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Objectives The objective of the study was to assess the methods used, and potential for bias, in posttrial studies of cardiovascular disease (CVD) where legacy effects may be estimated. Study Design and Setting We undertook a methods review of posttrial studies after randomized controlled trials (RCTs) of interventions to prevent CVD. For each included article, we extracted information on important aspects of the design and analysis of the study, and on the reporting of legacy effects. Results Of 2,622 retrieved articles, 46 were included in the review: 13 on blood glucose control, 13 on blood pressure control, and 20 on blood lipid control. The median duration for the RCT and posttrial follow-up studies was 5.0 and 5.7 years, respectively. At least 80% of initial RCT participants were enrolled in the posttrial study in 32 of the reports. Most reports used both linkage to routine administrative data sources and active data collection for the posttrial study. Of the 46 included articles, the authors assessed and reported posttrial covariate balance in 29 and made statistical adjustments in the analysis for potential confounding in 25. Posttrial results were reported separately to overall results (from time of randomization) in 21 articles. Legacy effects were claimed in 19 reports, of which 16 could be justified on the basis of the posttrial results. Conclusion Posttrial studies may provide valuable information for investigating legacy effects, but better reporting of results is needed to realize their full potential. Robust methods of data collection and analysis may address the risk of selection and confounding biases in posttrial studies.

Background Anticoagulation for preventing stroke in atrial fibrillation is under-utilised despite evidence supporting its use, resulting in avoidable death and disability. We aimed to evaluate an intervention to improve the uptake of anticoagulation. Methods We carried out a national, cluster randomised controlled trial in the Australian primary health care setting. General practitioners received an educational session, delivered via telephone by a medical peer and provided information about their patients selected either because they were not receiving anticoagulation or for whom anticoagulation was considered challenging. General practitioners were randomised to receive feedback from a medical specialist about the cases (expert decisional support) either before or after completing a post-test audit. The primary outcome was the proportion of patients reported as receiving oral anticoagulation. A secondary outcome assessed antithrombotic treatment as appropriate against guideline recommendations. Results One hundred and seventy-nine general practitioners participated in the trial, contributing information about 590 cases. At post-test, 152 general practitioners (84.9%) completed data collection on 497 cases (84.2%). A 4.6% (Adjusted Relative Risk = 1.11, 95% CI = 0.86–1.43) difference in the post-test utilization of anticoagulation between groups was not statistically significant (p = 0.42). Sixty-one percent of patients in both groups received appropriate antithrombotic management according to evidence-based guidelines at post-test (Adjusted Relative Risk = 1.0; 95% CI = 0.85 to 1.19) (p = 0.97). Conclusions Specialist feed-back in addition to an educational session did not increase the uptake of anticoagulation in patients with AF. Trial registration ANZCTRN12611000076976 Retrospectively registered.

Background Active surveillance (AS) enrolment criteria and follow-up schedules for low-risk prostate cancer vary between institutions. However, uncertainty remains about adherence to these protocols. Objective To determine adherence to institution-specific AS inclusion criteria and follow-up schedules within the Movember Foundation’s Global Action Plan Prostate Cancer Active Surveillance (GAP3) initiative. Design, setting, and participants We retrospectively assessed the data of 15 101 patients from 25 established AS cohorts worldwide between 2014 and 2016. Outcome measurements and statistical analysis Adherence to individual AS inclusion criteria was rated on a five-point Likert scale ranging from poor to excellent. Nonadherence to follow-up schedules was defined as absence of repeat biopsy 1 yr after the scheduled date. Cohorts were pooled into annual and Prostate Cancer Research International: Active Surveillance (PRIAS)-based biopsy schedules, and a generalised linear mixed model was constructed to test for nonadherence. Results and limitations Serum prostate-specific antigen (PSA) inclusion criteria were followed in 92%, Gleason score (GS) criteria were followed in 97%, and the number of positive biopsy cores was followed in 94% of men. Both age and tumour stage (T stage) criteria had 99% adherence overall. Pooled nonadherence rates increased over time—8%, 16%, and 34% for annual schedules and 11%, 30%, and 29% for PRIAS-based schedules at 1, 4, and 7 yr, respectively—and did not differ between biopsy schedules. A limitation is that our results do not consider the use of multiparametric magnetic resonance imaging. Conclusions In on-going development of evidence-based AS protocols, variable adherence to PSA and GS inclusion criteria should be considered. Repeat biopsy adherence reduces with increased duration of surveillance, independent of biopsy frequency. This emphasises the importance of risk stratification at the commencement of AS. Patient summary We studied adherence to active surveillance protocols for prostate cancer worldwide. We found that inclusion criteria were generally followed well, but adherence to repeat biopsy reduced with time. This should be considered when optimising future active surveillance protocols.

