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This is an Athena case highlighting a patient with dermatitis affecting the back with sparing of the lumbar area. We discuss common allergens and highlight important distinguishing features among them.

Purpose Machine learning (ML) is a powerful tool for interrogating datasets and learning relationships between multiple variables. We utilized a ML model to identify those early breast cancer (EBC) patients at highest risk of developing severe vasomotor symptoms (VMS). Methods A gradient boosted decision model utilizing cross-sectional survey data from 360 EBC patients was created. Seventeen patient- and treatment-specific variables were considered in the model. The outcome variable was based on the Hot Flush Night Sweats (HFNS) Problem Rating Score, and individual scores were dichotomized around the median to indicate individuals with high and low problem scores. Model accuracy was assessed using the area under the receiver operating curve, and conditional partial dependence plots were constructed to illustrate relationships between variables and the outcome of interest. Results The model area under the ROC curve was 0.731 (SD 0.074). The most important variables in the model were as follows: the number of hot flashes per week, age, the prescription, or use of drug interventions to manage VMS, whether patients were asked about VMS in routine follow-up visits, and the presence or absence of changes to breast cancer treatments due to VMS. A threshold of 17 hot flashes per week was identified as being more predictive of severe VMS. Patients between the ages of 49 and 63 were more likely to report severe symptoms. Conclusion Machine learning is a unique tool for predicting severe VMS. The use of ML to assess other treatment-related toxicities and their management requires further study.

Background Despite the frequency of vasomotor symptoms (VMS) in patients with early breast cancer (EBC), their optimal management remains unknown. A patient survey was performed to determine perspectives on this important clinical challenge. Methods Patients with EBC experiencing VMS participated in an anonymous survey. Patients reported on the frequency and severity of VMS using the validated Hot Flush Rating Scale (HFRS) and ranked their most bothersome symptoms. Respondents were also asked to determine endpoints that defined effective treatment of VMS and report on the effectiveness of previously tried interventions. Results Responses were received from 373 patients, median age 56 years (range 23–83), who experienced an average of 5.0 hot flashes per day (SD 6.57). Patients reported the most bothersome symptoms to be feeling hot/sweating (155/316, 49%) and sleeping difficulties (86/316, 27%). Fifty-five percent (201/365) of patients would consider a treatment to be effective if it reduced night-time awakenings. While 68% of respondents were interested in trying interventions from their healthcare team to manage VMS, only 18% actually did so. Of the 137 patients who had tried an intervention for VMS, pharmacological treatments, exercise, and relaxation strategies were more likely to be effective, while therapies such as melatonin and black cohosh were deemed less effective. Conclusion VMS are a common and bothersome problem for EBC patients, with a minority receiving interventions to manage these symptoms. Further research is needed to identify patient-centered strategies for managing these distressing symptoms.

Bullying, which includes cyberbullying and face-to-face bullying, is amongst the most pervasive threats to the wellbeing of children and young people. As social environments, schools are at the forefront of managing bullying behaviours. The rapidly changing and complex nature of bullying requires schools to put in place and maintain systems to prepare for and respond to such activities, and to continually test and refine these systems to ensure optimal performance. Despite this clear need, there is a lack of school level, self-assessment tools that enable schools to assess and measure their preparedness to deal with bullying and related disruptive activities. The aim of this paper was to describe the development, and reliability and validity testing, of such a tool – the School Self-Assessment Tool. The result is a 22-item, evidence-based, reliable, and validated instrument, situated within socio-ecological theory, and drawing on theories of behaviourism, social learning theory, prevention science, and systems change in the school climate literature. Schools may use the SSAT-22 in a number of ways depending on their needs, including to monitor progress, examine areas of strengths or challenges, and/or assist in collaborative efforts with other schools.

