ORCID Profile
0000-0003-1032-0457
Current Organisations
European Molecular Biology Laboratory
,
University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences
,
University of Melbourne
,
Alfred Health
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Publisher: Elsevier BV
Date: 10-2016
DOI: 10.1016/J.JOCD.2016.07.008
Abstract: Antiepileptic drug (AED) therapy is associated with decreased bone mineral density however, the time course for this development is unclear. The aim of this study was to evaluate bone mineral changes during the initial years of AED therapy in AED-naive, newly diagnosed epilepsy patients compared with non-AED users. In 49 epilepsy patients newly started on AEDs and in 53 non-AED users of both genders, bone mineral density (BMD) and bone mineral content were measured using dual-energy X-ray absorptiometry at baseline (within the first year of therapy) and at least 1 yr later. Bone changes between the 2 assessments, adjusted for age, height, and weight, were calculated as the annual rate of change. The median duration of AED therapy was 3.5 mo at baseline and 27.6 mo at follow-up. No overall difference was found in mean BMD and bone mineral content measures between user and nonuser cohorts in both cross-sectional baseline and the annual rate of change (p > 0.05). However, users on carbamazepine monotherapy (n = 11) had an increased annual rate of total hip (-2.1% vs -0.8%, p = 0.020) and femoral neck BMD loss (-2.1% vs -0.6%, p = 0.032) compared to nonusers. They also had a marginally higher rate of femoral neck BMD loss (-2.1%, p = 0.049) compared with valproate (-0.1%, n = 13) and levetiracetam users (+0.6%, n = 13). During the initial years of AED treatment for epilepsy, no difference was found in bone measures between AED users as a group and nonuser cohorts. However, the data suggested that carbamazepine monotherapy was associated with increased bone loss at the hip regions, compared to users of levetiracetam or valproate and nonusers. Larger studies of longer duration are warranted to better delineate the bone effects of specific AEDs, with further consideration of the role of early dual-energy X-ray absorptiometry scanning and careful AED selection in potentially minimizing the impact on bone health in these patients.
Publisher: Wiley
Date: 28-08-2015
DOI: 10.1111/APT.13353
Abstract: Crohn's disease recurs in the majority of patients after intestinal resection. To compare the relative efficacy of thiopurines and anti-TNF therapy in patients at high risk of disease recurrence. As part of a larger study comparing post-operative management strategies, patients at high risk of recurrence (smoker, perforating disease, ≥2nd operation) were treated after resection of all macroscopic disease with 3 months metronidazole together with either azathioprine 2 mg/kg/day or mercaptopurine 1.5 mg/kg/day. Thiopurine-intolerant patients received adalimumab induction then 40 mg fortnightly. Patients underwent colonoscopy at 6 months with endoscopic recurrence assessed blind to treatment. A total of 101 patients [50% male median (IQR) age 36 (25-46) years] were included. There were no differences in disease history between thiopurine- and adalimumab-treated patients. Fifteen patients withdrew prior to 6 months, five due to symptom recurrence (of whom four were colonoscoped). Endoscopic recurrence (Rutgeerts score i2-i4) occurred in 33 of 73 (45%) thiopurine vs. 6 of 28 (21%) adalimumab-treated patients [intention-to-treat (ITT) P = 0.028] or 24 of 62 (39%) vs. 3 of 24 (13%) respectively [per-protocol analysis (PPA) P = 0.020]. Complete mucosal endoscopic normality (Rutgeerts i0) occurred in 17/73 (23%) vs. 15/28 (54%) (ITT P = 0.003) and in 27% vs. 63% (PPA P = 0.002). The most advanced disease (Rutgeerts i3 and i4) occurred in 8% vs. 4% (thiopurine vs. adalimumab). In Crohn's disease patients at high risk of post-operative recurrence adalimumab is superior to thiopurines in preventing early disease recurrence.
Publisher: Wiley
Date: 15-08-2013
DOI: 10.1111/LIV.12278
Abstract: Volatile anaesthetic drug-induced liver injury can range from asymptomatic alanine transaminase elevations to fatal hepatic necrosis. There is very limited research regarding hepatotoxicity of modern volatile anaesthetic agents. The aim of this study was to determine how common liver injury consistent with volatile anaesthetic hepatitis is, following exposure to isoflurane, desflurane and sevoflurane and to propose risk factors for its development. Following ethics approval, we conducted a retrospective audit of adult trauma patients with abnormal liver biochemistry following volatile anaesthesia during January 1 to December 31, 2009. The data collected included patient demographics, volatile anaesthetic administration, concurrent medication, perioperative liver biochemistry results and comorbidities. The Council for International Organisations of Medical Sciences/Roussel Uclaf Causality Assessment Method scoring system was used to group cases according to the likelihood of volatile anaesthetic being the causative agent of drug-induced hepatotoxicity. Forty-seven (3%) of 1556 patients had abnormal post-operative liver biochemistry potentially attributable to volatile anaesthetic. Of the 47, 12 patients (26%) had peak alanine transaminase levels greater than 200 U/L. No significant predictors of volatile anaesthetic drug-induced liver injury following isoflurane, desflurane or sevoflurane anaesthesia could be identified. Volatile anaesthetic drug-induced liver injury in adult trauma patients may be significantly more common than previously noted. This study suggests that about a quarter of patients with volatile anaesthetic drug-induced liver injury develop significant liver injury. Further prospective studies are required to define risk factors and clinical outcomes.
Publisher: Public Library of Science (PLoS)
Date: 07-08-2023
DOI: 10.1371/JOURNAL.PONE.0289443
Abstract: To determine the availability and readiness of health facilities to provide family planning, antenatal care and basic emergency obstetric and newborn care in Nepal in 2021. Secondary objectives were to identify progress since 2015 and factors associated with readiness. This is a secondary analysis of cross-sectional Nepal Health Facility Survey (NHFS) data collected in 2015 and 2021. The main outcome measures were availability and readiness of family planning, antenatal care, and basic emergency obstetric and newborn care services. Readiness indices were calculated using WHO-recommended service availability and readiness assessment (SARA) methods (score range 0 to 100%, with 100% indicating facilities are fully prepared to provide a specific service). We used independent t-tests to compare readiness indices in 2015 and 2021. Factors potentially associated with readiness (rurality setting, ecological region, managing authority, management meeting, quality assurance activities, and external supervision) were explored using multivariable linear regression. There were 940 and 1565 eligible health facilities in the 2015 and 2021 surveys, respectively. Nearly all health facilities provided family planning (2015: n = 919 (97.8%) 2021: n = 1530 (97.8%)) and antenatal care services (2015: n = 920 (97.8%) 2021: n = 1538 (98.3%)) in both years, but only half provided delivery services (2015: n = 457 (48.6%) 2021: n = 804 (51.4%)). There were suboptimal improvements in readiness indices over time: (2015–21: family planning 68.0% to 70.9%, p .001, antenatal care 49.5% to 54.1%, p .001 and basic emergency obstetric and newborn care 56.7% to 58.0%, p = 0.115). The regression model comprising combined datasets of both NHFSs indicates facilities with regular management meetings and/or quality assurance activities had significantly greater readiness for all three indices. Similarly, public facilities had greater readiness for family planning and basic emergency obstetric and newborn care while they had lower readiness for antenatal care. Readiness to deliver family planning, antenatal care and basic emergency obstetric and newborn care services in Nepal remains inadequate, with little improvement observed over six years.
Publisher: Wiley
Date: 27-02-2017
Abstract: Targeted ultrasound of the liver (TUSL) has been proposed as a new approach in chronic liver disease to meet the increasing demands on ultrasound services in this patient population. This study analyses the impact of TUSL on examination time. Retrospective cohort analysis of time taken to perform liver ultrasound on consecutive chronic liver disease patients pre- (n = 230) and post- (n = 147) introduction of TUSL. Within each cohort, patients were sub ided into three categories based on the clinical indication: Group 1. hepatocellular carcinoma (HCC) surveillance Group 2. detection of cirrhosis, fibrosis or fatty liver Group 3. detection of portal hypertension. The primary outcome was difference in examination time in the pre- and post-intervention groups. Introduction of TUSL led to 49% reduction in examination time (median (Q1-Q3) 23.7 (16.7-36.2) min in pre-TUSL period vs 12.1 (6.4-19.5) min in post, P < 0.001) and it was consistent across all three clinical indication groups (gr1: median 23.1 minutes vs 8.1 minutes (P < 0.001), gr2: 23.0 minutes vs 14.3 minutes (P < 0.001), gr3: 32.2 minutes vs 15.3 minutes (P = 0.006)). After the adjustment for clinical indication and sonographer's experience, impact of TUSL on time reduction remained significant with a 66.6% time reduction (95% CI 53.6 to 79.5). Targeted ultrasound of the liver improves efficiency of chronic liver disease ultrasound with halving of examination times and consequently has the potential to greatly improve resource utilization.
Publisher: Springer Science and Business Media LLC
Date: 03-01-2013
Publisher: Wiley
Date: 06-2013
DOI: 10.1111/IMJ.12038
Abstract: Primary angiitis of the central nervous system is a rare condition, which is often difficult to diagnose and is associated with significant morbidity and mortality. There is no standardised treatment protocol or randomised clinical trial evidence to guide management. To describe the clinical features, diagnostic modalities, treatment and outcomes in an Australian hospital population-based series of primary cerebral angiitis. Data were collected via retrospective medical record review of patients with primary angiitis of the central nervous system for the period 1 July 1998 to 30 June 2009, using previously published diagnostic criteria. Eligible patient records were identified in two ways from routinely collected hospital episode data, coded using the ICD-10-AM coding standard and by review of cerebral biopsy data. Ten of 12 included patients had a positive cerebral biopsy, with two patients diagnosed by angiography. Mean age at diagnosis was 47.2 years (range 18-73 years), with a female predominance of 5:1. Headache was the most common symptom experienced. Seventy per cent of the biopsy specimens showed a lymphocytic vasculitis. All patients received treatment with either steroids alone or a combination of steroids and cyclophosphamide, the latter treatment being initiated for those with a higher modified Rankin score of disability. Nine (75%) responded to treatment. There was one in-hospital death, and two patients had no documented response to treatment. This study presents the first Australian case series data of primary cerebral angiitis. Better understanding of management and outcomes of this rare condition would be gained through multicentre studies.
Publisher: JMIR Publications Inc.
Date: 10-05-2016
DOI: 10.2196/RESPROT.5465
Publisher: Wiley
Date: 15-02-2012
DOI: 10.1111/J.1365-2648.2012.05950.X
Abstract: The aim of this study was to test the feasibility and impact of an intervention consisting of self-monitored blood pressure, medicine review, a Digital Versatile Disc, and motivational interviewing telephone calls to help people with diabetes and kidney disease improve their blood pressure control and adherence to prescribed medications. People with co-existing diabetes, kidney disease and hypertension require multiple medications to manage their health. About 50% of people are non-adherent to their prescribed medications with non-adherence increasing in the presence of chronic conditions. Randomized controlled trial. Patients aged ≥18 years with diabetes, chronic kidney disease and systolic hypertension were recruited from nephrology and diabetes outpatients' clinics of an Australian metropolitan hospital between 2008-2009. Participants were randomly allocated on a 1:1 basis to one of two groups in a randomized controlled trial: the intervention delivered over 3 months (n = 39) and usual care (n = 41), with follow-up at 3, 6 and 9 months postintervention. People collecting data and assessing outcomes were blinded to group assignment. Seventy-five participants completed the study. The intervention was acceptable and feasible for this cohort. There were no statistically significant differences between groups, although the mean systolic blood pressure reduction in the intervention group (n = 36) was -6·9 mmHg 95% CI (-13·8, -0·02) at 9 months postintervention. The study was feasible and statistically significant differences may be determinable in a larger s le to overcome the variability between groups, paying attention to recommendations for further research. The trial was prospectively registered with the Australian and New Zealand Clinical Trials Register (ACTRN12607000044426).