© 2019 The Author(s) 2019. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. Cambodia's healthcare system has seen significant improvements in the last two decades. Despite this, access to quality care remains problematic, particularly for poor rural Cambodians. The government has committed to universal health coverage (UHC) and is reforming the health financing system to align with this goal. The extent to which the reforms have impacted the poor is not always clear. Using a system-wide approach, this study assesses how benefits from healthcare spending are distributed across socioeconomic groups in Cambodia. Benefit incidence analysis was employed to assess the distribution of benefits from health spending. Primary data on the use of health services and the costs associated with it were collected through a nationally representative cross-sectional survey of 5000 households. Secondary data from the 2012-14 Cambodia National Health Accounts and other official documents were used to estimate the unit costs of services. The results indicate that benefits from health spending at the primary care level in the public sector are distributed in favour of the poor, with about 32% of health centre benefits going to the poorest population quintile. Public hospital outpatient benefits are quite evenly distributed across all wealth quintiles, although the concentration index of -0.058 suggests a moderately pro-poor distribution. Benefits for public hospital inpatient care are substantially pro-poor. The private sector was significantly skewed towards the richest quintile. Relative to health need, the distribution of total benefits in the public sector is pro-poor while the private sector is relatively pro-rich. Looking across the entire health system, health financing in Cambodia appears to benefit the poor more than the rich but a significant proportion of spending remains in the private sector which is largely pro-rich. There is the need for some government regulation of the private sector if Cambodia is to achieve its UHC goals.

Background: Many blood collection agencies are generating important data on donor health outcomes using large-scale blood donor cohort studies. Such studies can be very effective when donors provide access to linkage of their data to external health databases, and storage and genomic testing of their blood sample. In this study, we aimed to assess the willingness of Australian blood donors to provide additional data and blood sample for donation-related and other health research. Study design and methods: We invited 2017 donors to complete a survey using four methods (postal letter, postal letter and email, email only, and in-center recruitment). The survey asked for information on demographics, lifestyle behaviors, health, experience and attitude to blood donation, and willingness to give blood sample and additional data for research. Results: Response rates ranged from 23.8% for email only to 77.2% for in-center recruitment. Of those who responded (n = 827), 95.5% indicated they would be willing to provide a blood sample for donation and transfusion-related research. Of these, >90.0% were willing for their sample to be used in research involving genetic testing and other health-related topics. Also, >90.0% were willing to consent for linkage of their information to external health databases. Conclusions: Donors surveyed reported a high willingness to participate in health research by completing surveys, allowing linkage to external datasets, and providing a blood sample. These findings provide strong support for future longitudinal research studies with Australian blood donors.

Background Myocardial infarction mortality has declined since the 1970s, but contemporary drivers of this trend remain unexplained. The aim of this study was to compare the contribution of trends in event rates and case fatality to declines in myocardial infarction mortality in four high-income jurisdictions from 2002–15. Methods Linked hospitalisation and mortality data were obtained from New South Wales (NSW), Australia; Ontario, Canada; New Zealand; and England, UK. People aged between 30 years and 105 years were included in the study. Age-adjusted trends in myocardial infarction event rates and case fatality were estimated from Poisson and binomial regression models, and their relative contribution to trends in myocardial infarction mortality calculated. Findings 1 947 895 myocardial infarction events from a population of 80·4 million people were identified in people aged 30 years or older. There were significant declines in myocardial infarction mortality, event rates, and case fatality in all jurisdictions. Age-standardised myocardial infarction event rates were highest in New Zealand (men 893/100 000 person-years in 2002, 536/100 000 person-years in 2015; women 482/100 000 person-years in 2002, 271/100 000 person-years in 2015) and lowest in England (men 513/100 000 person-years in 2002, 382/100 000 person-years in 2015; women 238/100 000 person-years in 2002, 173/100 000 person-years in 2015). Annual age-adjusted reductions in event rates ranged from –2·6% (95% CI –3·0 to –2·3) in men in England to –4·3% (–4·4 to –4·1) in women in Ontario. Age-standardised case fatality was highest in England in 2002 (48%), but declined at a greater rate than in the other jurisdictions (men –4·1%/year, 95% CI –4·2 to –4·0%; women –4·4%/year, –4·5 to –4·3%). Declines in myocardial infarction mortality rates ranged from –6·1%/year to –7·6%/year. Event rate declines were the greater contributor to myocardial infarction mortality reductions in Ontario (69·4% for men and women), New Zealand (men 68·4%; women 67·5%), and NSW women (60·1%), whereas reductions in case fatality were the greater contributor in England (60% in men and women) and for NSW men (54%). There were greater contributions from case fatality than event rate reductions in people younger than 55 years in all jurisdictions, with contributions to mortality declines varying by country in those aged 55–74 years. Event rate declines had a greater impact than changes in case fatality in those aged 75 years and older. Interpretation While the mortality burden of myocardial infarction has continued to fall across these four populations, the relative contribution of trends in myocardial infarction event rates and case fatality to declining mortality varied between jurisdictions, including by age and sex. Understanding the causes of this variation will enable optimisation of prevention and treatment efforts. Funding National Health and Medical Research Council, Australia; Australian Research Council; Health Research Council of New Zealand; Canadian Institutes of Health Research, Canada; National Institute for Health Research, UK.