This article explores the potential of regulatory and policy reform for gender-equitable decent work in social and community services, a rapidly growing sector of female employment in many Organisation for Economic Co-operation and Development countries. Along with other feminised sectors, employment in this sector is marked by low rates of unionisation, poor pay and fragmented, insecure working hours. Internationally, gig economy work is now appearing in the sector. A distinguishing feature of the sector is employers’ reliance on government funding through contracted services or via direct payments to individuals. The distance of government from accountability for workers in publicly funded services directly contributes to gendered undervaluation and poor working conditions. However, the presence of the state also provides options for regulatory reform. This article considers the different roles played by government, as employment regulator, as funding and bargaining actor and as market manager and care regulator. Adopting a broad conception of regulation, it canvasses options for bringing the state back in to address gender inequality and precarious work. In the Australian context, it examines potential for rebuilding state accountability for gender-equitable decent work in individualised social care in which the gender inequalities and poor working conditions present in social and community services are amplified.

Research has identified ‘personalised risks’ for workers due to changes in the public/private dimensions of care where workers are directly employed or engaged by care users in individualised care systems. Drawing on interviews with workers in Australia’s new individualised disability services market, the research explores personalised risk and the effects of involvement in personalised care relationships of market-based organisations, including online digital care platforms. It finds that rather than having a protective role, both digital platforms and employing organisations can increase risks for workers in individualised care relationships.

Increasing awareness of the extent of preventable harm from healthcare has led to efforts to improve patient safety through a variety of efforts, including legislation. Extending legal privilege to quality and safety reviews leads to further harm for many patients, families and healthcare providers. The intentional isolation, silencing and exclusion after the incident undermines trust, prevents learning and impedes an opportunity to heal and recover for all those directly involved. Our case study examines Section 51 of British Columbia's Evidence Act (1996) and concludes that amending this legislation is an urgent and necessary step toward trauma-informed care.

Background. Many Australian primary schools have established school breakfast clubs (SBCs) to address concerns about children arriving at school hungry and the subsequent impact on learning but their effectiveness is uncertain. This study aimed to identify the perceived benefits, impacts, operational practices, and challenges of running SBCs. Method. Case studies with 10 Australian primary schools from different socioeconomic and geographic areas. Focus groups or interviews were held with 142 participants including students, parents/carers, school staff, and funding body representatives between July 2016 and October 2017. Results. There were no eligibility criteria to attend SBCs with all students able to attend, regardless of household income. Thus, participating in the SBC was often reported as a matter of choice rather than a consequence of food insecurity. Participants, including children, discussed the many social benefits of SBCs (i.e., social eating, relationship building, school connection, and engagement) as well as perceived improved classroom behavior. Challenges for program delivery included resource limitations, particularly, the reliance on volunteers and sourcing food. Discussion/Conclusion. SBCs offered a range of benefits beyond their primary goal of addressing food security. SBCs were highly valued by members of the school community for their social, welfare, well-being, and educational benefits, but program sustainability is constrained by resource limitations.

Trastuzumab-based chemotherapy is usually administered through either a peripherally inserted central catheter (PICC) or a totally implanted vascular access device (PORT). As the most effective type of access is unknown, a feasibility trial, prior to conducting a large pragmatic trial, was undertaken. The trial methodology utilized the integrated consent model incorporating oral consent. Patients receiving trastuzumab-based neo/adjuvant chemotherapy for early-stage breast cancer were randomized to a PICC or PORT insertion. Feasibility was reflected through a combination of endpoints; however, the a priori definition of feasibility was > 25% of patients approached agreed to randomization and > 25% of physicians approached patients. Secondary outcomes included rates of line-associated complications such as thrombotic events requiring anticoagulation, line infections or phlebitis. During the study period, 4/15 (26.7%) medical oncologists approached patients about study participation. Of 59 patients approached, 56 (94.9%) agreed to randomization, 29 (51.8%) were randomized to PICC and 27 (48.2%) to PORT access. Overall, 17.2% (5/29) and 14.8% (4/27) of patients had at least one line-associated complication in the PICC and PORT arms respectively. The study was terminated early due to slow accrual. The study met its feasibility endpoints with respect to patient and physician engagement. However, the slow rate of accrual (56 patients in 2 years) means that conducting a large pragmatic trial would require additional strategies to make such a study possible. ClinicalTrials.gov Identifier: NCT02632435

Australia’s newly introduced National Disability Insurance Scheme establishes a cash-for-care model that pits the human rights of people with disabilities against the employment rights of care work...