Publisher: Elsevier BV
Date: 04-2015
Publisher: Wiley
Date: 30-05-2017
DOI: 10.1111/JGH.13677
Abstract: Disease recurs frequently after Crohn's disease resection. The role of serological antimicrobial antibodies in predicting recurrence or as a marker of recurrence has not been well defined. A total of 169 patients (523 s les) were prospectively studied, with testing peri-operatively, and 6, 12 and 18 months postoperatively. Colonoscopy was performed at 18 months postoperatively. Serologic antibody presence (perinuclear anti-neutrophil cytoplasmic antibody [pANCA], anti-Saccharomyces cerevisiae antibodies [ASCA] IgA/IgG, anti-OmpC, anti-CBir1, anti-A4-Fla2, anti-Fla-X) and titer were tested. Quartile sum score (range 6-24), logistic regression analysis, and correlation with phenotype, smoking status, and endoscopic outcome were assessed. Patients with ≥ 2 previous resections were more likely to be anti-OmpC positive (94% vs 55%, ≥ 2 vs < 2, P = 0.001). Recurrence at 18 months was associated with anti-Fla-X positivity at baseline (49% vs 29% positive vs negative, P = 0.033) and 12 months (52% vs 31%, P = 0.04). Patients positive (n = 28) for all four antibacterial antibodies (anti-CBir1, anti-OmpC, anti-A4-Fla2, and anti-Fla-X) at baseline were more likely to experience recurrence at 18 months than patients negative (n = 32) for all four antibodies (82% vs 18%, P = 0.034 odds ratio 6.4, 95% confidence interval 1.16-34.9). The baseline quartile sum score for all six antimicrobial antibodies was higher in patients with severe recurrence (Rutgeert's i3-i4) at 18 months, adjusted for clinical risk factors (odds ratio 1.16, 95% confidence interval 1.01-1.34, P = 0.039). Smoking affected antibody status. Anti-Fla-X and presence of all anti-bacterial antibodies identifies patients at higher risk of early postoperative Crohn's disease recurrence. Serologic screening pre-operatively may help identify patients at increased risk of recurrence.
Publisher: JMIR Publications Inc.
Date: 07-03-2017
DOI: 10.2196/MHEALTH.5717
Publisher: Elsevier BV
Date: 11-2021
Publisher: Springer Science and Business Media LLC
Date: 03-02-2016
DOI: 10.1007/S00223-016-0109-7
Abstract: Long-term anti-epileptic drug (AED) therapy is associated with increased fracture risk. This study tested whether substituting the newer AED levetiracetam has less adverse effects on bone than older AEDs. An open-label randomized comparative trial. Participants had "failed" initial monotherapy for partial epilepsy and were randomized to substitution monotherapy with levetiracetam or an older AED (carbamazepine or valproate sodium). Bone health assessments, performed at 3 and 15 months, included areal bone mineral density (aBMD) and content at lumbar spine (LS), total hip (TH), forearm (FA), and femoral neck (FN), radial and tibial peripheral quantitative computed tomography and serum bone turnover markers. Main outcomes were changes by treatment group in aBMD at LS, TH, and FA, radial and tibial trabecular BMD and cortical thickness. 70/84 patients completed assessments (40 in levetiracetam- and 30 in older AED group). Within-group analyses showed decreases in both groups in LS (-9.0 % p < 0.001 in levetiracetam vs. -9.8 % p < 0.001 in older AED group), FA (-1.46 % p < 0.001 vs. -0.96 % p < 0.001, respectively) and radial trabecular BMD (-1.46 % p = 0.048 and -2.31 % p = 0.013, respectively). C-terminal telopeptides of type I collagen (βCTX bone resorption marker) decreased in both groups (-16.1 % p = 0.021 vs. -15.2 % p = 0.028, respectively) whereas procollagen Ι N-terminal peptide (PΙNP bone formation marker) decreased in older AED group (-27.3 % p = 0.008). The treatment groups did not differ in any of these measures. In conclusion, use of both levetiracetam and older AEDs was associated with bone loss over 1 year at clinically relevant fracture sites and a reduction in bone turnover.
Publisher: Oxford University Press (OUP)
Date: 08-04-2015
Abstract: Patients with Crohn's disease have poorer health-related quality of life [HRQoL] than healthy in iduals, even when in remission. Although HRQoL improves in patients who achieve drug-induced or surgically induced remission, the effects of surgery overall have not been well characterised. In a randomised trial, patients undergoing intestinal resection of all macroscopically diseased bowel were treated with postoperative drug therapy to prevent disease recurrence. All patients were followed prospectively for 18 months. C-reactive protein [CRP], Crohn's Disease Activity Index [CDAI], and faecal calprotectin [FC] were measured preoperatively and at 6, 12, and 18 months. HRQoL was assessed with a general [SF36] and disease-specific [IBDQ] questionnaires at the same time points. A total of 174 patients were included. HRQoL was poor preoperatively but improved significantly [p < 0.001] at 6 months postoperatively. This improvement was sustained at 18 months. Females and smokers had a poorer HRQoL when compared with males and non-smokers, respectively. Persistent endoscopic remission, intensification of drug treatment at 6 months, and anti-tumour necrosis factor therapy were not associated with HRQoL outcomes different from those when these factors were not present. There was a significant inverse correlation between CDAI, [but not endoscopic recurrence, CRP, or FC] on HRQoL. Intestinal resection of all macroscopic Crohn's disease in patients treated with postoperative prophylactic drug therapy is associated with significant and sustained improvement in HRQoL irrespective of type of drug treatment or endoscopic recurrence. HRQoL is lower in female patients and smokers. A higher CDAI, but not direct measures of active disease or type of drug therapy, is associated with a lower HRQoL.
Publisher: JMIR Publications Inc.
Date: 25-02-2019
Publisher: American Society of Neuroradiology (ASNR)
Date: 08-03-2018
DOI: 10.3174/AJNR.A5572
Publisher: Springer Science and Business Media LLC
Date: 04-02-2023
DOI: 10.1186/S12875-023-01976-Z
Abstract: Electronic health record datasets have been used to determine the prevalence of musculoskeletal complaints in general practice but not to examine the associated characteristics and healthcare utilisation at the primary care level. To describe the prevalence and characteristics of patients presenting to general practitioners with musculoskeletal complaints. A five-year analysis within three Primary Health Networks (PHNs) in Victoria, Australia. We included patients with at least one face-to-face consultation 2014 to 2018 inclusive and a low back (≥ 18 years), and/or neck, shoulder or knee (≥ 45 years) complaint determined by SNOMED codes derived from diagnostic text within the medical record. We determined prevalence, socio-demographic characteristics and diagnostic codes for patients with an eligible diagnosis and number of consultations within one year of diagnosis. 324,793/1,294,021 (25%) presented with at least one musculoskeletal diagnosis, of whom 41% ( n = 133,279) fulfilled our inclusion criteria. There were slightly more females ( n = 73,428, 55%), two-thirds ( n = 88,043) were of working age (18–64 years) and 83,816 (63%) had at least one comorbidity. Over half had a low back diagnosis ( n = 76,504, 57%) followed by knee ( n = 33,438, 25%), shoulder ( n = 26,335, 20%) and neck ( n = 14,492, 11%). Most codes included ‘pain’ and/or ‘ache’ (low back: 58%, neck: 41%, shoulder: 32%, knee 26%). Median (IQR) all-cause consultations per patient within one year of diagnosis was 7 (4–12). The burden of MSK complaints at the primary care level is high as evidenced by the prevalence of people with musculoskeletal complaints presenting to a general practitioner, the preponderance of comorbidities and the numerous consultations per year. Identification and evaluation of strategies to reduce this burden are needed.
Publisher: Wiley
Date: 27-07-2022
DOI: 10.1111/COBI.13807
Abstract: Marine fisheries in coastal ecosystems in many areas of the world have historically removed large‐bodied in iduals, potentially impairing ecosystem functioning and the long‐term sustainability of fish populations. Reporting on size‐based indicators that link to food‐web structure can contribute to ecosystem‐based management, but the application of these indicators over large (cross‐ecosystem) geographical scales has been limited to either fisheries‐dependent catch data or er‐based methods restricted to shallow waters ( m) that can misrepresent the abundance of large‐bodied fished species. We obtained data on the body‐size structure of 82 recreationally or commercially targeted marine demersal teleosts from 2904 deployments of baited remote underwater stereo‐video (stereo‐BRUV). S ling was at up to 50 m depth and covered approximately 10,000 km of the continental shelf of Australia. Seascape relief, water depth, and human gravity (i.e., a proxy of human impacts) were the strongest predictors of the probability of occurrence of large fishes and the abundance of fishes above the minimum legal size of capture. No‐take marine reserves had a positive effect on the abundance of fishes above legal size, although the effect varied across species groups. In contrast, sublegal fishes were best predicted by gradients in sea surface temperature (mean and variance). In areas of low human impact, large fishes were about three times more likely to be encountered and fishes of legal size were approximately five times more abundant. For conspicuous species groups with contrasting habitat, environmental, and biogeographic affinities, abundance of legal‐size fishes typically declined as human impact increased. Our large‐scale quantitative analyses highlight the combined importance of seascape complexity, regions with low human footprint, and no‐take marine reserves in protecting large‐bodied fishes across a broad range of species and ecosystem configurations.
Publisher: JMIR Publications Inc.
Date: 05-10-2015
DOI: 10.2196/MHEALTH.4263
Publisher: Medical Journals Sweden AB
Date: 2017
Abstract: To investigate whether the use of cognitive behavioural therapy in pulmonary rehabilitation addresses the depression and anxiety burden and thereby improves rehabilitation outcomes. Prospective controlled clinical trial. A total of 70 patients with chronic obstructive pulmonary disease who were referred to a community centre for pulmonary rehabilitation. Patients were allocated to either the control group, consisting of pulmonary rehabilitation alone, or to the treatment group, receiving pulmonary rehabilitation and an additional 6 sessions of group-based cognitive behavioural therapy. Assessments consisting of questionnaires and walk tests were conducted pre- and post-pulmonary rehabilitation. A total of 28 patients were enrolled. The cognitive behavioural therapy group had significant improvements in exercise capacity following pulmonary rehabilitation (mean change 32.9 m, p = 0.043), which was maintained at 3 months post-pulmonary rehabilitation (mean change 23.4 m, p = 0.045). Patients in the cognitive behavioural therapy group showed significant short-term improvements in fatigue, stress and depression (mean change 2.4, p = 0.016, 3.9, p = 0.024 and 4.3, p = 0.047, respectively) and a 3-month post-pulmonary rehabilitation improvement in anxiety score (mean change 3.1, p = 0.01). No significant changes were seen in the control group. The addition of cognitive behavioural therapy improved patients' physical, psychological and quality of life results. Cognitive behavioural therapy should be considered for inclusion in a pulmonary rehabilitation programme to enhance outcomes.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 13-06-2012
Publisher: Wiley
Date: 10-2009
DOI: 10.1111/J.1742-6723.2009.01209.X
Abstract: To determine injuries significantly associated with traumatic thoracic spine (T-spine) fractures This was a case-control study undertaken in an adult trauma centre. Cases were patients admitted with a traumatic T-spine fracture between January 1999 and August 2007. Each case had two controls matched for sex, age (+/-5 years) and injury severity classification (major/minor). Data were collected from patient medical records and the trauma service database. Multivariate logistic regression was used to determine injuries significantly associated with T-spine fracture. Two hundred and sixty-one cases and 512 controls were enrolled. In both groups, mean age was 41 years and 70% of patients were male. Univariate analysis revealed a range of injuries that were significantly more common among the cases, especially cervical and lumbar spine injuries, sternal/scapular/clavicular/rib fractures, pneumo/haemothorax and pulmonary contusions (P < 0.01). Skull fractures and lower limb injuries were significantly more common among the controls (P < 0.01). Logistic regression analysis revealed that only cervical and lumbar spine injuries and rib fractures were positively associated with T-spine fracture (P < 0.001). Skull fractures and lower limb injuries were negatively associated with T-spine injury (P < 0.001). Cervical and lumbar spine injuries and rib fractures are significantly associated with T-spine fracture. The presence of these injuries should raise suspicion of concomitant T-spine injury.