This study examines the impact of longitudinal dietary trajectories on obesity and early childhood caries (ECC) in preschool children in Australia. Mother–infant dyads from the Healthy Smiles Healthy Kids study were interviewed at 4 and 8 months, and 1, 2, and 3 years of age. Children underwent anthropometric and oral health assessments between 3 and 4 years of age. Multivariable logistic regression and negative binomial regression analysis were performed for the prevalence of overweight and obesity, and the number of tooth surfaces with dental caries, respectively. The intake of core, discretionary, and sugary foods showed distinct quadratic (n = 3) trajectories with age. The prevalence of overweight or obesity was 10% (n = 72) and that of early childhood caries (ECC) was 33% (mean decayed, missing, and filled tooth surfaces (dmfs) score: 1.96). Children with the highest trajectories of discretionary foods intake were more likely to be overweight or obese (adjusted OR: 2.51, 95 %CI: 1.16–5.42). Continued breastfeeding beyond 12 months was associated with higher dmfs scores (adjusted IRR: 2.17, 95 %CI: 1.27–3.73). Highest socioeconomic disadvantage was the most significant determinant for overweight or obesity (adjusted OR: 2.86, 95 %CI: 1.11–7.34) and ECC (adjusted IRR: 2.71, 95 %CI: 1.48–4.97). Targeted health promotion interventions should be designed to prevent the incidence of two highly prevalent conditions in preschool children.

Objective Programmes that reduce the time to defibrillation are likely to improve overall survival rates from out-of-hospital cardiac arrests (OHCAs). This research sought to identify human factors common among community responders taking an automated external defibrillator (AED) to a victim of an OHCA that are either barriers or enablers of desired behaviour. Methods A qualitative methodology was used. Community members who had access to an AED and who had been notified of an incident of OHCA near them were approached to participate in the research. Participants completed a written survey and undertook a semi-structured interview. A thematic analysis was undertaken using NVivo software and triangulated against findings from an automated data-mining package, Leximancer. Results The study found that 100% of people who were notified of the need for an AED responded. Twelve participants subsequently identified during interviews that they held some form of leadership role in their community. First aid training and previous experience of, and competency in managing emergencies were the strongest motivations for their response. Personal risk was not a concern when responding to victims in immediately life-threatening situations. Conclusion Prospective programmes may be able to be designed to increase the likelihood that community members with AEDs will respond in advance of emergency medical services by targeting common human factors, such as leadership behaviour, training, competency and experience in managing emergencies, leading to better overall survival rates from OHCA.

