been no urge to push the movement until recently. PPP has become increasingly popular amongst governments. The Hong Kong Special Administrative Region (HKSAR) government is no exception. Some of the more active works departments have commissioned studies to investigate the best ways to deliver these projects, others have even trialed the method themselves. The efficiency Unit of the HKSAR government has also become an active arm in conducting research in this area. Although so, the information that is currently available is still very broad. Building from their works there is a need to develop a best practice framework for implementing PPP projects in Hong Kong by incorporating international experiences. To develop a best practice framework will require thorough investigation into the benefits, difficulties and critical success factor of PPP. PPP should also be compared with other procurement methods. In order to do so it is important to clearly understand the local situation by an analysis of projects conducted to date. Lessons learnt can further be derived from other countries and incorporated to those derived locally. Finally the best conditions in terms of project nature, complexity, types, and scales for adopting PPP should be derived. The aim and objectives of this study were achieved via a comprehensive literature review, in-depth case analyses, interview survey with experts from both Hong Kong and overseas, and finally a large scale data collection was conducted via a questionnaire survey with PPP practitioners. These findings were further triangulated before they were used as the basis to form the best practice framework presented in this thesis. The framework was then further validated by PPP experts to ensure it is comprehensive, objective, reliable and practical. This study has presented a methodology that can be adopted for future studies. It has also updated our knowledge on the development trends of PPP as well as opened up the experiences of other jurisdictions. The findings have shown that the local industry is familiar with “what” should be done in PPP projects but they are unsure of “how” these goals can be achieved. This framework has allowed this further knowledge to be delivered to PPP practitioners. As a result, the development of this framework can help to resolve the current economic crisis by encouraging more developments and business opportunities for the private sector. In addition, the correct projects can be delivered by PPP, the advantages of PPP can be maximised, and the general public can benefit from the private sector’s participation.

Skin preparation with alcohol versus alcohol followed by any antiseptic for preventing bacteraemia or contamination of blood for transfusion (Review)

Background: Blood for transfusion may become contaminated at any point between collection and transfusion and may result in bacteraemia (the presence of bacteria in the blood),severe illness or even death for the blood recipient. Donor arm skin is one potential source of blood contamination, so it is usual to cleanse the skin with an antiseptic before blood donation. One-step and two-step alcohol based antiseptic regimens are both commonly advocated but there is uncertainty as to which is most effective.----- Objectives: To assess the effects of cleansing the skin of blood donors with alcohol in a one-step compared with alcohol in a two-step procedure to prevent contamination of collected blood or bacteraemia in the recipient.----- Search strategy: We searched the Cochrane Wounds Group Specialised Register (March 10 2009); The Cochrane Central Register of Controlled Trials(CENTRAL) The Cochrane Library 2009, Issue 1; Ovid MEDLINE - (1950 to February Week 4 2009); Ovid EMBASE - (1980 to 2009 Week 9); and EBSCO CINAHL - (1982 to February Week 4 2009). We also searched the reference lists of key papers.----- Selection criteria: All randomised trials (RCTs) comparing alcohol based donor skin cleansing in a one-step versus a two-step process that includes alcohol and any other antiseptic for pre-venepuncture skin cleansing were considered. Quasi randomised trials were to have been considered in the absence of RCTs.----- Data collection and analysis: Two review authors independently assessed studies for inclusion.----- Main results: No studies (RCTs or quasi RCTs) met the inclusion criteria. Authors’ conclusions We did not identify any eligible studies for inclusion in this review. It is therefore unclear whether a two-step, alcohol followed by antiseptic skin cleansing process prior to blood donation confers any reduction in the risk of blood contamination or bacteraemia in blood recipients, or conversely whether a one-step process increases risk above that associated with a two-step process.

Early detection : a strategy to reduce risk and severity?