Publisher: Oxford University Press (OUP)
Date: 16-04-2012
Abstract: The aim was to develop an electronic adverse event (AE) screening tool applicable to acute care hospital episodes for patients admitted with chronic heart failure (CHF) and pneumonia. Consensus building using a modified Delphi method and descriptive analysis of hospital discharge data. Consultant physicians in general medicine (n = 38). In-hospital acquired (C-prefix) diagnoses associated with CHF and pneumonia admissions to 230 hospitals in Victoria, Australia, were extracted from the Victorian Admitted Episodes Data Set between July 2004 and June 2007. A 9-point rating scale was used to prioritize diagnoses acquired during hospitalization (routinely coded as a 'C-prefix' diagnosis to distinguish from diagnoses present on admission) for inclusion within an AE screening tool. Diagnoses rated a group median score between 7 and 9 by the physician panel were included. Selection of C-prefix diagnoses with a group median rating of 7-9 in a screening tool, and the level of physician agreement, as assessed using the Interpercentile Range Adjusted for Symmetry. Of 697 initial C-prefix diagnoses, there were high levels of agreement to include 113 (16.2%) in the AE screening tool. Using these selected diagnoses, a potential AE was flagged in 14% of all admissions for the two index conditions. Intra-rater reliability for each clinician ranged from kappa 0.482 to 1.0. A high level of physician agreement was obtained in selecting in-hospital diagnoses for inclusion in an AE screening tool based on routinely collected data. These results support further tool validation.
Publisher: Wiley
Date: 21-06-2016
Abstract: The accuracy of Acoustic Radiation Force Impulse (ARFI) imaging has been validated in the setting of hepatitis C, however, the accuracy in the setting of fatty liver disease (FLD) has been less well-established. The aim of this study was to assess the accuracy of ARFI in the setting of hepatic steatosis. Patients with biopsy proven or sonographically diagnosed liver steatosis were assessed for ARFI trends including: inter-operator concordance, interquartile range, ARFI failure rate, relationship between ARFI velocity and steatosis severity, and concordance between biopsy and ARFI fibrosis scores. Three hundred and forty-nine patients were assessed (53 'biopsy' cohort and 296 'ultrasound' cohort), with 28 patients having biopsy on the same day as ARFI. Low stages of fibrosis (F0/1) were over-estimated by ARFI in 62% of cases with biopsy correlation (n = 16, P < 0.001), with ARFI offering increased accuracy in regard to higher-stage fibrosis (14/15 cases, 93%). In both the biopsy and ultrasound cohorts the failure rate and median inter-quartile range increased with increasing steatosis, and the inter-operator concordance remained good across all liver steatosis severities. In the setting of steatosis, ARFI is very sensitive in detecting, and accurate in diagnosing, higher stages of fibrosis regardless of steatosis severity. It tends to overestimate the fibrosis category in lower stages of fibrosis. The present study does not show conclusively if the presence of steatosis or its severity independently alters ARFI measurements.
Publisher: Wiley
Date: 05-2013
DOI: 10.1111/IMJ.12068
Abstract: Chronic hepatitis B (HBV) and cirrhosis are major risk factors for hepatocellular carcinoma (HCC). The proportion and characteristics of cases with cirrhosis are not well documented. Our aim was to compare demographic, viral and tumour characteristics of HBV-associated HCC in an Australian cohort, in patients with and without cirrhosis. Existing HCC databases at six Melbourne teaching hospitals were reviewed for cases associated with HBV. Patient demographics, HBV viral characteristics, presence of cirrhosis, serum alpha-fetoprotein and tumour size were assessed. Mode of diagnosis was recorded through surveillance or symptoms, and treatment was either palliative, percutaneous or surgical. We identified 197 cases of HBV-related HCC. The mean age was 57.9 ± 12.9 years 83% were male, and 55.3% and 35.3% were of Asian and European descent respectively. Of 168 patient with available data, 146 (87%) had cirrhosis versus 22 (13%) without. Patients with cirrhosis tended to be older (median 60 vs 52 years, P = 0.078). Asian patients were more likely to have HCC without cirrhosis than Europeans (17% vs 6%, P = 0.04). There were no other differences identified between cirrhotic and non-cirrhotic patients. Thirty-four per cent of patients had tumours greater than 5 cm at diagnosis, and 47% were diagnosed after presenting with symptoms. Twelve patients with HBV-HCC were outside current screening guidelines. Most patients in Melbourne with HBV-associated HCC have cirrhosis. HCC characteristics in non-cirrhotic and cirrhotic patients were similar. The large number of patients detected through symptoms and with large tumours reinforces the need for vigilance in screening.
Publisher: Wiley
Date: 24-09-2020
Publisher: JMIR Publications Inc.
Date: 05-10-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2012
DOI: 10.1161/CIRCEP.112.972208
Abstract: Catheter–tissue contact is critical for effective lesion creation. We characterized the contact force (CF) at different anatomic sites during antral pulmonary vein (PV) isolation for atrial fibrillation. Two experienced operators performed PV isolation in 22 patients facilitated by a novel CF-sensing ablation catheter in a blinded fashion. Average CF and force-time integral data from 1602 lesions were analyzed. The left and right PV antra were ided into the following: carina, superior, inferior, anterior, and posterior quadrants for analysis. There was significant variability in CF within and between different PV quadrants ( P .05). Lowest CF of all left PV sites was at the carina and anterior quadrant, whereas highest CF was at the superior and inferior quadrants ( P .05). Lowest CF of all right PV sites was at the carina, whereas highest CF was at the anterior and inferior quadrants ( P .05). When comparing similar PV quadrants on the left versus right (eg, left carina versus right carina), CF was always higher in the right PVs ( P .05), except at the superior quadrant where CF was similar in the left and right PVs ( P =0.19). There was no specific pattern of anatomic distribution of excess CF ( P =0.39). Monitoring of catheter–tissue CF during PV isolation demonstrates significant variability in CF within and between different PV antral sites. Sites of lowest CF were the carina and anterior left PVs and the carina of the right PVs. This information may be important for improving ablation efficacy and clinical outcomes during PV isolation.
Publisher: Springer Science and Business Media LLC
Date: 16-01-2017
DOI: 10.1007/S00256-016-2564-7
Abstract: Calf muscle strains have become increasingly prevalent in recent seasons of the Australian Football League (AFL) and represent a significant cause of time lost from competition. The purpose of this study was to examine the association between MRI features of calf muscle strains and games missed and to thereby identify parameters that are of prognostic value. A retrospective analysis of MRI scans of AFL players with calf strains referred to a musculoskeletal radiology clinic over a 5-year period (2008-2012) was performed. The muscle(s) and muscle component affected, the site and size of strain, and the presence of an intramuscular tendon tear or intermuscular fluid were recorded. These data were cross-referenced with whether a player missed at least one game. Imaging features of prognostic value were thus identified. Sixty-three athletes had MRI scans for calf muscle strains. Soleus strains were more common than strains of other muscles. Players with soleus strains were more likely to miss at least one game if they had multiple muscle involvement (p = 0.017), musculotendinous junction strains (p = 0.046), and deep strains (p = 0.036). In a combined analysis of gastrocnemius and soleus strains, intramuscular tendon tears were observed in a significantly greater proportion of players who missed games (p = 0.010). Amongst AFL players with calf injuries, there is an association between missing at least one game and multiple muscle involvement, musculotendinous junction strains, deep strain location, and intramuscular tendon tears. In this setting, MRI may therefore provide prognostic information to help guide return-to-play decisions.
Publisher: Elsevier BV
Date: 09-2013
DOI: 10.1016/J.HLC.2013.02.002
Abstract: To report on two-year cardiovascular (CV) event rates and quantify the cost of cardiovascular disease using the Australian Reduction of Atherothrombosis for Continued Health (REACH) registry. Prospective registry of 2873 patients with multiple risk factors (MRF), coronary artery disease (CAD), cerebrovascular disease (CerVD) and peripheral artery disease (PAD), recruited through 273 Australian general practitioners. Government reimbursement data from 2011 was used to calculate direct health care costs (pharmaceuticals, outpatient and hospitalisation costs). The main outcome of interest was two-year rates and associated excess costs of cardiovascular death, myocardial infarction, stroke, and hospitalisation for cardiovascular procedures. The two year follow-up data were available for 2856 (99.4%) patients. Incidence of any hospitalisation and cardiovascular death was highest among those with previous history of PAD at baseline 49% (n=126), and 5.1% (n=13). Non-fatal cardiovascular events were highest among the PAD and CAD groups (21.8% (n=56) and 14.1% (n=297) respectively). Those with previous history of PAD and CerVD at baseline had the highest likelihood of CV death (OR=2.53 (95% CI: 1.58-4.08) and OR=1.61 (1.05-2.46) respectively) in comparison to other groups. Patients with PAD had the highest likelihood of vascular interventions OR=3.11 (95% CI: 2.09-4.63) at two years. Overall, the mean (SD) direct expenditure over two years of follow-up per person was A$7544 (A$10,758). In the adjusted model, patients with CAD and PAD incurred A$1093 (95% CI A$24 - A$2072) and A$4890 (95% CI A$3105 - A$6869) more in mean total costs compared to patients with MRF. Patients with PAD had the highest likelihood of vascular interventions and CV death, and incurred high excess costs in comparison to other groups.
Publisher: Elsevier BV
Date: 12-2016
DOI: 10.1016/J.JVAL.2016.05.013
Abstract: The aim of this study was to evaluate the cost-effectiveness of nivolumab versus ipilimumab for the treatment of previously untreated patients with BRAF-advanced melanoma (BRAF-AM) from an Australian health system perspective. A state-transition Markov model was constructed to simulate the progress of Australian patients with BRAF-AM. The model had a 10-year time horizon with outcomes discounted at 5% annually. For the nivolumab group, risks of progression and death were based on those observed in the nivolumab arm of a phase III trial (nivolumab vs. dacarbazine). Progression-free survival and overall survival were extrapolated using parametric survival modeling with a log-logistic distribution. In the absence of head-to-head evidence, overall survival and progression-free survival for ipilimumab were estimated on the basis of an indirect comparison using published data. Costs of managing AM were estimated from a survey of Australian clinicians. The cost of ipilimumab was based on the reimbursement price in Australia. The cost of nivolumab was based on expected reimbursement prices in Australia. Quality-of-life data were obtained within the trial using the EuroQol five-dimensional questionnaire. Compared with ipilimumab, nivolumab therapy over 10 years was estimated to yield 1.58 life-years and 1.30 quality-adjusted life-years per person, at a (discounted) net cost of US $39,039 per person. The incremental cost-effectiveness ratios for nivolumab compared with ipilimumab were US $25,101 per year of life saved and $30,475 per quality-adjusted life-year saved. Nivolumab is a cost-effective means of preventing downstream mortality and morbidity in patients with AM compared with ipilimumab in the Australian setting.
Publisher: Springer Science and Business Media LLC
Date: 02-08-2015
Publisher: Wiley
Date: 05-06-2014
DOI: 10.1111/EPI.12662
Abstract: The isocitrate dehydrogenase 1 (IDH1) R132H mutation is the most common mutation in World Health Organization (WHO) grade II gliomas, reported to be expressed in 70-80%, but only 5-10% of high grade gliomas. Low grade tumors, especially the protoplasmic subtype, have the highest incidence of tumor associated epilepsy (TAE). The IDH1 mutation leads to the accumulation of 2-hydroxyglutarate (2HG), a metabolite that bears a close structural similarity to glutamate, an excitatory neurotransmitter that has been implicated in the pathogenesis of TAE. We hypothesized that expression of mutated IDH1 may play a role in the pathogenesis of TAE in low grade gliomas. Thirty consecutive patients with WHO grade II gliomas were analyzed for the presence of the IDH1-R132H mutation using immunohistochemistry. The expression of IDH1 mutation was semiquantified using open-source biologic-imaging analysis software. The percentage of cells positive for the IDH1-R132H mutation was found to be higher in patients with TAE compared to those without TAE (median and interquartile range (IQR) 25.3% [8.6-53.5] vs. 5.2% [0.6-13.4], p = 0.03). In addition, we found a significantly higher median IDH1 mutation expression level in the protoplasmic subtype of low grade glioma (52.2% [IQR 19.9-58.6] vs. 13.8% [IQR 3.9-29.4], p = 0.04). Increased expression of the IDH1-R132H mutation is associated with seizures in low grade gliomas and also with the protoplasmic subtype. This supports the hypothesis that this mutation may play a role in the pathogenesis of both TAE and low grade gliomas.