Background Men with prostate cancer (PCa) on active surveillance (AS) are followed through regular prostate biopsies, a burdensome and often unnecessary intervention, not without risks. Identifying men with at a low risk of disease reclassification may help reduce the number of biopsies. Objective To assess the external validity of two Canary Prostate Active Surveillance Study Risk Calculators (PASS-RCs), which estimate the probability of reclassification (Gleason grade ≥7 with or without >34% of biopsy cores positive for PCa) on a surveillance biopsy, using a mix of months since last biopsy, age, body mass index, prostate-specific antigen, prostate volume, number of prior negative biopsies, and percentage (or ratio) of positive cores on last biopsy. Design, setting, and participants We used data up to November 2017 from the Movember Foundation’s Global Action Plan (GAP3) consortium, a global collaboration between AS studies. Outcome measurements and statistical analysis External validity of the PASS-RCs for estimating reclassification on biopsy was assessed by calibration, discrimination, and decision curve analyses. Results and limitations Five validation cohorts (Prostate Cancer Research International: Active Surveillance, Johns Hopkins, Toronto, Memorial Sloan Kettering Cancer Center, and University of California San Francisco), comprising 5105 men on AS, were eligible for analysis. The individual cohorts comprised 429–2416 men, with a median follow-up between 36 and 84 mo, in both community and academic practices mainly from western countries. Abilities of the PASS-RCs to discriminate between men with and without reclassification on biopsy were reasonably good (area under the receiver operating characteristic curve values 0.68 and 0.65). The PASS-RCs were moderately well calibrated, and had a greater net benefit than most default strategies between a predicted 10% and 30% risk of reclassification. Conclusions Both PASS-RCs improved the balance between detecting reclassification and performing surveillance biopsies by reducing unnecessary biopsies. Recalibration to the local setting will increase their clinical usefulness and is therefore required before implementation. Patient summary Unnecessary prostate biopsies while on active surveillance (AS) should be avoided as much as possible. The ability of two calculators to selectively identify men at risk of progression was tested in a large cohort of men with low-risk prostate cancer on AS. The calculators were able to prevent unnecessary biopsies in some men. Usefulness of the calculators can be increased by adjusting them to the characteristics of the population of the clinic in which the calculators will be used.

In the absence of a civil registration system, a house-to-house survey is often used to estimate cause-specific mortality in low- and middle-income countries. However, house-to-house surveys are resource and time intensive. We applied a low-cost community knowledge approach to identify maternal deaths from any cause and jaundice-associated deaths among persons aged ≥ 14 years, and stillbirths and neonatal deaths in mothers with jaundice during pregnancy in five rural communities in Bangladesh. We estimated the method’s sensitivity and cost savings compared with a house-to-house survey. In the five communities with a total of 125,570 population, we identified 13 maternal deaths, 60 deaths among persons aged ≥ 14 years associated with jaundice, five neonatal deaths, and four stillbirths born to a mother with jaundice during pregnancy over the 3-year period before the survey using the community knowledge approach. The sensitivity of community knowledge method in identifying target deaths ranged from 80% for neonatal deaths to 100% for stillbirths and maternal deaths. The community knowledge approach required 36% of the staff time to undertake compared with the house-to-house survey. The community knowledge approach was less expensive but highly sensitive in identifying maternal and jaundice-associated mortality, as well as all-cause adult mortality in rural settings in Bangladesh. This method can be applied in rural settings of other low- and middle-income countries and, in conjunction with hospital-based hepatitis diagnoses, used to monitor the impact of programs to reduce the burden of cause-specific hepatitis mortality, a current World Health Organization priority.

Purpose The purpose of this paper is to present findings from a mixed methods study investigating leadership development of allied health practitioners within a large public healthcare organization in Australia. Design/methodology/approach The South Eastern Sydney Local Health District Allied Health Leadership Development Program was undertaken with an allied health cohort (n=16) between May 2014 and March 2015 and comprised all-day workshops, action learning sets and individual coaching. Using experiential learning, the program tested whether practice development methods and action learning approaches developed the leadership skills of participants compared with a control group (n=17). Descriptive statistics were collected to evaluate participant and program outcomes. Leadership, workplace culture and engagement measures were analyzed as part of the study. Findings The Allied Health Leadership Development Program received high ratings by participants. They reported enhanced skills in leading self and others through mechanisms such as critical reflection and facilitation, and greater confidence managing change and with engaging staff, colleagues and patients in decision making, affecting the quality and safety of healthcare. Statistically significant differences were found with transformational leadership elements, leadership outcomes, and measures of workplace culture and engagement after program completion for intervention group participants, compared with the control group. Research limitations/implications Results provide new empirical evidence about the effectiveness of using practice development for allied health leadership development. Practical implications This low-cost leadership program can be replicated by other organizations. Originality/value Outcomes from an Allied Health Leadership Development Program have not been previously reported in the literature.