427 Background: Patient support lines (PSLs) help in triaging clinical problems, addressing patient queries and assist in navigating a complex multi-disciplinary oncology team. While providing support and training to nursing staff who operate these lines is key, there is limited data on their experience and feedback to guide this. Our objective was to identify areas of quality improvement for The Ottawa Hospital Cancer Centre (TOHCC) patient support lines. Methods: We conducted a cross-sectional study of oncology nurses’ (ONs’) perspectives on the provision of care via PSLs at a tertiary referral cancer center via an anonymous, descriptive survey. Measures collected included nursing/patient characteristics, nature of questions addressed by the PSL, patient/nursing satisfaction with the service, common challenges faced, and initiatives to improve the patient and nursing experience. Results: Seventy-one percent (30/42) of eligible nurses responded to the survey. The most common disease site, stage, issue, and symptom addressed were breast cancer, metastatic disease, treatment-related toxicity, and pain, respectively. Despite majority of nurses reporting personal and patient satisfaction with the care provided by the PSL, there was variance in the perceived appropriate use of PSL by physicians and patients. As such, fifty-nine percent (17/29) of nurses recommended redefining the responsibilities of the PSL to achieve its maximal potential, with 75% (6/8) ONs identifying high call volumes due to inappropriate questions as a barrier to care. Sixty percent (18/30) of nurses reported that having TOHCC-specific management plans for common issues would improve their experience, and the quality of care provided on PSL. Lastly, 80% (24/30) of nurses denied experiencing a reduction in PSL call volumes with increased patient access to their electronic medical record. Conclusions: Our study identified several important areas for improvement warranting further investigation, despite high reported rates of satisfaction with care provided on PSL. A need for TOHCC standardized management algorithms for common issues addressed on the PSL as well as increased physician and patient education to redefine goals of the PSL to address problems with high volume, and inappropriate calls was identified.

The emergence and subsequent decline of the so-called Islamic State of Iraq and Syria provides new challenges for Western governments facing the return of foreign fighters and their families to hom...

The purpose of education and school reform is a topic of constant debate, which take on a different perspective depending on the motivation of those calling for change. In the Australian context, two of the loudest school reform agendas in the early 21st century center on school autonomy and social justice. The school autonomy agenda focuses on freeing up schools from the centralized and bureaucratic authorities, enabling them to respond to the local needs of their students and school community. Social justice reform focuses on equity, including lack of opportunity, long-term health conditions, low educational attainment, and other intersecting inequalities, and practices of care and nurture that focus on emotional, behavioral, and social difficulties in order to address the disadvantages and inequalities experienced by many students and families. In the early 21st century, school autonomy and social justice reform have been engulfed by neoliberal ideology and practices. Schools are encouraged to engage in a culture of competitive performativity dictated by market-driven agendas, whereas equity has been transformed by measurements and comparisons. Neoliberalism has been heavily critiqued by scholars who argue that it has mobilized the school autonomy agenda in ways that generate injustice and that it fails to address the social issues facing students, families, schools, and the system. Schools are committed to care and social justice, and, when given autonomy without systems-level constraints, they are adept at implementing socially just practices. While the neoliberal agenda focuses on the market and competitive performativity, the premise of school autonomy is to empower school leadership to innovate and pursue opportunities to respond more effectively to the needs and demands of their school at the local level. Schools are implementing social justice practices and programs that introduce responsive caregiving and learning environments into their school culture in order to address the holistic wellbeing and learning needs of their students and school community. With an increasing commitment to addressing disadvantage through the provision of breakfast food, schools are creating wraparound environments of nurture and care that have become enablers of students’ learning and of their connectedness to school and their local community. Adopting a whole-school approach, principals have demonstrated how social justice and school autonomy reform has aligned to address the overall educational commitment to excellence and equity in Australian education.