Despite changes in surgical techniques, radiotherapy targeting and the apparent earlier detection of cancers, secondary lymphoedema is still a significant problem for about 20–30% of those who receive treatment for cancer, although the incidence and prevalence does seem to be falling. The figures above generally relate to detection of an enlarged limb or other area, but it seems that about 60% of all patients also suffer other problems with how the limb feels, what can or cannot be done with it and a range of social or psychological issues. Often these ‘subjective’ changes occur before the objective ones, such as a change in arm volume or circumference. For most of those treated for cancer lymphoedema does not develop immediately, and, while about 60–70% develop it in the first few years, some do not develop lymphoedema for up to 15 or 20 years. Those who will develop clinically manifest lymphoedema in the future are, for some time, in a latent or hidden phase of lymphoedema. There also seems to be some risk factors which are indicators for a higher likelihood of lymphoedema post treatment, including oedema at the surgical site, arm dominance, age, skin conditions, and body mass index (BMI).

Does lymphedema following breast cancer warrant clinical attention?

Secondary lymphedema (swelling) after breast cancer treatment usually develops on the hand, arm, shoulder, and/or breast on the treated side. It is commonly associated with the presence of other upper-body symptoms, such as pain and aching1; it impacts physical and psychosocial functioning and adversely influences quality of life.2 Moreover, it is considered incurable, progressive, and difficult to treat. Arguably, lymphedema is the most problematic and dreaded treatment-related complication of breast cancer.3

What determines the health-related quality of life among regional and rural breast cancer survivors?

Objective: To assess the health-related quality of life (HRQoL) of regional and rural breast cancer survivors at 12 months post-diagnosis and to identify correlates of HRQoL. Methods: 323 (202 regional and 121 rural) Queensland women diagnosed with unilateral breast cancer in 2006/2007 participated in a population-based, cross-sectional study. HRQoL was measured using the Functional Assessment of Cancer Therapy, Breast plus arm morbidity (FACT-B+4) self-administered questionnaire. Results: In age-adjusted analyses, mean HRQoL scores of regional breast cancer survivors were comparable to their rural counterparts 12 months post-diagnosis (122.9, 95% CI: 119.8, 126.0 vs. 123.7, 95% CI: 119.7, 127.8; p>0.05). Irrespective of residence, younger (<50 years) women reported lower HRQoL than older (50+ years) women (113.5, 95% CI: 109.3, 117.8 vs. 128.2, 95%CI: 125.1, 131.2; p<0.05). Those women who received chemotherapy, reported two complications post-surgery, had poorer upper-body function than most, reported more stress, reduced coping, who were socially isolated, had no confidante for social-emotional support, had unmet healthcare needs, and low health self-efficacy reported lower HRQoL scores. Together, these factors explained 66% of the variance in overall HRQoL. The pattern of results remained similar for younger and older age groups. Conclusions and Implications: The results underscore the importance of supporting and promoting regional and rural breast cancer programs that are designed to improve physical functioning, reduce stress and provide psychosocial support following diagnosis. Further, the information can be used by general practitioners and other allied health professionals for identifying women at risk of poorer HRQoL.

Age-related maculopathy : linking aetiology and pathophysiological changes to the ischaemia hypothesis

Age-related maculopathy (ARM) has remained a challenging topic with respect to its aetiology, pathomechanisms, early detection and treatment since the late 19th century when it was first described as its own entity. ARM was previously considered an inflammatory disease, a degenerative disease, a tumor and as the result of choroidal hemodynamic disturbances and ischaemia. The latter processes have been repeatedly suggested to have a key role in its development and progression. In vivo experiments under hypoxic conditions could be models for the ischaemic deficits in ARM. Recent research has also linked ARM with gene polymorphisms. It is however unclear what triggers a person's gene susceptibility. In this manuscript, a linking hypothesis between aetiological factors including ischaemia and genetics and the development of early clinicopathological changes in ARM is proposed. New clinical psychophysical and electrophysiological tests are introduced that can detect ARM at an early stage. Models of early ARM based upon hemodynamic, photoreceptor and post-receptoral deficits are described and the mechanisms by which ischaemia may be involved as a final common pathway are considered. In neovascular age-related macular degeneration (neovascular AMD), ischaemia is thought to promote release of vascular endothelial growth factor (VEGF) which induces chorioretinal neovascularisation. VEGF is critical in the maintenance of the healthy choriocapillaris. In the final section of the manuscript the documentation of the effect of new anti-VEGF treatments on retinal function in neovascular AMD is critically viewed.