Background and objective Current guidelines for the diagnosis of idiopathic pulmonary fibrosis (IPF) provide specific criteria for diagnosis in the setting of multidisciplinary discussion (MDD). We evaluate the utility and reproducibility of these diagnostic guidelines, using clinical data from the Australian IPF Registry. Methods All patients enrolled in the registry undergo a diagnostic review whereby international IPF guidelines are applied via a registry MDD. We investigated the clinical applicability of these guidelines with regard to: (i) adherence to guidelines, (ii) Natural history of IPF diagnostic categories and (iii) Concordance for diagnostic features. Results A total of 417 participants (69% male, 70.6 ± 8.0 years) with a clinical diagnosis of IPF underwent MDD. The 23% of participants who did not meet IPF diagnostic criteria displayed identical disease behaviour to those with confirmed IPF. Honeycombing on radiology was associated with a worse prognosis and this translated into poorer prognosis in the ‘definite’ IPF group. While there was moderate agreement for IPF diagnostic categories, agreement for specific radiological features, other than honeycombing, was poor. Conclusion In clinical practice, physicians do not always follow IPF diagnostic guidelines. We demonstrate a cohort of IPF patients who do not meet IPF diagnostic guideline criteria, based largely on their radiology and lack of lung biopsy, but who have outcomes identical to those with IPF.

Background Midwives and obstetricians are key maternity care providers; they are the most trusted source of information regarding nutrition and gestational weight gain. However, their views, practices and perceived barriers to managing pregnancy related weight gain have not been studied in Ethiopia. The aim of this study was to explore midwives’ and obstetricians’ observations and perspectives about gestational weight gain and postpartum weight management in Ethiopia. Methods We conducted face-to-face interviews with 11 midwives and 10 obstetricians, from January 2019 to March 2019. All interview data were transcribed verbatim. We analysed the data using thematic analysis with an inductive approach. Results We identified three themes and associated subthemes. Midwives and obstetricians had limited knowledge of the optimal gestational weight gain. Almost all participants were unaware of the presence of the Institute of Medicine recommendations for optimal weight gain in pregnancy. According to the study participants, women in Ethiopia do not want to gain weight during pregnancy, but do want to gain weight after the birth. Counselling about gestational weight gain and postpartum weight management was not routinely provided for pregnant women. This is mostly because gestational weight gain counselling was not considered to be a priority by maternity care providers in Ethiopia. Conclusions The limited knowledge of and low attention to pregnancy related weight management by midwives and obstetricians in this setting needs appropriate intervention. Adapting a guideline for pregnancy weight management and integrating it into antenatal care is essential.

Understanding the determinants of early introduction of sugar sweetened beverages (SSBs) may assist in designing effective public health interventions to prevent childhood weight related conditions (obesity). This study explores the relationship between family/infant characteristics and the early introduction of SSBs among infants in Sydney, Australia. Mothers (n = 934) from an ongoing birth cohort study were interviewed at 8, 17, 34, and 52 weeks postpartum. Multivariable logistic regression analysis was used to identify family/infant factors independently associated with the likelihood of early introduction of SSBs (&lt, 52 weeks of age). Of the 934 mothers interviewed, 42.7% (n = 399) of infants were introduced to SSBs before 52 weeks. Mothers who were born in Vietnam (adjusted Odds Ratio (AOR) = 2.14, 95% confidence interval (CI) 1.33, 3.47), other Asian countries (AOR = 1.62, 95% CI 1.02, 2.58) as well as single mothers (AOR = 3.72, 95% CI 2.46, 5.62) had higher odds of introducing SSBs early to their infants. Mothers from highly advantaged socioeconomic background (AOR = 0.43, 95% CI 0.28, 0.68), those who breastfed their baby for 17&ndash, 25 weeks (AOR = 0.60, 95% CI 0.37, 0.99), 26&ndash, 51 weeks (AOR = 0.65, 95% CI 0.45, 0.94), and 52 weeks or more (AOR = 0.62, 95% CI 0.43, 0.90), and those who introduced solids between 17&ndash, 25 weeks (AOR = 0.58, 95% CI 0.36, 0.91) and 26 weeks or more (AOR = 0.55, 95% CI 0.34, 0.91) had reduced odds of introducing SSBs early. Tailoring health promotion programs for these vulnerable groups may delay the introduction of SSBs.