Publisher: Elsevier BV
Date: 03-2016
DOI: 10.1016/J.JCV.2015.11.018
Abstract: Australian guidelines for cervical cancer screening are being revised under the "renewal program". Physicians' willingness to accept these changes will play a pivotal role in its success. To understand the willingness and acceptance of, as well as barriers and facilitators for Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) affiliates to screening using human papillomavirus (HPV) testing, starting at 25 years of age, every 5 years. An electronic survey of RANZCOG affiliates was undertaken April-June 2014, while renew was announced April 28th 2014. Responses used a 7 point Likert scale, which was dichotomized as ≤4, indicating 'unwilling' and >4, indicating 'willing' to adopt revised practices. Response rate was 22% (n=956): 60% were obstetricians and gynaecologists (OG) 27% general practitioner diplomates 13% OG trainees. Overall, 60% (n=526/874) were willing to revise their screening practice. This correlated with awareness of new guidelines (p=<0.001). Fifty percent (n=438/869) of respondents were concerned about delaying to 25 years, and 48% (n=421/869) concerned cervical cancers would be missed. Reasons respondents gave for wishing to continue screening from 18 years contrary to guidelines included: women not being vaccinated (65.6%), immunosuppressed women (92.2%) and women who had been victims of childhood sexual assault (73.9%). The majority of RANZCOG affiliates were willing to change screening practice however, a number of barriers to delaying onset of screening age to age 25 years were reported. Effective change management strategies will need to be implemented to address the concerns raised to ensure best practice for cervical screening.
Publisher: Informa UK Limited
Date: 07-11-2015
DOI: 10.3109/00365513.2015.1099722
Abstract: Tumor associated macrophages are present in hepatocellular carcinoma (HCC) and associated with a poor prognosis. The aim of the present study was to investigate the levels and dynamics of soluble (s)CD163, a specific macrophage activation marker, in patients with HCC. In a cohort from Australia, we studied 109 HCC patients, 116 patients with chronic liver disease (CLD), and 52 healthy controls. We examined associations between baseline sCD163 and parameters of HCC severity as well as overall and progression-free survival. In a cohort of 42 Danish HCC patients, we measured sCD163 at baseline and 1, 4 and 12 weeks after ablative treatment. In the Australian cohort, median sCD163 was similarly increased in HCC (5.6[interquartile range 3.5-8.0] mg/L) and CLD (6.1[3.6-9.6] mg/L) patients as compared to controls (2.0[1.5-2.7] mg/L, p < 0.001). sCD163 correlated with Child-Pugh and MELD scores in both HCC and CLD patients. Patients with high sCD163 levels had shorter progression-free survival (p < 0.001), but not overall survival (p = 0.15). In the Danish cohort, patients with HCC progression at 12 weeks had an increase in sCD163. There was no association between sCD163 and HCC size, number, vascular invasion or metastasis in any of the cohorts. We confirmed increased sCD163 levels in CLD and HCC patients associated with Child-Pugh and MELD scores and portal hypertension, but not with HCC size and number, or metastasis. As a novel finding, baseline sCD163 appeared to predict a rapid HCC progression, as sCD163 increased during follow-up in HCC patients who showed progression.
Publisher: BMJ
Date: 26-02-2013
Publisher: BMJ
Date: 03-01-2013
DOI: 10.1136/BMJSPCARE-2012-000331
Abstract: To investigate factors associated with referral of patients from an Australian stroke care unit (SCU) to an inpatient palliative care service (PCS). This retrospective observational cohort study included patients who were referred to the PCS after SCU admission between 1 January and 31 December 2008. Variables measured included patient demographics, premorbid functional status, premorbid living situation, stroke type, history of previous stroke and discharge outcomes. Group differences between all SCU patients seen and not seen by the PCS were compared using univariate analyses. Multivariate logistic regression analysis was undertaken to identify factors associated with PCS involvement. Group differences were also compared between deceased stroke patients seen and not seen by the PCS. 544 patients were admitted to the SCU during the study period with 62 (11.4%) referred to the PCS. Assistance with end-of-life care was the commonest reason for referral. From univariate analyses, factors significantly associated with PCS involvement included age, gender, premorbid modified Rankin score, living situation prior to stroke and stroke type. Factors predicting PCS involvement for SCU patients from logistic regression were: increasing age, higher premorbid modified Rankin score and haemorrhagic stroke. 87 (16.0%) SCU patients died during their admission, with 49 (56.3%) seen by PCS. Deceased patients seen were significantly older, more disabled premorbidly and lived significantly longer. This study indicates there are patient and condition-level factors associated with referral of stroke patients to PCS. It highlights factors that might better stratify hospitalised stroke patients to timely palliative care involvement, and adds an Australian perspective to limited data addressing this patient population.
Publisher: Elsevier BV
Date: 03-2011
DOI: 10.1016/J.CLINRE.2010.11.002
Abstract: Type 2 diabetes (T2DM) is associated with liver inflammation and carcinogenesis. The prevalence of T2DM among patients with liver cirrhosis and hepatocellular carcinoma is increasing. However, the effect of T2DM on the natural history of hepatocellular carcinoma is not known. To examine the effect of T2DM on hepatocellular carcinoma (HCC) survival in treated and untreated disease. Retrospective analysis was performed on HCC cases diagnosed during 2000-2005, and prospectively during 2006-August 2007. Demographics, HCC staging, response to treatment, and survival were collected. A comparison was made between patients with T2DM and without T2DM. One hundred and thirty-five patients were recruited in total 58 (43%) had T2DM. Seventy (37 diabetic) patients were treated with percutaneous radiological therapies, with 168 treatments given. Treatment was determined by AASLD guidelines and patient tolerance, there was no randomisation. There was no significant difference in survival between diabetic and nondiabetic patients. There was a nonsignificant trend towards greater survival in diabetic patients (overall median survival diabetics 21 mths vs nondiabetics 5 mths, P=0.355). T2DM does not negatively impact on the natural history of treated or untreated HCC.
Publisher: Elsevier BV
Date: 03-2016
DOI: 10.1016/J.JCV.2015.10.026
Abstract: Revised Australian guidelines have been announced under the Renew(®) program to commence screening at 25 years of age with HPV testing in 5-yearly intervals, in 2017. We conducted a study of young Victorian women to assess attitudes towards a change in cervical screening practice. An online survey was conducted of young women aged 16-28 years enrolled in the Young Female Health Initiative (YFHI) study at the Royal Women's Hospital, Melbourne, to assess attitudes towards delaying the age of cervical screening, widening screening intervals and screening with HPV DNA testing, prior to the announcement of the renewal. Of 149 respondents (response rate 75%), mean age was 23.2 (range 16-27) years. Most (85/131, 65%) were concerned about delaying the age of cervical screening until 25 years. The majority (79% (106/135) were willing to undertake primary screening with HPV testing, whilst 66% (88/133) were willing to undertake HPV testing from 25 years, only 34% (45/132) were willing to undertake such screening every five years. Those willing to change screening practice were more likely to perceive that people important to them would expect them to do so to have been vaccinated and to value the importance of national guidelines (p≤0.05). While 69% (95/136) of participants indicated that a positive HPV test would be a source of worry, 76% (103/136) reported they would not feel ashamed about it. Targeted health c aigns are needed to address the concerns of young women prior to the introduction of new cervical screening guidelines in 2017.
Publisher: Springer Science and Business Media LLC
Date: 21-04-2022
DOI: 10.1038/S41598-022-10529-W
Abstract: Over the last century, many shark populations have declined, primarily due to overexploitation in commercial, artisanal and recreational fisheries. In addition, in some locations the use of shark control programs also has had an impact on shark numbers. Still, there is a general perception that populations of large ocean predators cover wide areas and therefore their ersity is less susceptible to local anthropogenic disturbance. Here we report on temporal genomic analyses of tiger shark ( Galeocerdo cuvier ) DNA s les that were collected from eastern Australia over the past century. Using Single Nucleotide Polymorphism (SNP) loci, we documented a significant change in genetic composition of tiger sharks born between ~1939 and 2015. The change was most likely due to a shift over time in the relative contribution of two well-differentiated, but hitherto cryptic populations. Our data strongly indicate a dramatic shift in the relative contribution of these two populations to the overall tiger shark abundance on the east coast of Australia, possibly associated with differences in direct or indirect exploitation rates.
Publisher: Wiley
Date: 04-2017
DOI: 10.1111/IMJ.13382
Abstract: Current international clinical practice guidelines do not adequately address all clinical scenarios in the management of venous thromboembolism (VTE), and no comprehensive Australian guidelines exist. To identify areas of uncertainty in VTE management and whether self-reported practice is consistent with guidelines. We conducted an Australian cross-sectional online survey consisting of 53 questions to investigate doctors' VTE management practices. The survey was distributed to consultant and trainee/registrar haematologists and respiratory physicians with the aid of participating medical societies. A total of 71 haematologists and 110 respiratory physicians responded to the survey. The majority of survey respondents were 31-50-years old and worked in teaching hospitals and in the acute care setting. Under-treatment was reported for high-risk pulmonary embolism (PE) and duration of anticoagulation for first-episode unprovoked PE (32 and 83% respectively). Over-treatment was reported in areas of thrombolysis for intermediate-risk PE (16%) and duration of anticoagulation for first-episode provoked PE (41%). Uncertainty and variations in doctors' management approaches were also found. This survey demonstrated significant over-treatment, under-treatment and variability in the practice of VTE management. The findings highlight the need for the development and implementation of national guidelines for the management of VTE in Australia.
Publisher: Elsevier BV
Date: 11-2015
Publisher: Wiley
Date: 06-2009
DOI: 10.1111/J.1445-5994.2009.01913.X
Abstract: There are delays in implementing evidence about effective therapy into clinical practice. Clinical indicators may support implementation of guideline recommendations. To develop and evaluate the short-term impact of a clinical indicator set for general medicine. A set of clinical process indicators was developed using a structured process. The indicator set was implemented between January 2006 and December 2006, using strategies based on evidence about effectiveness and local contextual factors. Evaluation included a structured survey of general medical staff to assess awareness and attitudes towards the programme and qualitative assessment of barriers to implementation. Impact on documentation of adherence to clinical indicators was assessed by auditing a random s le of medical records before (2003-2005) and after (2006) implementation. Clinical indicators were developed for the following areas: venous thromboembolism, cognition, chronic heart failure, chronic obstructive pulmonary disease, diabetes, low trauma fracture, patient written care plans. The programme was well supported and incurred little burden to staff. Implementation occurred largely as planned however, documentation of adherence to clinical indicators was variable. There was a generally positive trend over time, but for most indicators this was independent of the implementation process and may have been influenced by other system improvement activities. Failure to demonstrate a significant impact during the pilot phase is likely to have been influenced by administrative factors, especially lack of an integrative data documentation and collection process. Successful implementation in phase two is likely to depend upon an effective data collection system integrated into usual care.