The efficacy of an augmented virtual reality system to alleviate pain in children undergoing burns dressing changes : a randomised controlled trial

In children, the pain and anxiety associated with acute burn dressing changes can be severe, with drug treatment alone frequently proving to be inadequate. Virtual reality (VR) systems have been successfully trialled in limited numbers of adult and paediatric burn patients. Augmented reality (AR) differs from VR in that it overlays virtual images onto the physical world, instead of creating a complete virtual world. This prospective randomised controlled trial investigated the use of AR as an adjunct to analgesia and sedation in children with acute burns. Forty-two children (30 male and 12 female), with an age range of 3–14 years (median age 9 years) and a total burn surface area ranging from 1 to 16% were randomised into a treatment (AR) arm and a control (basic cognitive therapy) arm after administration of analgesia and/or sedation. Pain scores, pulse rates (PR), respiratory rates (RR) and oxygen saturations (SaO2) were recorded pre-procedurally, at 10 min intervals and post-procedurally. Parents were also asked to grade their child's overall pain score for the dressing change. Mean pain scores were significantly lower (p = 0.0060) in the AR group compared to the control group, as were parental pain assessment scores (p = 0.015). Respiratory and pulse rates showed significant changes over time within groups, however, these were not significantly different between the two study groups. Oxygen saturation did not differ significantly over time or between the two study groups. This trial shows that augmented reality is a useful adjunct to pharmacological analgesia.

The insured's non-disclosure in the formation of insurance contracts : a comparative perspective

The requirements that an insured disclose all facts material to a transaction as well as not misrepresent material facts in the formation of an insurance contract are universal requirements of insurance law. The nature and extent of these obligations varies from one jurisdiction to the next. Disclosure in the insurance context is distinct from the general approach in commercial contracts, and in others between persons dealing at arm's length. It is the purpose of this article therefore to examine, on a comparative basis, the approaches adopted in the Anglo-Commonwealth context of England, Australia New Zealand and Singapore to the resolution of disclose issues in the formation of insurance contracts. Particular attention is focused on the Insurance Contracts Act 1984 (Australia) as this statue effects the most significant overhaul of the common law and the National Consumer Council in the United Kingdom has advocated that similar reforms be adopted.

Continuous infusion of ticarcillin-clavulanate for home treatment of serious infections : clinical efficacy, safety, pharmacokinetics and pharmacodynamics

Continuous infusion (CI) ticarcillin–clavulanate is a potential therapeutic improvement over conventional intermittent dosing because the major pharmacodynamic (PD) predictor of efficacy of β-lactams is the time that free drug levels exceed the MIC. This study incorporated a 6-year retrospective arm evaluating efficacy and safety of CI ticarcillin–clavulanate in the home treatment of serious infections and a prospective arm additionally evaluating pharmacokinetics (PK) and PD. In the prospective arm, steady-state serum ticarcillin and clavulanate levels and MIC testing of significant pathogens were performed. One hundred and twelve patients (median age, 56 years) were treated with a CI dose of 9.3–12.4 g/day and mean CI duration of 18.0 days. Infections treated included osteomyelitis (50 patients), septic arthritis (6), cellulitis (17), pulmonary infections (12), febrile neutropenia (7), vascular infections (7), intra-abdominal infections (2), and Gram-negative endocarditis (2); 91/112 (81%) of patients were cured, 14 (13%) had partial response and 7 (6%) failed therapy. Nine patients had PICC line complications and five patients had drug adverse events. Eighteen patients had prospective PK/PD assessment although only four patients had sufficient data for a full PK/PD evaluation (both serum steady-state drug levels and ticarcillin and clavulanate MICs from a bacteriological isolate), as this was difficult to obtain in home-based patients, particularly as serum clavulanate levels were found to deteriorate rapidly on storage. Three of four patients with matched PK/PD assessment had free drug levels exceeding the MIC of the pathogen. Home CI of ticarcillin–clavulanate is a safe, effective, convenient and practical therapy and is a therapeutic advance over traditional intermittent dosing when used in the home setting.