Many inherited conditions cause cholestasis in the neonate or infant. Next-generation sequencing methods can facilitate a prompt diagnosis in some of these cases; application of these methods in patients with liver diseases of unknown cause has also uncovered novel gene-disease associations and improved our understanding of physiological bile secretion and flow. By helping to define the molecular basis of certain cholestatic disorders, these methods have also identified new targets for therapy as well patient subgroups more likely to benefit from specific therapies. At the same time, sequencing methods have presented new diagnostic challenges, such as the interpretation of single heterozygous genetic variants. This article discusses those challenges in the context of neonatal and infantile cholestasis, focusing on difficulties in predicting variant pathogenicity, the possibility of other causal variants not identified by the genetic screen used, and phenotypic variability among patients with variants in the same genes. A prospective, observational study performed between 2010–2013, which sequenced six important genes (ATP8B1, ABCB11, ABCB4, NPC1, NPC2 and SLC25A13) in an international cohort of 222 patients with infantile liver disease, is given as an example of potential benefits and challenges that clinicians could face having received a complex genetic result. Further studies including large cohorts of patients with paediatric liver disease are needed to clarify the spectrum of phenotypes associated with, as well as appropriate clinical response to, single heterozygous variants in cholestasis-associated genes.

Purpose The purpose of this paper is to investigate the possibilities of performative research practices in the dissemination of social science research. The paper introduces the benefits of these practices and demonstrates the relational benefits of sound. The paper explores the possibility that sound may be used to reposition the listener to a new way of hearing. Design/methodology/approach This research emerged from a larger research project investigating the silent racism that was evident in an inclusive education program. A constructivist narrative approach was adopted to investigate the benefits of sharing the sensorial qualities of participant responses as an aural excerpt. The aim here is to reposition the listener from their own cultural value systems to being open to new understandings. Findings The paper highlights the relationship between the storyteller and the listener. Sharing a young man’s personal experience of racism enabled the visceral and affective quality of his deeply personal experience to be conveyed to the listener. Research limitations/implications This paper reports on the experiences of one participant. It is not designed to represent the experiences of all young people with African heritage, but rather to present the possibilities of using sound in the dissemination of research findings. Originality/value The methodological approach of this paper offers a unique and valuable contribution to the growing interest in new avenues to disseminate research findings, particularly those that convey the deeply personal experience of participants.

It is well documented that the construction industry is perceived as an environment dominated by males, and as a result the industry has difficulty attracting qualified female employees. Th...

Purpose Vasomotor symptoms (VMS) such as hot flashes and night sweats are common in breast cancer patients and can affect both quality of life and treatment adherence. However, there is limited practical data to guide clinicians in the optimal selection of therapeutic strategies. A survey of health care providers was performed to better understand perspectives and prescribing practices for managing this problem. Methods Canadian health care providers who treat patients with early stage breast cancer (EBC) participated in an anonymous electronic survey. Participants provided their perspectives on the prevalence and severity of VMS among patients with EBC, outlined their management strategies, and provided feedback on the perceived efficacy of interventions for VMS. Results Responses were received from 65 providers including breast oncologists (36/65, 55%) and nurses with oncology expertise (29/65, 45%). Seventy-seven percent of participants reported regularly asking patients about VMS, and most indicated that bothersome VMS occurred in the majority of patients. Health care providers cited hot flash severity and sleep disruption as the most important issues for patients. The most common first- and second-line interventions recommended were lifestyle modifications (n = 32/65, 49.2%) and pharmacologic strategies (n = 27/65, 41.5%), respectively. Most respondents felt that interventions, including pharmacologic, over-the-counter, and complementary therapies, were only “somewhat effective”. Overall, half of respondents (n = 35/65, 54%) reported being “confident” in managing VMS. Conclusion Given the variability of treatment recommendations, and health care provider uncertainty around the benefits of therapies for VMS, more ‘real-world’ trials are needed to optimize patient care.

Many gaps and deficiencies in standards and protections in Australia’s employment regulation reflect and reinforce historically strong gendered norms including a male breadwinner model. Compared with full-time jobs, part-time and casual forms of employment, in which women predominate, offer fewer benefits and less protection from employment risks and insecurities. Gendered undervaluation has been a long-standing problem in feminised social care work, affecting both pay and working conditions. In the new individualised cash-for-care scheme established by the National Disability Insurance Scheme (NDIS), deficiencies and gaps in labour laws and other labour market regulations affecting workers’ rights provide significant opportunity for Australia’s feminised social care workforce to be re-shaped, either as a low-paid and highly insecure independent contractor workforce or as an informalised workforce undertaking ‘private’ work on the margins of effective employment regulation and governed by domestic and familial relations.