Publisher: Wiley
Date: 23-07-2012
Publisher: University of Chicago Press
Date: 04-2023
DOI: 10.1086/723405
Publisher: BMJ
Date: 08-03-2017
DOI: 10.1136/BMJ.J783
Publisher: Wiley
Date: 27-10-2018
DOI: 10.1111/ANS.13833
Abstract: Thyroid nodules are a common presenting complaint for endocrine surgeons many require ultrasound-guided fine-needle aspiration cytology (US-FNAC). In an attempt to streamline our service, we introduced same-day surgeon-performed US-FNAC in 2014. Three groups were defined: (A) retrospective group with FNAC performed in radiology prior to August 2014 (B) prospective radiology FNAC group and (C) prospective surgeon-performed group. Demographics, nodule characteristics, pathology and management plans were recorded. The number and dates of hospital attendances were extracted from the patient information system. Over 4 years, 635 patients underwent 757 FNACs. There were 438 patients in group A, 78 in group B and 119 in group C. Patient demographics and nodule size were similar between groups. Those patients undergoing FNAC in endocrine surgery clinic required two visits prior to receiving a diagnosis and management plan, compared with three visits for those performed in radiology. Non-diagnostic rates between three groups were 6.5%, 7.4% and 5.4% (P = 0.842) whilst malignant FNAC results occurred in 3%, 4% and 8% (P = 0.015) respectively. Median time from US-FNAC to definitive management plan was 42, 41 and 14 days (P < 0.001). The introduction of the one-stop clinic resulted in a 41% reduction of patients attending the radiology department for FNAC. Surgeon-performed US-FNAC decreases the time from fine-needle aspiration request to definitive plan and reduces the number of patient visits, providing more efficient care. Patients referred to the endocrine surgery clinic with thyroid nodules have thyroid cancer more frequently than patients referred to radiology.
Publisher: American Medical Association (AMA)
Date: 12-2012
DOI: 10.1001/ARCHNEUROL.2012.2203
Abstract: OBJECTIVE To determine whether patients who fail their first antiepileptic drug (AED) have better neuropsychiatric and quality-of-life (QOL) outcomes if substituted to levetiracetam monotherapy compared with a second older AED. DESIGN Randomized comparative trial. Participants with partial epilepsy who had failed monotherapy with phenytoin sodium, carbamazepine, or valproate sodium were randomized to substitution monotherapy with levetiracetam or a different older AED. Assessments were performed at baseline, 3 months, and 12 months using questionnaires measuring neuropsychiatric, QOL, seizure control, AED adverse effects, and neurocognitive outcomes. SETTING Epilepsy service of a teaching hospital. PATIENTS Fifty-one patients were randomized to levetiracetam and 48 were randomized to a second older AED (25 to valproate and 23 to carbamazepine). MAIN OUTCOME MEASURES Proportions showing improvements in depression (on the Hospital Anxiety and Depression Scale) and QOL scores (on the 89-item Quality of Life in Epilepsy Inventory) at 3 months. RESULTS There were no differences between the groups in depression scores at 3 months (improvement in 17 of 43 patients [39.5%] in the levetiracetam group and 15 of 44 patients [34.1%] in the older AED group P = .60), but a greater proportion of the older AED group improved on the 89-item Quality of Life in Epilepsy Inventory compared with the levetiracetam group (27 of 38 patients [71.1%] vs 21 of 43 patients [48.8%], respectively P = .04). The QOL, anxiety, and AED adverse effects scores were improved in both groups at 3 and 12 months after randomization. CONCLUSIONS Substitution monotherapy in a patient experiencing ongoing seizures or tolerability issues is associated with sustained improvements in measures of QOL, psychiatric, and adverse events outcomes. Patients switched to levetiracetam do not have better outcomes than those switched to a second older AED. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12606000102572.
Publisher: Wiley
Date: 24-07-2016
DOI: 10.1111/ANS.13238
Abstract: The acute surgical unit (ASU) is a recently established model of care in Australasia and worldwide. Limited data are available regarding its effect on the management of small bowel obstruction. We compared the management of small bowel obstruction before and after introduction of ASU at a major tertiary referral centre. We hypothesized that introduction of ASU would correlate with improved patient outcomes. A retrospective review of prospectively maintained databases was performed over two separate 2-year periods, before and after the introduction of ASU. Data collected included demographics, co-morbidity status, use of water-soluble contrast agent and computed tomography. Outcome measures included surgical intervention, time to surgery, hospital length of stay, complications, 30-day readmissions, use of total parenteral nutrition, intensive care unit admissions and overall mortality. Total emergency admissions to the ASU increased from 2640 to 4575 between the two time periods. A total of 481 cases were identified (225 prior and 256 after introduction of ASU). Mortality decreased from 5.8% to 2.0% (P = 0.03), which remained significant after controlling for confounders with multivariate analysis (odds ratio = 0.24, 95% confidence interval 0.08-0.73, P = 0.012). The proportion of surgically managed patients increased (20.9% versus 32.0%, P = 0.003) and more operations were performed within 5 days from presentation (76.6% versus 91.5%, P = 0.02). Fewer patients received water-soluble contrast agent (27.1% versus 18.4%, P = 0.02), but more patients were investigated with a computed tomography (70.7% versus 79.7%, P = 0.02). The ASU model of care resulted in decreased mortality, shorter time to intervention and increased surgical management. Overall complications rate and length of stay did not change.
Publisher: Cold Spring Harbor Laboratory
Date: 05-10-2021
DOI: 10.1101/2021.10.04.459351
Abstract: A universal scaling relationship exists between organism abundance and body size 1,2 . Within ocean habitats this relationship deviates from that generally observed in terrestrial systems 2–4 , where marine macro-fauna display steeper size-abundance scaling than expected. This is indicative of a fundamental shift in food-web organization, yet a conclusive mechanism for this pattern has remained elusive. We demonstrate that while fishing has partially contributed to the reduced abundance of larger organisms, a larger effect comes from ocean turbulence: the energetic cost of movement within a turbulent environment induces additional biomass losses among the nekton. These results identify turbulence as a novel mechanism governing the marine size-abundance distribution, highlighting the complex interplay of biophysical forces that must be considered alongside anthropogenic impacts in processes governing marine ecosystems.
Publisher: SAGE Publications
Date: 17-11-2015
Abstract: Vitamin D deficiency has been associated with both poor bone health and mental ill-health. More recently, a number of studies have found in iduals with depressive symptoms tend to have reduced bone mineral density. To explore the interrelationships between vitamin D status, bone mineral density and mental-ill health we are assessing a range of clinical, behavioural and lifestyle factors in young women (Part A of the Safe-D study). Part A of the Safe-D study is a cross-sectional study aiming to recruit 468 young females aged 16-25 years living in Victoria, Australia, through Facebook advertising. Participants are required to complete an extensive, online questionnaire, wear an ultra-violet dosimeter for 14 consecutive days and attend a study site visit. Outcome measures include areal bone mineral measures at the lumbar spine, total hip and whole body, as well as soft tissue composition using dual energy x-ray absorptiometry. Trabecular and cortical volumetric bone density at the tibia is measured using peripheral quantitative computed tomography. Other tests include serum 25-hydroxyvitamin D, serum biochemistry and a range of health markers. Details of mood disorder/s and depressive and anxiety symptoms are obtained by self-report. Cutaneous melanin density is measured by spectrophotometry. The findings of this cross-sectional study will have implications for health promotion in young women and for clinical care of those with vitamin D deficiency and/or mental ill-health. Optimising both vitamin D status and mental health may protect against poor bone health and fractures in later life.
Publisher: Wiley
Date: 06-2010
DOI: 10.1111/J.1445-5994.2009.01960.X
Abstract: Osteoarthritis of the hip and knee is a highly prevalent chronic condition in Australia that commonly affects older people who have other comorbidities. We report the pilot implementation of a new chronic disease management osteoarthritis service, which was multidisciplinary, evidence-based, supported patient self-management and care coordination. A musculoskeletal coordinator role was pivotal to service redesign and osteoarthritis pathway implementation. Impact evaluation included: service utilization, patient and general practitioner service experience, a 'before and after' audit of clinician adherence to recommendations, and 3- and 6-month patient health outcomes (pain, physical function, patient and physician global health (Visual Analogue Scale), disability (Multi-Attribute Prioritisation Tool), Partners in Health Scale and body mass index). A total of 123 patients, median age of 66 years, were assessed. Documentation of osteoarthritis assessment and management improved for all parameters. At 3 months there were improvements in self-reported pain (P < 0.001), global function (P < 0.001), physician and patient reported global health (P < 0.001), Partners in Health Score (P < 0.001) and Hip and Knee Multi-Attribute Prioritisation Tool score (P < 0.014). Body mass index did not improve. Patients and general practitioners reported positive experiences, but there was variable uptake of recommendations by patients. The main factors influencing uptake of recommendations were access block to community services in the first 3 months and patient preferences for therapy. The cost implications for implementation were low. The osteoarthritis service model is feasible to implement, is well received by patients and staff, and provides a template for translation into other settings.
Publisher: Elsevier BV
Date: 03-2014
DOI: 10.1016/J.ORCP.2013.03.007
Abstract: Excessive body weight is increasingly seen in type 1 diabetes but its impact is debated. To address this uncertainty, we aimed to determine the association between excess body weight and the macro- and microvascular complications of type 1 diabetes. We identified 501 adults with type 1 diabetes attending an Australian hospital clinic and extracted their clinical and biochemical data from our patient management database. In both men and women, obesity (BMI > 30 kg/m(2)) was the predominant risk factor for retinopathy and cardiovascular disease despite similar HbA1c and increased use of cardioprotective drugs compared to non-obese patients. Obesity was associated with albuminuria in women, but not renal impairment or neuropathy in either sex. We conclude that obesity in type 1 diabetes may promote retinopathy and macrovascular disease. Future trials to determine the effect of weight loss on type 1 diabetes in obese people are needed.
Publisher: Medical Journals Sweden AB
Date: 2011
Abstract: To assess the effectiveness of a high- vs low--intensity multidisciplinary ambulatory rehabilitation programme over 12 months for persons in the chronic phase after Guillain-Barré syndrome (pwGBS) in an Australian community cohort. A total of 79 pwGBS, recruited from a tertiary hospital, were randomized to a treatment group (n = 40) for an in idualized high-intensity programme, or a control group (n = 39) for a lower intensity programme. The primary outcome the Functional Independence Measure (FIM) motor subscale assessed "activity limitation" while secondary measures for "participation" included: World Health Organization Quality of Life Depression, Anxiety Stress Scale and Perceived Impact Problem Profile (PIPP) scales. All outcome measures were assessed at baseline and at 12 months. Intention to treat analysis of data from 69 participants (treatment n = 35, control n = 34) showed reduced disability in the treatment group in post-treatment FIM domains (mobility, transfers, sphincter control and locomotion all p < 0.005) and PIPP scores (relationships p = 0.011), with moderate-to-small effect sizes (r = 0.36-0.23). The treatment group compared with control group showed significant improvement in function (FIM scores): 68% vs 32%. Higher intensity rehabilitation compared with less intense intervention reduces disability in pwGBS in later stages of recovery. Further information on rehabilitation modalities and impact on quality of life is needed.
Publisher: Oxford University Press (OUP)
Date: 22-10-2015
DOI: 10.1002/BJS.9954
Abstract: Patients presenting with emergency surgical conditions place significant demands on healthcare services globally. The need to improve emergency surgical care has led to establishment of consultant-led emergency surgery units. The aim of this study was to determine the effect of a changed model of service on outcomes. A retrospective observational study of all consecutive emergency general surgical admissions in 2009–2012 was performed. A 2-year time frame before and after the establishment of the emergency general surgery (EGS) service was used to determine the number of admissions and operations, emergency department and hospital length of stay, as well as complication rates. The study included 7233 acute admissions. The EGS service managed 4468 patients (61·6 per cent increase) and performed 1804 operations (41·0 per cent increase). The most common diagnoses during the EGS period included acute appendicitis (532, 11·9 per cent), biliary disease (361, 8·1 per cent) and abdominal pain (561, 12·6 per cent). Appendicectomy (536, 29·7 per cent), cholecystectomy (239, 13·2 per cent) and laparotomy (226, 12·5 per cent) were the most commonly performed procedures. In the EGS period, time in the emergency department was reduced (from 8·0 to 6·0 h P & 0·001), as was length of hospital stay (from 3·0 to 2·0 days P & 0·001). The number of complications was reduced by 46·8 per cent, from 172 (6·2 per cent) to 147 (3·3 per cent) (P & 0·001), with a 53 per cent reduction in the number of deaths in the EGS period, from 29 (16·9 per cent) to seven (8 per cent) (P = 0·039). The establishment of a consultant-led emergency surgical service has been associated with improved provision of care, resulting in timely management and improved clinical outcomes.