On the use of different spatial reference frames for movement control

Previous work has shown that amplitude and direction are two independently controlled parameters of aimed arm movements, and performance, therefore, suffers when they must be decomposed into Cartesian coordinates. We now compare decomposition into different coordinate systems. Subjects pointed at visual targets in 2-D with a cursor, using a two-axis joystick or two single-axis joysticks. In the latter case, joystick axes were aligned with the subjects’ body axes, were rotated by –45°, or were oblique (i.e., one axis was in an egocentric frame and the other was rotated by –45°). Cursor direction always corresponded to joystick direction. We found that compared with the two-axis joystick, responses with single-axis joysticks were slower and less accurate when the axes were oriented egocentrically; the deficit was even more pronounced when the axes were rotated and was most pronounced when they were oblique. This confirms that decomposition of motor commands is computationally demanding and documents that this demand is lowest for egocentric, higher for rotated, and highest for oblique coordinates. We conclude that most current vehicles use computationally demanding man–machine interfaces.

Relational factors that explain supply chain relationships

Purpose: The purpose of this paper is to gain a better understanding of the types of relationships that exist along the supply chain and the capabilities that are needed to manage them effectively. ---------- Design/methodology/approach: This is exploratory research as there has been little empirical research into this area. Quantitative data were gathered by using a self-administered questionnaire, using the Australian road freight industry as the context. There were 132 usable responses. Inferential and descriptive analysis, including factor analysis, confirmatory factor and regression analysis was used to examine the predictive power of relational factors in inter-firm relationships. ---------- Findings: Three factors were identified as having significant influence on relationships: sharing, power and interdependency. “Sharing” is the willingness of the organisation to share resources with other members of the supply chain. “Power” relates to exercising control based on experience, knowledge and position in the supply chain. “Interdependency” is the relative levels of dependency along the supply chain. ---------- Research limitations/implications: The research only looks at the Australian road freight industry; a wider sample including other industries would help to strengthen the generalisability of the findings. ---------- Practical implications: When these factors are correlated to the types of relationship, arm's length, cooperation, collaboration and alliances, managerial implications can be identified. The more road freight businesses place importance on power, the less they will cooperate. The greater the importance of sharing and interdependency, the greater is the likelihood of arm's length relationships. ---------- Originality/value: This paper makes a contribution by describing empirical work conducted in an under-researched but important area – supply chain relationships in the Australian road freight industry.

Creation of a validated 3D finite element model of an ovine tibia

Introduction Ovine models are widely used in orthopaedic research. To better understand the impact of orthopaedic procedures computer simulations are necessary. 3D finite element (FE) models of bones allow implant designs to be investigated mechanically, thereby reducing mechanical testing. Hypothesis We present the development and validation of an ovine tibia FE model for use in the analysis of tibia fracture fixation plates. Material & Methods Mechanical testing of the tibia consisted of an offset 3-pt bend test with three repetitions of loading to 350N and return to 50N. Tri-axial stacked strain gauges were applied to the anterior and posterior surfaces of the bone and two rigid bodies – consisting of eight infrared active markers, were attached to the ends of the tibia. Positional measurements were taken with a FARO arm 3D digitiser. The FE model was constructed with both geometry and material properties derived from CT images of the bone. The elasticity-density relationship used for material property determination was validated separately using mechanical testing. This model was then transformed to the same coordinate system as the in vitro mechanical test and loads applied. Results Comparison between the mechanical testing and the FE model showed good correlation in surface strains (difference: anterior 2.3%, posterior 3.2%). Discussion & Conclusion This method of model creation provides a simple method for generating subject specific FE models from CT scans. The use of the CT data set for both the geometry and the material properties ensures a more accurate representation of the specific bone. This is reflected in the similarity of the surface strain results.