OBJECTIVE: To develop a model and methodology for predicting the risk of Gleason upgrading in patients with prostate cancer on active surveillance (AS) and using the predicted risks to create risk-based personalised biopsy schedules as an alternative to one-size-fits-all schedules (e.g. annually). Furthermore, to assist patients and doctors in making shared decisions on biopsy schedules, by providing them quantitative estimates of the burden and benefit of opting for personalised vs any other schedule in AS. Lastly, to externally validate our model and implement it along with personalised schedules in a ready to use web-application.PATIENTS AND METHODS: Repeat prostate-specific antigen (PSA) measurements, timing and results of previous biopsies, and age at baseline from the world's largest AS study, Prostate Cancer Research International Active Surveillance (PRIAS; 7813 patients, 1134 experienced upgrading). We fitted a Bayesian joint model for time-to-event and longitudinal data to this dataset. We then validated our model externally in the largest six AS cohorts of the Movember Foundation's third Global Action Plan (GAP3) database (>20 000 patients, 27 centres worldwide). Using the model predicted upgrading risks; we scheduled biopsies whenever a patient's upgrading risk was above a certain threshold. To assist patients/doctors in the choice of this threshold, and to compare the resulting personalised schedule with currently practiced schedules, along with the timing and the total number of biopsies (burden) planned, for each schedule we provided them with the time delay expected in detecting upgrading (shorter is better).RESULTS: The cause-specific cumulative upgrading risk at the 5-year follow-up was 35% in PRIAS, and at most 50% in the GAP3 cohorts. In the PRIAS-based model, PSA velocity was a stronger predictor of upgrading (hazard ratio [HR] 2.47, 95% confidence interval [CI] 1.93-2.99) than the PSA level (HR 0.99, 95% CI 0.89-1.11). Our model had a moderate area under the receiver operating characteristic curve (0.6-0.7) in the validation cohorts. The prediction error was moderate (0.1-0.2) in theGAP3 cohorts where the impact of the PSA level and velocity on upgrading risk was similar to PRIAS, but large (0.2-0.3) otherwise. Our model required re-calibration of baseline upgrading risk in the validation cohorts. We implemented the validated models and the methodology for personalised schedules in a web-application (http://tiny.cc/biopsy).CONCLUSIONS: We successfully developed and validated a model for predicting upgrading risk, and providing risk-based personalised biopsy decisions in AS of prostate cancer. Personalised prostate biopsies are a novel alternative to fixed one-size-fits-all schedules, which may help to reduce unnecessary prostate biopsies, while maintaining cancer control. The model and schedules made available via a web-application enable shared decision-making on biopsy schedules by comparing fixed and personalised schedules on total biopsies and expected time delay in detecting upgrading.

Objectives and importance of the study: Adult literacy programs aim to empower learners to participate more effectively in everyday life. This includes programs with health content embedded in curricula to target health literacy. Adult learners who attend these programs represent a heterogeneous population, but include a high proportion of hard-to-reach or socially disadvantaged groups in terms of age, ethnicity, educational background, language and prevalence of learning disabilities. In 2014, we conducted a cluster-randomised controlled trial of a health literacy program in adult basic education classes across New South Wales, Australia. This paper reports findings from a qualitative study exploring learners’ experience of the course and its perceived impact on their lives, as well as their understanding and confidence about health. Study type: Qualitative interview study. Method: We conducted semistructured interviews as part of the evaluation of the 18-week health literacy program, with participants purposively recruited from six health literacy classes (n = 22). Researchers trained in qualitative methods interviewed adult learners either face to face or over the phone using a topic guide. Data was analysed using the Framework method, a matrix-based approach to thematic analysis. Results: The majority of interviewees were female, lived in metropolitan areas and were from non-English–speaking backgrounds. Most had existing self-reported health problems and inadequate functional health literacy. Most participants described positive impacts of the health literacy course on their language, literacy and numeracy skills, functional health literacy skills, and health knowledge. They also reported being able to translate this into health actions including interacting with providers, accessing and using healthcare, and managing health and illness (e.g. making healthier food choices). Learners also described positive social outcomes of the course, including feelings of connectedness and interpersonal trust within a new network of learners, and reported sharing new knowledge with others in their communities. Conclusions: The findings add value to existing limited evidence that has demonstrated the untapped potential of adult basic education to develop health literacy skills among socially disadvantaged groups. Learners valued the opportunity to share experiences in structured group learning, and reported confidence to transfer new knowledge into their home and wider social network.