Publisher: Elsevier BV
Date: 2018
DOI: 10.1016/J.JOCD.2017.02.003
Abstract: Dual-energy X-ray absorptiometry (DXA) as currently used has limitations in identifying patients with osteoporosis and predicting occurrence of fracture. We aimed to express peripheral quantitative computed tomography (pQCT) variables of patients with low-trauma fracture as T-scores by using T-score scales obtained from healthy young women, and to evaluate the potential clinical utility of pQCT for the assessment of bone fragility. Fracture patients were recruited from a fracture liaison service at the Royal Melbourne Hospital. Reference pQCT data were obtained from studies on women's health conducted by our group. A study visit was arranged with fracture patients, during which DXA and pQCT were applied to measure their bone strength. A total of 59 fracture patients were recruited, and reference data were obtained from 78 healthy young females. All DXA variables and most pQCT variables were significantly different between healthy young females and fracture patients (p < 0.05), except polar stress-strain index (p = 0.34) and cortical bone density (p = 0.19). Fracture patients were ided into osteoporosis and non-osteoporosis groups according to their DXA T-scores. Significant differences were observed in most pQCT variables (p 0.9 and p = 0.5, respectively). By applying pQCT T-scores, 11 (27%) of patients who were classified as having low or medium risk of osteoporosis on DXA T-scores alone were reclassified as high risk. Results of logistic regression suggested trabecular bone density as an independent predictor of osteoporosis status. More patients can be identified with osteoporosis by applying pQCT T-score variables in older people with low-trauma fracture. Peripheral QCT T-scores contribute to the understanding of bone fragility in this population.
Publisher: Springer Science and Business Media LLC
Date: 22-08-2015
DOI: 10.1007/S00268-015-3196-0
Abstract: Since 2011, all acute general surgical admissions have been managed by the consultant-led emergency general surgery service (EGS) at our institution. We aim to compare EGS management of acute biliary disease to its preceding model. Retrospective review of prospectively collated databases was performed to capture consecutive emergency admissions with biliary disease from 1st February 2009 to 31st January 2013. Patient demographics, surgical intervention, use of diagnostic radiology, histological diagnosis, complications and hospital length of stay (LOS) were retrieved. A total of 566 patients were included (pre-EGS 254 vs. EGS 312). In the EGS period, the number of patients having surgery on index admission increased from 43.7 to 58.7 % (p < 0.001) as did use of intra-operative cholangiography from 75.7 to 89.6 % (p = 0.003). The conversion to open cholecystectomy rate also was reduced from 14.4 to 3.3 % (p 1) imaging modalities for diagnosis was noted (p = 0.003). There was a positive trend in reduction of bile leaks but no significant difference in the overall morbidity and mortality. Time to theatre was reduced by 1 day [pre-EGS 2.7 (IQR 1.5-5.0) vs. EGS 1.7 (IQR 1.2-2.6) p < 0.001]. The overall hospital LOS was reduced by 1.5 days [pre-EGS 5.0 (IQR 3-7) vs. EGS 3.5 (IQR 2-5) p < 0.001]. Since the advent of EGS, more judicious use of diagnostic radiology, reduced complications, reduced LOS, reduced time to theatre and an increased rate of definitive management during the index admission were demonstrated.
Publisher: BMJ
Date: 12-03-2013
DOI: 10.1136/BMJSPCARE-2012-000386
Abstract: Frailty denotes a vulnerability to poor outcomes and is a common risk factor for mortality in older persons. The Vulnerable Elders Survey (VES) is an easy to administer validated screening tool to detect a frail population. Assessment of frailty has the potential to aid in prognostication for the older community dwelling palliative population. This study seeks to evaluate the relationship of the VES to prognosis in this population. Prospective cohort study of patients over 65 years old admitted to a community palliative care service. The VES was performed in addition to the usual assessments of physical function. Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Physical function and CCI were assessed to determine whether they improved the prognostic power of the VES. Patients were followed-up for 8 months with the primary endpoint of survival. 197 patients completed the study with a high proportion of malignant diagnoses (87.5%) 98% of patients died during the study with a median survival of 61 days 93.4% of patients were vulnerable on the VES and high risk scores predicted death within 100 days. In this study the VES demonstrated high rates of vulnerability and has the potential to improve the accuracy of prognosis in older palliative community dwelling patients. Improving prognostication has potential clinical benefits, including aiding clinical communication and determining the best use of community services. The limitations of this study and the evolving understanding of frailty suggest that further work in this area is required.
Publisher: Informa UK Limited
Date: 03-03-2016
DOI: 10.3109/14767058.2016.1149564
Abstract: We compared the efficacy of Carbetocin (long-acting oxytocin receptor agonist) versus Oxytocin given at non-elective caesarean section. We performed a double-blind, randomised, single-centre study. Eligible women were ≥37 weeks of gestation undergoing emergency caesarean section. Participants received either carbetocin of 100 μg or oxytocin 5 international units. The primary outcome was the need to administer additional uterotonics, as determined by the clinician. Secondary outcomes included estimated blood loss, haemoglobin drop pre-post operation and the need for a blood transfusion Results: From August 2012 to February 2013, 114 women were enroled. Two were excluded from analysis as they received a general anaesthetic. Fifty-nine patients received 100-μg carbetocin 53 received 5 international units oxytocin. There was no statistically significant difference in the number of women requiring additional uterotonics between the two groups: Carbetocin group 22% and Oxytocin group 13% (p = 0.323). There were no significant differences in the fall in haemoglobin, estimated blood loss, rates of post-partum haemorrhage or blood transfusions. Oxytocin and carbetocin have similar requirements for additional uterotonics, estimated blood loss, haemoglobin drop and blood transfusions. There was a trend towards requiring additional uterotonics in patients receiving Carbetocin which was not statistically significant. This study found no benefits in using carbetocin over oxytocin.
Publisher: JMIR Publications Inc.
Date: 16-11-2017
Abstract: oor bone health in adolescent and young adult females is a growing concern. Given the widespread use of mobile phones in this population, mobile health (mHealth) interventions may help improve health behaviors related to bone health in young women. he goal of the study was to determine the acceptability and feasibility of an mHealth intervention called Tap4Bone in improving health behaviors associated with the risk of osteoporosis in young women. he Tap4Bone mHealth intervention comprised the use of mobile phone apps, short messaging service (text messaging), and Web emails to encourage health behavior changes. The education group received osteoporosis prevention education leaflets. Changes in the bone health–related behaviors exercise, smoking, and calcium intake were assessed. User experiences and acceptance of the app were collected through focus group interviews. total of 35 (22 completed, mean age 23.1 [SD 1.8] years) were randomized to either the mobile phone (intervention n=18) or education (control n=17) group. Although there were trends toward improvement in calcium intake, sports activity, and smoking behaviors in the mHealth intervention group compared to the education group, these were not statistically significant. he Tap4Bone mHealth intervention was shown to be acceptable and feasible in subsets of the participants. The intervention should be improved upon using participant feedback to improve functionality. Findings from this study may aid in the development and modification of health care apps to reduce participant attrition.
Publisher: Wiley
Date: 25-04-2017
DOI: 10.1002/GPS.4491
Abstract: To compare healthcare utilisation outcomes among older hospitalised patients with and without cognitive impairment, and to compare the costs associated with these outcomes. Retrospective cohort study of administrative data from a large teaching hospital in Melbourne, Australia from 1 July 2006 to 30 June 2012. People with cognitive impairment were defined as having dementia or delirium coded during the admission. Outcome measures included length of stay, unplanned readmissions within 28 days and costs associated with these outcomes. Regression analysis was used to compare differences between those with and without cognitive impairment. There were 93 300 hospital admissions included in the analysis. 6459 (6.9%) involved cognitively impaired patients. The adjusted median length of stay was significantly higher for the cognitively impaired group compared with the non-cognitively impaired group (7.4 days 6.7-10.0 vs 6.6 days, interquartile range 5.7-8.3 p < 0.001). There were no differences in odds of 28-day readmission. When only those discharged back to their usual residence were included in the analysis, the risk of 28-day readmission was significantly higher for those with cognitive impairment compared with those without. The cost of admissions involving patients with cognitive impairment was 51% higher than the cost of those without cognitive impairment. Hospitalised people with cognitive impairment experience significantly greater length of stay and when discharged to their usual residence are more likely to be readmitted to hospital within 28 days compared with those without cognitive impairment. The costs associated with hospital episodes and 28-day readmissions are significantly higher for those with cognitive impairment. Copyright © 2016 John Wiley & Sons, Ltd.
Publisher: Wiley
Date: 28-12-2012
DOI: 10.1111/J.1440-1797.2011.01507.X
Abstract: New onset diabetes after transplantation (NODAT) is a common adverse outcome of organ transplantation that increases the risk of cardiovascular disease, infection and graft rejection. In kidney transplantation, apart from traditional risk factors, autosomal dominant polycystic kidney disease (ADPKD) has also been reported by several authors as a predisposing factor to the development of NODAT, but any rationale for an association between ADPKD and NODAT is unclear. We examined the cumulative incidence of NODAT in or own transplant population comparing ADPKD patients with non-ADPKD controls. A retrospective cohort study to determine the cumulative incidence of patients developing NODAT (defined by World Health Organization-based criteria and/or use of hypoglycaemic medication) was conducted in 79 patients with ADPKD (79 transplants) and 423 non-ADPKD controls (426 transplants) selected from 613 sequential transplant recipients over 8 years. Patients with pre-existing diabetes as a primary disease or comorbidity and/or with minimal follow up or early graft loss/death were excluded. Of the 502 patients (505 transplants) studied, 86 (17.0%) developed NODAT. There was no significant difference in the cumulative incidence of NODAT in the ADPKD (16.5% CI 13.6-20.7%) compared with the non-ADPKD (17.1% CI 8.3-24.6%) control group. Of the 13 patients in the ADPKD group with NODAT, three required treatment with insulin with or without oral hypoglycaemic agents. Among the 73 NODAT patients in the non-ADPKD group, eight received insulin with or without oral hypoglycaemics. Furthermore, of the patients that did develop NODAT, there was no difference in the time to its development in patients with and without ADPKD. There was no evidence of an increased incidence of NODAT in ADPKD kidney transplant recipients.
Publisher: Wiley
Date: 09-2012
DOI: 10.1111/J.1445-5994.2012.02877.X
Abstract: Our ageing population creates challenges for palliative care, including accuracy of prognostication. This study highlights this by profiling the outcomes of an Australian, community-based palliative service over 6 months with collection of epidemiological, comorbidity and physical function data. Most patients had cancer, comorbidities and died during the study. Low scores on the Australian-modified Karnofsky Performance Scale and the presence of congestive cardiac failure were predictive of shorter survival.
Publisher: Elsevier BV
Date: 05-2015
DOI: 10.1053/J.GASTRO.2015.01.026
Abstract: Crohn's disease (CD) usually recurs after intestinal resection postoperative endoscopic monitoring and tailored treatment can reduce the chance of recurrence. We investigated whether monitoring levels of fecal calprotectin (FC) can substitute for endoscopic analysis of the mucosa. We analyzed data collected from 135 participants in a prospective, randomized, controlled trial, performed at 17 hospitals in Australia and 1 hospital in New Zealand, that assessed the ability of endoscopic evaluations and step-up treatment to prevent CD recurrence after surgery. Levels of FC, serum levels of C-reactive protein (CRP), and Crohn's disease activity index (CDAI) scores were measured before surgery and then at 6, 12, and 18 months after resection of all macroscopic Crohn's disease. Ileocolonoscopies were performed at 6 months after surgery in 90 patients and at 18 months after surgery in all patients. Levels of FC were measured in 319 s les from 135 patients. The median FC level decreased from 1347 μg/g before surgery to 166 μg/g at 6 months after surgery, but was higher in patients with disease recurrence (based on endoscopic analysis Rutgeerts score, ≥i2) than in patients in remission (275 vs 72 μg/g, respectively P < .001). Combined 6- and 18-month levels of FC correlated with the presence (r = 0.42 P < .001) and severity (r = 0.44 P < .001) of CD recurrence, but the CRP level and CDAI score did not. Levels of FC greater than 100 μg/g indicated endoscopic recurrence with 89% sensitivity and 58% specificity, and a negative predictive value (NPV) of 91% this means that colonoscopy could have been avoided in 47% of patients. Six months after surgery, FC levels less than 51 μg/g in patients in endoscopic remission predicted maintenance of remission (NPV, 79%). In patients with endoscopic recurrence at 6 months who stepped-up treatment, FC levels decreased from 324 μg/g at 6 months to 180 μg/g at 12 months and 109 μg/g at 18 months. In this analysis of data from a prospective clinical trial, FC measurement has sufficient sensitivity and NPV values to monitor for CD recurrence after intestinal resection. Its predictive value might be used to identify patients most likely to relapse. After treatment for recurrence, the FC level can be used to monitor response to treatment. It predicts which patients will have disease recurrence with greater accuracy than CRP level or CDAI score.