An initial technology roadmap for home automation : home and personal life management

Home Automation (HA) has emerged as a prominent ¯eld for researchers and in- vestors confronting the challenge of penetrating the average home user market with products and services emerging from technology based vision. In spite of many technology contri- butions, there is a latent demand for a®ordable and pragmatic assistive technologies for pro-active handling of complex lifestyle related problems faced by home users. This study has pioneered to develop an Initial Technology Roadmap for HA (ITRHA) that formulates a need based vision of 10-15 years, identifying market, product and technology investment opportunities, focusing on those aspects of HA contributing to e±cient management of home and personal life. The concept of Family Life Cycle is developed to understand the temporal needs of family. In order to formally describe a coherent set of family processes, their relationships, and interaction with external elements, a reference model named Fam- ily System is established that identi¯es External Entities, 7 major Family Processes, and 7 subsystems-Finance, Meals, Health, Education, Career, Housing, and Socialisation. Anal- ysis of these subsystems reveals Soft, Hard and Hybrid processes. Rectifying the lack of formal methods for eliciting future user requirements and reassessing evolving market needs, this study has developed a novel method called Requirement Elicitation of Future Users by Systems Scenario (REFUSS), integrating process modelling, and scenario technique within the framework of roadmapping. The REFUSS is used to systematically derive process au- tomation needs relating the process knowledge to future user characteristics identi¯ed from scenarios created to visualise di®erent futures with richly detailed information on lifestyle trends thus enabling learning about the future requirements. Revealing an addressable market size estimate of billions of dollars per annum this research has developed innovative ideas on software based products including Document Management Systems facilitating automated collection, easy retrieval of all documents, In- formation Management System automating information services and Ubiquitous Intelligent System empowering the highly mobile home users with ambient intelligence. Other product ideas include robotic devices of versatile Kitchen Hand and Cleaner Arm that can be time saving. Materialisation of these products require technology investment initiating further research in areas of data extraction, and information integration as well as manipulation and perception, sensor actuator system, tactile sensing, odour detection, and robotic controller. This study recommends new policies on electronic data delivery from service providers as well as new standards on XML based document structure and format.

Upper-body morbidity following breast cancer treatment is common, may persist longer-term and adversely influences quality of life

Background: Impairments in upper-body function (UBF) are common following breast cancer. However, the relationship between arm morbidity and quality of life (QoL) remains unclear. This investigation uses longitudinal data to describe UBF in a population-based sample of women with breast cancer and examines its relationship with QoL. ---------- Methods: Australian women (n = 287) with unilateral breast cancer were assessed at three-monthly intervals, from six- to 18-months post-surgery (PS). Strength, endurance and flexibility were used to assess objective UBF, while the Disability of the Arm, Shoulder and Hand questionnaire and the Functional Assessment of Cancer Therapy- Breast questionnaire were used to assess self-reported UBF and QoL, respectively. ---------- Results: Although mean UBF improved over time, up to 41% of women revealed declines in UBF between sixand 18-months PS. Older age, lower socioeconomic position, treatment on the dominant side, mastectomy, more extensive lymph node removal and having lymphoedema each increased odds of declines in UBF by at least twofold (p < 0.05). Lower baseline and declines in perceived UBF between six- and 18-months PS were each associated with poorer QoL at 18-months PS (p < 0.05). ---------- Conclusions: Significant upper-body morbidity is experienced by many following breast cancer treatment, persisting longer term, and adversely influencing the QoL of breast cancer survivors.