Background It is commonly recommended that microbiological assessment should accompany the use of antibiotics prone to resistance. We sought to estimate the rate of microbiology testing and compare this to dispensing of the World Health Organization classified “watch” group antibiotics in primary care. Methods Data from a cohort of older adults (mean age 69 years) were linked to Australian national health insurance (Pharmaceutical Benefits Scheme & Medicare Benefits Schedule) records of community-based antibiotic dispensing and microbiology testing in 2015. Participant characteristics associated with greater watch group antibiotic dispensing and microbiology testing were estimated using adjusted incidence rate ratios (aIRR) and 95% confidence intervals (CI) in multivariable zero-inflated negative binomial regression models. Results In 2015, among 244,299 participants, there were 63,306 watch group antibiotic prescriptions dispensed and 149,182 microbiology tests conducted; the incidence rate was 0.26 per person-year for watch group antibiotic dispensing and 0.62 for microbiology testing. Of those antibiotic prescriptions, only 19% were accompanied by microbiology testing within − 14 to + 7 days. After adjusting for socio-demographic factors and co-morbidities, individuals with chronic respiratory diseases were more likely to receive watch group antibiotics than those without, e.g. asthma (aIRR:1.59, 95%CI:1.52–1.66) and chronic obstructive pulmonary disease (COPD) (aIRR:2.71, 95%CI:2.48–2.95). However, the rate of microbiology testing was not comparably higher among them (with asthma aIRR:1.03, 95%CI:1.00–1.05; with COPD aIRR:1.00, 95%CI:0.94–1.06). Conclusions Priority antibiotics with high resistance risk are commonly dispensed among community-dwelling older adults. The discord between the rate of microbiology testing and antibiotic dispensing in adults with chronic respiratory diseases suggests the potential for excessive empirical prescribing.

Objective The purpose of this study was to examine the timing of introduction of complementary (solid) foods among infants in South Western Sydney, Australia, and describe the maternal and infant characteristics associated with very early introduction of solids. Methods Mother-infant dyads (n = 1035) were recruited into the “Healthy Smiles Healthy Kids” study by Child and Family Health Nurses at the first post-natal home visit. Data collected via telephone interviews at 8, 17, 34 and 52 weeks postpartum included timing of introduction of solids and a variety of maternal and infant characteristics (n = 934). Multiple logistic regression was used to identify factors independently associated with the risk of introducing solids very early, which for the purpose of this study was defined as being before 17 weeks. Results The median age of introduction of solids was 22 weeks. In total, 13.6% (n = 127) of infants had received solids before 17 weeks and 76.9% (n = 719) before 26 weeks of age. The practice of introducing solids early decreased with older age of the mother. Compared to women 95 0.14–0.58). Single mothers had more than twice the odds of introducing solids before the age of 17 weeks compared to married women (OR = 2.35, CI95 1.33–4.16). Women who had returned to work between 6 to 12 months postpartum were 46% less likely to introduce solids very early compared with those who were not working at the child’s first birthday (OR = 0.54, CI95 0.30–0.97). Women born in Vietnam and Indian sub-continent had lower odds of introducing solids very early compared to Australian born women (OR = 0.42, CI95 0.21–0.84 and OR = 0.30, CI95 0.12–0.79, respectively). Infants who were exclusively formula-fed at 4 weeks postpartum had more than twice the odds of receiving solids very early (OR = 2.34, CI95 1.49–3.66). Conclusions Women who are younger, single mothers, those not working by the time of child’s first birthday, those born in Australia, and those who exclusively formula-feed their babies at 4 weeks postpartum should be targeted for health promotion programs that aim to delay the introduction of solids in infants to the recommended time.

Early introduction of complementary foods can have a detrimental impact on children&rsquo, s long-term health. This study examined the timing and determinants of early introduction of core and discretionary foods among infants in Sydney, Australia. Mothers (n = 1035) from an ongoing population-based birth cohort study were interviewed at 8, 17, 34 and 52 weeks postpartum. The outcome was &lsquo, age at which particular core and discretionary food items were first introduced&rsquo, Multivariable logistic regression models were used to investigate family and infant-related determinants of early introduction of core (&lt, 17 weeks of age) and discretionary foods (&lt, 52 weeks of age). Of the 934 mother-infant dyads interviewed, 12% (n = 113) of infants were introduced core foods before 17 weeks of age (median: 22). Mothers working part-time (adjusted odds ratio (OR): 3.42, 95% confidence interval (CI): 1.54&ndash, 7.62) and those exclusively formula-feeding their babies at four-weeks postpartum (adjusted OR 3.26, 95% CI: 1.99&ndash, 5.33) were most likely to introduce core foods early. Ninety-five percent (n = 858) of infants were introduced discretionary foods before 52 weeks of age (median: 28). Low socio-economic status was significantly associated with early introduction of discretionary foods (adjusted OR: 3.72, 95% CI: 1.17&ndash, 11.78). Compliance with infant feeding guidelines related to core foods was better, however, discretionary foods were introduced early in most infants.