Publisher: Oxford University Press (OUP)
Date: 05-2016
Publisher: Wiley
Date: 28-01-2016
DOI: 10.1111/JGH.13148
Abstract: The glycoprotein CD147 has a role in tumor progression, is readily detectable in the circulation, and is abundantly expressed in hepatocellular carcinoma (HCC). Advanced HCC patients are a heterogeneous group with some in iduals having dismal survival. The aim of this study was to examine circulating soluble CD147 levels as a prognostic marker in HCC patients. CD147 was measured in 277 patients (110 HCC, 115 chronic liver disease, and 52 non-liver disease). Clinical data included etiology, tumor progression, Barcelona Clinic Liver Cancer (BCLC) stage, and treatment response. Patients with HCC were stratified into two groups based upon the 75th percentile of CD147 levels (24 ng/mL). CD147 in HCC correlated inversely with poor survival (P = 0.031). Increased CD147 predicted poor survival in BCLC stages C and D (P = 0.045), and CD147 levels >24 ng/mL predicted a significantly diminished 90-day and 180-day survival time (hazard ratio [HR] = 6.1 95% confidence interval [CI]: 2.1-63.2 P = 0.0045 and HR = 2.8 95% CI: 1.2-12.6 P = 0.028, respectively). In BCLC stage C, CD147 predicted prognosis levels >24 ng/mL were associated with a median survival of 1.5 months compared with 6.5 months with CD147 levels ≤24 ng/mL (P = 0.03). CD147 also identified patients with a poor prognosis independent from treatment frequency, modality, and tumor size. Circulating CD147 is an independent marker of survival in advanced HCC. CD147 requires further evaluation as a potential new prognostic measure in HCC to identify patients with advanced disease who have a poor prognosis.
Publisher: BMJ
Date: 09-2021
DOI: 10.1136/BMJOPEN-2021-055528
Abstract: General practice is integral to the Australian healthcare system. Outcome Health’s POpulation Level Analysis and Reporting (POLAR) database uses de-identified electronic health records to analyse general practice data in Australia. Previous studies using routinely collected health data for research have not consistently reported the codes and algorithms used to describe the population, exposures, interventions and outcomes in sufficient detail to allow replication. This paper reports a study protocol investigating patterns of care for people presenting with musculoskeletal conditions to general practice in Victoria, Australia. Its focus is on the systematic approach used to classify and select eligible records from the POLAR database to facilitate replication. This will be useful for other researchers using routinely collected health data for research. This is a retrospective cohort study. Patient-related data will be obtained through electronic health records from a subset of general practices across three primary health networks (PHN) in southeastern Victoria. Data for patients with a low back, neck, shoulder and/or knee condition and who received at least one general practitioner (GP) face-to-face consultation between 1 January 2014 and 31 December 2018 will be included. Data quality checks will be conducted to exclude patients with poor data recording and/or non-continuous follow-up. Relational data files with eligible and valid records will be merged to select the study cohort and the GP care received (consultations, imaging requests, prescriptions and referrals) between diagnosis and 31 December 2018. Number and characteristics of patients and GPs, and number, type and timing of imaging requests, prescriptions for pain relief and referrals to other health providers will be investigated. Ethics approval was obtained from the Cabrini and Monash University Human Research Ethics Committees (Reference Numbers 02-21-01-19 and 16975, respectively). Study findings will be reported to Outcome Health, participating PHNs, disseminated in academic journals and presented in conferences.
Publisher: Elsevier BV
Date: 11-2015
Publisher: Elsevier BV
Date: 05-2017
DOI: 10.1016/J.BBMT.2017.01.086
Abstract: Donor T cell chimerism is associated with relapse outcomes after allogeneic stem cell transplantation (alloSCT) for acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS). However, measures of statistical association do not adequately assess the performance of a prognostic biomarker, which is best characterized by its sensitivity and specificity for the chosen outcome. We analyzed donor T cell chimerism results at day 100 (D100chim) after myeloablative alloSCT for AML or MDS in 103 patients and determined its sensitivity and specificity for relapse-free survival at 6 months (RFS6) and 12 months (RFS12) post-alloSCT. The area under the receiver operating characteristic curve for RFS6 was .68, demonstrating only modest utility as a predictive biomarker, although this was greater than RFS12 at .62. Using a D100chim threshold of 65%, the specificity for RFS6 was 96.6% however, sensitivity was poor at 26.7%. This equated to a negative predictive value of 88.5% and positive predictive value of 57.1%. Changing the threshold for D100chim to 75% or 85% modestly improved the sensitivity of D100chim for RFS6 however, this was at the expense of specificity. D100chim is specific but lacks sensitivity as a prognostic biomarker of early RFS after myeloablative alloSCT for AML or MDS. Caution is required when using D100chim to guide treatment decisions including immunologic manipulation, which may expose patients to unwarranted graft-versus-host disease.
Publisher: Cambridge University Press (CUP)
Date: 05-11-2009
Publisher: Wiley
Date: 23-06-2022
Abstract: Recent studies suggest many patients with non‐specific low back pain presenting to public hospital EDs receive low‐value care. The primary aim was to describe management of patients presenting with low back pain to the ED of a private hospital in Melbourne, Australia, and received a final ED diagnosis of non‐specific low back pain. We also determined predictors of hospital admission. Retrospective review of patients who presented with low back pain and received a final ED diagnosis of non‐specific low back pain to Cabrini Malvern ED in 2015. Demographics, lumbar spinal imaging, pathology tests and medications were extracted from hospital records. Multivariate logistic regression was used to determine independent predictors of hospital admission. Four hundred and fifty presentations were included (60% female) 238 (52.9%) were admitted to hospital. One hundred and seventy‐seven (39.3%) patients received lumbar spine imaging. Two hundred and eighty (62.2%) patients had pathology tests and 391 (86.9%) received medications, which included opioids ( n = 298, 66.2%), paracetamol ( n = 219, 48.7%), NSAIDs ( n = 161, 35.8%), benzodiazepines ( n = 118, 26.2%) and pregabalin ( n = 26, 5.8%). Predictors of hospital admission included older age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.02–1.05), arrival by ambulance (OR 2.03, 95% CI 1.06–3.90) and receipt of pathology tests (OR 3.32, 95% CI 2.01–5.49) or computed tomography scans (OR 1.86, 95% CI 1.12–3.11). We observed high rates of imaging, pathology tests and hospital admissions compared with previous public hospital studies, while medication use was similar. Implementation of strategies to optimise evidence‐based ED care is needed to reduce low‐value care and improve patient outcomes.
Publisher: JMIR Publications Inc.
Date: 27-11-2019
DOI: 10.2196/14545
Abstract: Health care practitioners (HPs), in particular general practitioners (GPs), are increasingly adopting Web-based social media platforms for continuing professional development (CPD). As GPs are restricted by time, distance, and demanding workloads, a health virtual community of practice (HVCoP) is an ideal solution to replace face-to-face CPD with Web-based CPD. However, barriers such as time and work schedules may limit participation in an HVCoP. Furthermore, it is difficult to gauge whether GPs engage actively or passively in HVCoP knowledge-acquisition for Web-based CPD, as GPs’ competencies are usually measured with pre- and posttests. This study investigated a method for measuring the engagement features needed for an HVCoP (the Community Fracture Capture [CFC] Learning Hub) for learning and knowledge sharing among GPs for their CPD activity. A prototype CFC Learning Hub was developed using an Igloo Web-based social media software platform and involved a convenience s le of GPs interested in bone health topics. This Hub, a secure Web-based community site, included 2 key components: an online discussion forum and a knowledge repository (the Knowledge Hub). The discussion forum contained anonymized case studies (contributed by GP participants) and topical discussions (topics that were not case studies). Using 2 complementary tools (Google Analytics and Igloo Statistical Tool), we characterized in idual participating GPs’ engagement with the Hub. We measured the GP participants’ behavior by quantifying the number of online sessions of the participants, activities undertaken within these online sessions, written posts made per learning topic, and their time spent per topic. We calculated time spent in both active and passive engagement for each topic. Seven GPs participated in the CFC Learning Hub HVCoP from September to November 2017. The complementary tools successfully captured the GP participants’ engagement in the Hub. GPs were more active in topics in the discussion forum that had direct clinical application as opposed to didactic, evidence-based discussion topics (ie, topical discussions). From our knowledge hub, About Osteoporosis and Prevention were the most engaging topics, whereas shared decision making was the least active topic. We showcased a novel complementary analysis method that allowed us to quantify the CFC Learning Hub’s usage data into (1) sessions, (2) activities, (3) active or passive time spent, and (4) posts made to evaluate the potential engagement features needed for an HVCoP focused on GP participants’ CPD process. Our design and evaluation methods for ongoing use and engagement in this Hub may be useful to evaluate future learning and knowledge-sharing projects for GPs and may allow for extension to other HPs’ environments. However, owing to the limited number of GP participants in this study, we suggest that further research with a larger cohort should be performed to validate and extend these findings.
Publisher: Hindawi Limited
Date: 20-04-2016
DOI: 10.1111/TBJ.12595
Abstract: To examine practice patterns for breast cancer patients with limited sentinel node (SN) disease in light of the ACOSOG Z0011 results. Retrospective analysis of patients with T1-2 breast cancer and positive sentinel lymph node biopsy (SLNB) admitted between January 2009 and December 2012. Patient demographics, tumor characteristics, and treatments were recorded. Eight hundred positive SLNBs were identified. A total of 452 (56.5%) proceeded to completion axillary lymph node dissection (cALND). cALND rate decreased from 65.1% to 49.7% from 2009-2010 to 2011-2012. cALND was performed for micrometastasis or isolated tumor cells in 39.3% in 2009-2010 and 22.2% in 2011-2012, whereas for macrometastases the rates were 83.1% and 68.6%, respectively. cALND rates diminished for both Z0011-eligible and -ineligible patients. The ACOSOG Z0011 trial presentation and publication coincided with a reduction in cALND for breast cancer with limited nodal disease. There appears equipoise regarding management of macrometastatic SN disease.
Publisher: Wiley
Date: 29-10-2015
DOI: 10.1111/EPI.13136
Abstract: To investigate cross-sectional and longitudinal differences in static and dynamic standing balance measures and lower limb muscle strength in patients who are treated chronically with antiepileptic drugs (AEDs). Twenty-six AED exposure-discordant same-gender twin and sibling pairs were studied. Clinical and laboratory balance examinations were conducted twice, separated by at least 1 year. The mean within-pair differences in balance measures were calculated cross-sectionally at baseline and follow-up, and longitudinally. No significant mean within-pair difference was found at baseline in age (44 years), weight, and height (p > 0.05). Between study assessments, the median (interquartile range [IQR]) interval was 3.0 (2.1-4.3) years in users and 2.9 (2.0-4.4) years in nonusers. The median duration of AED therapy was 19 (11-21) years. At baseline and follow-up, cross-sectional sway measures from posturography (Chattecx Balance System) and clinical static balance tests showed poorer performance in users compared to nonusers on several test conditions (p = 0.002-0.032). At follow-up, the users took longer than nonusers to complete the Four-Square-Step Test (p = 0.005) and Five-Times-Sit-to-Stand Test (p = 0.018). A greater annual rate of deterioration in sway was found in users compared to nonusers using posturography on the anteroposterior tilting platform task with distraction (p = 0.032). In both groups, higher baseline sway predicted greater annual deterioration in sway in all platform conditions (β = 0.3-0.5, p < 0.001-0.013). The annual change in measures did not differ between groups in the clinical balance and lower limb strength assessments. In this longitudinal twin and sibling study, chronic AED users had poorer standing balance compared to nonusers. Users showed greater deterioration in postural sway with one dynamic platform condition. AEDs may progressively impair balance mechanisms, although this requires further investigations. Repeated dynamic posturography could provide a basis for preventive trials for maintaining or improving balance.