Australia’s new cash-for-care scheme for support and care for people with disability provides a unique and important opportunity to examine the impacts of an individualised and highly marketised model of social care on the low-paid social care workforce. This book details the findings of research investigating how social care work and employment are being transformed in the new individualised social care scheme to understand the impacts of the market model for decent work. Decent work for care workers matters for the future of work, it matters for gender equality and it matters for the quality of care. This chapter introduces these arguments and provides an overview of the book.

This chapter continues the exploration of workers’ experiences, examining individualised risks for social care workers. Risks of isolating and individualising workers include risks arising from transfers of responsibility that occur in the individualised system and devolve decision-making and duty to individual people with disability and to frontline workers. The responsibility devolved to workers exposes workers to increased risk. At the same time, for many workers, formal recognition and reward are reduced. Risks of fragmenting work, working time and life are perhaps the most conspicuous of the individualised risks identified. These risks are also some of the most problematic for frontline workers and for the future of a skilled and sustainable workforce. They impact on workers’ ability to earn a living and enjoy time away from work and they reduce skills development opportunities and prospects.

In the United Kingdom continuing debates about individualised funding of social care have accompanied the development and implementation over 20 years or so of what is known there as personalised social care. Questions about the implications of individualised funding for frontline social care workers are sometimes raised in these debates. However, over the decade or so since the global financial crisis in 2008–2009 austerity funding the main concern when the problems of low-paid social workers are raised, particularly in England, has been austerity funding. This chapter introduces the personalisation debates and reviews the evidence relating to the success of personalised social care in England, including the evidence relating to how social care workers fare. This provides a reference point for appraising the policy rationale and design of Australia’s new National Disability Insurance Scheme (NDIS), and its potential for re-shaping care work and employment.

Australia’s new individualised National Disability Insurance Scheme (NDIS) establishes a market in which service providers compete with each other to provide services to individual social care ‘consumers’ within the context of tight pricing and an individualised hourly-based pricing arrangement. The NDIS has the potential for a very large proportion of the publicly-funded individualised social care market to be highly unregulated. This chapter draws on analysis of texts of key documents containing the arguments and ideas underlying the design and management of the individualised and marketised social care scheme. It explores what evidence informed the policy development process, what ideas guide the management of the scheme and what considerations are given to the frontline social care workforce in these processes. The analysis reveals some of the underlying ideas and values embedded in the new social care system. It identifies some inherent tensions and apparent contradictions in the NDIS design, market approach and system aspirations for quality and safety. These tensions and contradictions suggest risks for the ongoing sustainability of the workforce, for individual workers and for people relying on the system for their care and support.

This chapter examines how Australia’s new individualised social care system, the National Disability Insurance Scheme (NDIS), introduces new risks for frontline social care workers. It focuses on risks of reinforcing the gendered undervaluation of social care work. While gendered undervaluation of social care work is a long-standing problem, it is reinforced in two ways in individualised and marketised social care: first, through the removal of access to many of the mechanisms and avenues that might be used to tackle undervaluation and second, through the reversal of past gains made towards recognition and valuing of social care work. Social care work becomes (re)defined as low-skilled and task-based work or as informal ‘help’; jobs become casualised, with little opportunity for skill development and access to career pathways; employment is moved beyond the reach of protective regulation; and workers are isolated from opportunities for collective organisation and representation.

Governments have increasingly adopted market mechanisms in public care systems since the 1980s. The ideas and ideologies behind marketisation are complex and, across care systems, diverse policy objectives and rationales drive marketisation strategies. Cash-for-care schemes marketise care by re-framing individual care users as care consumers and providing them with a funding allocation to purchase their care. This chapter canvasses some of the literature on marketisation and individualised care to provide a basis for appraising Australia’s new cash-for-care scheme for support for people with disability and its likely impacts on social care work and employment. A framework to guide the research is developed, drawing on insights from the three theoretical traditions of feminist socioeconomics, comparative institutionalist approaches and labour segmentation theory. Three aspects of care and employment regimes are identified as particularly important for shaping work and employment for care workers in cash-for-care schemes.