Publisher: BMJ
Date: 05-2023
DOI: 10.1136/BMJOPEN-2023-072248
Abstract: Consistent evidence shows pathology services are overused worldwide and that about one-third of testing is unnecessary. Audit and feedback (AF) is effective for improving care but few trials evaluating AF to reduce pathology test requesting in primary care have been conducted. The aim of this trial is to estimate the effectiveness of AF for reducing requests for commonly overused pathology test combinations by high-requesting Australian general practitioners (GPs) compared with no intervention control. A secondary aim is to evaluate which forms of AF are most effective. This is a factorial cluster randomised trial conducted in Australian general practice. It uses routinely collected Medicare Benefits Schedule data to identify the study population, apply eligibility criteria, generate the interventions and analyse outcomes. On 12 May 2022, all eligible GPs were simultaneously randomised to either no intervention control or to one of eight intervention groups. GPs allocated to an intervention group received in idualised AF on their rate of requesting of pathology test combinations compared with their GP peers. Three separate elements of the AF intervention will be evaluated when outcome data become available on 11 August 2023: (1) invitation to participate in continuing professional development-accredited education on appropriate pathology requesting, (2) provision of cost information on pathology test combinations and (3) format of feedback. The primary outcome is the overall rate of requesting of any of the displayed combinations of pathology tests of GPs over 6 months following intervention delivery. With 3371 clusters, assuming no interaction and similar effects for each intervention, we anticipate over 95% power to detect a difference of 4.4 requests in the mean rate of pathology test combination requests between the control and intervention groups. Ethics approval was received from the Bond University Human Research Ethics Committee (#JH03507 approved 30 November 2021). The results of this study will be published in a peer-reviewed journal and presented at conferences. Reporting will adhere to Consolidated Standards of Reporting Trials. ACTRN12622000566730.
Publisher: Wiley
Date: 04-07-2023
DOI: 10.1002/ACR.25189
Abstract: To examine imaging requested by general practitioners (GPs) for patients with low back, neck, shoulder and knee complaints over five years (2014‐2018). This analysis from the Australian POpulation Level Analysis Reporting (POLAR) database included patients presenting with a diagnosis of low back, neck, shoulder and/or knee complaints. Eligible imaging requests included low back and neck X‐ray, CT and MRI knee X‐ray, CT, MRI and ultrasound and shoulder X‐ray, MRI and ultrasound. We determined number of imaging requests and examined their timing, associated factors and trends over time. Primary analysis included imaging requests from two weeks before diagnosis to one‐year post‐diagnosis. There were 133,279 patients (57% low back, 25% knee, 20% shoulder and 11% neck complaints). Imaging was most common among those with a shoulder (49%), followed by knee (43%), neck (34%) and low back complaint (26%). Most requests occurred simultaneously with the diagnosis. Imaging modality varied by body region and to a lesser extent by gender, socioeconomic status and PHN. For low back, there was a 1.3% (95% CI 1.0 to 1.6) annual increase in proportion of MRI and concomitant 1.3% (95% CI 0.8 to 1.8) decrease in CT requests. For neck, there was a 3.0% (95% CI 2.1 to 3.9) annual increase in proportion of MRI and concomitant 3.1% (95% CI 2.2 to 4.0) decrease in X‐ray requests. GPs commonly request early diagnostic imaging for musculoskeletal complaints at odds with recommended practice. We observed a trend towards more complex imaging for neck and back complaints. This article is protected by copyright. All rights reserved.
Publisher: Elsevier BV
Date: 02-2014
DOI: 10.1016/J.HLC.2013.07.008
Abstract: This prospective cohort study aimed to assess LV recovery post aortic valve replacement, stratified according to pre-operative valve lesion (aortic stenosis (AS), mixed disease (AS/AR) or aortic regurgitation (AR)), as well as define predictors of persistent LV dilatation post operation. We prospectively followed all patients post Ross procedure performed between 1992 and 2009 by a single surgeon. Echocardiography was performed pre-operatively, at approximately one year post operation then second yearly thereafter. 265 patients were followed for a mean of 6.4 years (range 1-14 years, total 1702 patient-years). Seventy percent were male and mean age was 38.8 ± 12.6 years. The indication for surgery was AS in 44.5% (118), AS/AR in 23.4% (62), and AR in 32.1% (85). Overall mortality was 1.8% and 80% of deaths were non-cardiac. Morbidity was low and the need for pacing was less than 1%. Ninety-nine percent of patients were NYHA class 1 at one year follow up. The indexed LV end diastolic diameter (LVEDDi) decreased significantly post-operation in the AR (3.34 ± 0.39-2.66 ± 0.32 cm/m(2), p<0.001) and mixed (2.85 ± 0.38-2.65 ± 0.30 cm/m(2), p = 0.01) groups, whilst the indexed systolic LV dimension decreased significantly post-operation in the AR group (2.26 ± 0.34-1.87 ± 0.27, p 3.0 cm/m(2) and the presence of mild aortic regurgitation at one year post-operation. Pre-operative valve lesion was not a predictor. The only independent predictor of a lesser reduction of LVEDDi at five year follow-up was mild post-operative AR, whilst predictors of a lesser reduction in indexed left ventricular end systolic diameter (LVESDi) at five year follow-up included mild post-operative AR and a larger pre-operative LVEDDi. LV wall thickness decreased significantly the AS and AS/AR groups within one year post operation, whilst the neo-aortic root size remained stable throughout follow-up. Recovery of LV size post Ross procedure is influenced predominantly by the pre-operative LV size, in particular the indexed LV end diastolic diameter. The pre-operative valve lesion was not predictive of larger ventricular dimensions post AVR, but independent predictors of a larger ventricular dimensions post operation included female gender, enlarged pre-operative LVEDDi and the presence of mild AR in the first post operative year. Those with mild post-operative AR did not have progressive LV enlargement, thus the clinical significance of this finding remains unclear.
Publisher: Wiley
Date: 27-10-2015
DOI: 10.1111/DME.12979
Abstract: To use continuous glucose monitoring to examine the effects of insulin initiation with glargine, with or without glulisine, on glycaemic variability and glycaemia in a cohort of people with Type 2 diabetes receiving maximum oral hypoglycaemic agents in primary healthcare. We conducted a post hoc analysis of continuous glucose monitoring data from 89 participants at baseline and at 24 weeks after insulin commencement. Indicators of glycaemic variability (standard deviation, J-index and mean litude of glycaemic excursion) and glycaemia (HbA1c , mean glucose, area under the glucose-time curve) were assessed. Multi-level regression analysis was used to identify the predictors of change. Complete glycaemic variability data were available for 78 participants. Of these participants, 41% were women, their mean (sd) age was 59.2 (10.4) years, the median (interquartile range) diabetes duration was 10.4 (6.5, 13.3) years and the median (interquartile range) baseline HbA1c was 82.5 (71.6, 96.7) mmol/mol [9.7 (8.7, 11.0)%]. At baseline, BMI correlated negatively with standard deviation (r = -0.30) and mean litude of glycaemic excursion (r = -0.26), but not with J-index HbA1c correlated with J-index (r = 0.61) but not with mean litude of glycaemic excursion and standard deviation. After insulin initiation the mean (sd) glucose level decreased [from 12.0 (3.0) to 8.5 (1.6) mmol/l P < 0.001], as did the median (interquartile range) J-index [from 66.9 (47.7, 95.1) to 36.9 (27.6, 49.8) mmol/l P < 0.001]. Baseline HbA1c correlated with a greater J-index reduction (r = -0.45 P < 0.001). The mean litude of glycaemic excursion and standard deviation values were unchanged. The baseline temporal profile, showing elevated postprandial morning glucose levels, was unchanged after insulin initiation, despite an overall reduction in glycaemia. Insulin initiation reduced hyperglycaemia but did not alter glycaemic variability in adults with Type 2 diabetes receiving maximum oral hypoglycaemic agents. The most significant postprandial excursions were seen in the morning, which identifies prebreakfast as the most effective target for short-acting insulin therapy.
Publisher: Medical Journals Sweden AB
Date: 2014
Abstract: To examine the benefits of high intensity ambulatory rehabilitation programmes over usual care following botulinum toxin A (BoNT-A) for post-stroke spasticity in Australian adults. Prospective single centre, controlled clinical trial. Fifty-nine adults, median 61 years old and 2.5 years following stroke. PARTICIPANTS were dichotomised into high intensity ambulatory rehabilitation programmes (≥ 3 × 1-h weekly sessions for approximately 10 weeks) or usual care programmes (≤ 2 × 1-h weekly sessions) following BoNT-A injections for spasticity. A blinded assessor completed outcomes at 0 (baseline), 6, 12 and 24 weeks. Primary endpoints: proportion of participants achieving ≥ 50% of their goals (using Goal Attainment Scaling: GAS) and GAS T-score change at 12 weeks. Modified Ashworth Scale (MAS), participant satisfaction, activity articipation measures and caregiver burden. Both groups showed significant improvement in goal attainment and participant satisfaction up to 24 weeks, with no overall between-group significant differences. There was, however, a statistical trend (p = 0.052) for participants to achieve more upper limb goals in the high intensity therapy group. GAS and satisfaction benefits persisted beyond the duration of spasticity reduction as measured by MAS. While patient-centred outcomes following BoNT-A injections for post-stroke spasticity were not influenced by intensity of ambulatory rehabilitation programmes, there was a trend for high intensity therapy to be associated with greater upper limb goal attainment. This suggests that the effects of more intensive therapy may be a modifier of the 'black box' of rehabilitation however, further research is required to evaluate this effect and determine which elements of therapy programmes optimise post-BoNT-A outcomes.
Publisher: Elsevier BV
Date: 12-2016
DOI: 10.1016/J.JAD.2016.10.002
Abstract: While there is evidence linking vitamin D status with mood, this association and its clinical significance remain uncertain. Moreover, few studies have focused on young, community-dwelling females. The Safe-D study examined the association between serum 25-hydroxyvitamin D (25OHD) levels and mental health in young women. Participants completed an online questionnaire, wore a UV dosimeter to measure personal sun exposure and underwent a comprehensive health assessment. Serum 25OHD was measured by liquid chromatography-tandem mass spectrometry in 353 healthy women aged 16-25 years, living in Victoria, Australia. Mental health measures included: Patient Health Questionnaire (PHQ-9), 7-item Generalized Anxiety Disorder Scale (GAD-7), Kessler psychological distress scale (K10) and 12-item short-form health survey (SF-12), plus any self-reported mental disorder diagnoses or medication use. The prevalence of self-reported mental disorder was 26% and of vitamin D deficiency 27%. The median (Q1, Q3) scores for the PHQ-9, GAD-7, K10 and SF-12 MCS were 6 (3, 9), 5 (2, 8), 19 (15, 25) and 43 (34, 49), respectively. Serum 25OHD levels were not associated with mental health scores. Vitamin D status was not associated with a reported diagnosis of depression or anxiety. There was a low prevalence of severe vitamin D deficiency and mental health symptoms, which may reduce study power. Our findings do not support an association between serum 25OHD levels and mental health status in young women. Longitudinal studies and randomized clinical trials investigating vitamin D and mood in young women are needed to confirm and extend these results.
Location: United States of America
Location: United States of America
No related grants have been discovered for Alexandra Gorelik.