Social care policy and employment regulation are both significant in producing the conditions for individualised risk for social care workers. Solutions for decent work for care and support workers lie in the design and regulation of the care system; however, employment regulation also needs rejuvenation. The achievement of an equitable person-centred social care system cannot be left to the market. Nor will the market develop the skilled workforce in secure and fairly-remunerated jobs that is necessary for a sustainable social care system. Government is the key actor with power to make the changes required. Care and care workers must be properly valued within and beyond the care system. There must be opportunity for collective effort and responsibility in the care system. Employment regulation and arrangements must provide all workers in personal work relations with protections and rights in the labour market if we are to re-fashion care jobs as sustainable and secure work.

Using a case study of Australia’s National Disability Insurance Scheme, this article examines the role of prices in individualised funding schemes. It argues that prices were set too low to cover the full costs of disability support, placing pressure on relationship-building and other tasks required for high-quality care. We argue that the use of prices as mechanisms for cost containment in individualised funding schemes is predicated on the undervaluation of care. Our analysis can inform discussion among scholars, activists, policymakers and others about the design and impact of individualised funding, and the challenge of fully valuing care under market-based approaches.

Workplace and industrial relations regulations are key sites for policy intervention to address Australia's gender pay gap, which, at 15.3 per cent, is almost as large as it was in 1997. In both the Fair Work Act 2009 (Cth) and the Workplace Gender Equality Act 2012 (Cth) the goal of equal pay has a more central place than it did in predecessor legislation. In particular, the Fair Work Act has the potential to deliver more gender-equitable wage structures through addressing systemic gender-based undervaluation at the industry level. Adopting a feminist institutional approach this article examines equal pay policy in the operations of workplace and industrial relations regulation to ask why, despite some recent successes, this potential appears unlikely to be realised.

Increasingly, jurisdictions are adopting “apology legislation” that allow medical professionals to apologize to patients and family members when an adverse event occurs while disallowing the introduction of the apology in a liability case as evidence of fault or liability. While apology legislation itself is fairly straightforward, its potential meaning and impact is much more complex. This paper conceptualizes apology legislation from an accountability and ethics of care perspective. These two concepts—accountability and care—are distinct but interrelated concepts and this dual theoretical approach offers a rich analysis on the potential impact(s) of apology legislation. We argue that apology legislation is a mechanism added to the existing accountability regime that can offer important opportunities to express and practise care. As an accountability mechanism, apology legislation creates space for an accountability relationship to emerge between medical professionals and their patients. Apology legislation also addresses long-standing gaps in how we as a society think about health care and respond to patients and families in ways that challenge the dominant “consumer of services” role. It is in this sense that apology legislation has the potential to destabilize traditional notions of social citizenship. Last, we argue that empirical research is urgently needed to know to what degree apologies contribute to accountability and the transformation of health care.

Objectives: Student wellbeing is closely linked to young people’s satisfaction with life at school. Wellbeing practices in an alternative learning environment take on a particularly significant role as they aim to re-engage young people who are disenfranchised from Australia’s education system. The Wellbeing Project, which is described and reported on here, aimed to capture young people’s perceptions to strengthen and create a Youth+ model of wellbeing in participating centres. Design: A mixed methods approach was employed to explore student experiences of wellbeing. A quantitative methodology informed the development of surveys, and focus groups adopted a semi-structured qualitative approach. Setting: Youth+ Flexible Learning Centres (Flexis) in various parts of Australia. Method: Students in the flexible learning centres were invited to complete a survey during class time. Young people from each centre were then invited to participate in focus group discussions. Four groups were held in Melbourne, two in Geelong and Adelaide and one each in Hobart, St Mary’s, Alice Springs, Wollongong and Geraldton. Results: Thematic analysis revealed that being supported by staff to learn and working towards long-term goals in an individual way were central to the development of wellbeing among young people involved in the centres. Relationships with staff were highly valued. Conclusion: Findings demonstrate that wellbeing for young people in flexible learning centres is associated with staff support and respect. There is value in giving young people the opportunity to engage in a socially transformative education, enabling them to envision new learning and work opportunities.