Background The Action to Control Cardiovascular Risk in Diabetes (ACCORD)-Lipid study found no evidence of a beneficial effect of statin-fibrate combined treatment, compared to statins alone, on cardiovascular outcomes and mortality in type 2 diabetes mellitus after 5 years of active treatment. However, a beneficial reduction in major CVD events was shown in a pre-specified sub-group of participants with dyslipidemia. The extended follow-up of this trial provides the opportunity to further investigate possible beneficial effects of fibrates in this group of patients. We aimed to evaluate possible “legacy effects” of fibrate add-on therapy on mortality and major cardiovascular outcomes in patients with dyslipidemia. Methods The ACCORD-lipid study was a randomized controlled trial of 5518 participants assigned to receive simvastatin plus fenofibrate vs simvastatin plus placebo. After randomized treatment allocation had finished at the end of the trial, all surviving participants were invited to attend an extended follow-up study (ACCORDION) to continue prospective collection of clinical outcomes. We undertook a secondary analysis of trial and post-trial data in patients who had dyslipidemia. The primary outcome was all-cause and cardiovascular mortality, and secondary outcomes were nonfatal myocardial infarction, stroke, congestive heart failure and major coronary heart disease. We used an intention-to-treat approach to analysis to make comparisons between the original randomized treatment groups. Results 853 participants with dyslipidemia had survived at the end of the trial. Most participants continued to use statins, but few used fibrates in either group during the post-trial period. The incidence rates in the fenofibrate group were lower with respect to all-cause mortality, CVD mortality, nonfatal myocardial infarction, congestive heart failure and major coronary heart disease than those in the placebo group over a post-trial follow-up. Allocation to the combined fibrate-statin treatment arm during the trial period had a beneficial legacy effect on all-cause mortality (adjusted HR = 0.65, 95% CI 0.45–0.94; P = 0.02). Conclusions Fibrate treatment during the initial trial period was associated with a legacy benefit of improved survival over a post-trial follow-up. These findings support re-evaluation of fibrates as an add-on strategy to statins in order to reduce cardiovascular risk in diabetic patients with dyslipidemia. Trial registration clinicaltrials.gov, Identifier: NCT00000620

Obesity and dental caries in children are significant health problems. The aims of this review are to identify whether children aged 6 years and younger with overweight and/or obesity have higher dental caries experience compared with children with normal weight and, secondly, to identify the common risk factors associated with both conditions. Medline, Embase, and seven other databases were systematically searched followed by lateral searches from reference lists, grey literature, theses, conference proceedings, and contacting field experts. Longitudinal observational studies addressing overweight and/or obesity and dental caries in children aged 6 years and younger were included. A random effects model meta-analyses were applied. Nine studies were included in this review. Children with overweight and obesity had a significantly higher dental caries experience compared with children with normal weight (n = 6). The pooled estimates showed that difference in caries experience between the two groups was statistically significant. Low levels of parental income and education were identified to be associated with both conditions in the sample population. Children with overweight and obesity are more vulnerable to dental caries. Low levels of parental income and education influence the relationship between the two conditions. However, the quality of evidence varied considerably; therefore, findings should be interpreted cautiously.

Background Young people with problematic alcohol and other drug (AOD) use are often referred to residential treatment. Subsequent mortality rates among this high-risk group is not known. This study estimates mortality rates and determines causes of death amongst young people referred to residential treatment in Sydney, Australia. Design Retrospective data linkage study. Data of young people (13-18 years) referred to a residential treatment service 2001-2015 (n = 3256) linked with Australian death registration data, and followed up to 16 years (2001-2016). Methods Mortality rates (CMRs) and standardised mortality ratios (SMRs, age-, gender-, calendar-year-adjusted) calculated using population mortality rates. Causes of death were analysed using ICD-10 codes for AOD-induced, AOD as contributory and non-AOD related causes. Results During follow-up of the cohort (28,838 person-years), 63 people died (71.4 % males; 48 % Indigenous; median age at death = 21.9 years; median follow-up = 5.1years), with 76 % dying before aged 25 years. Overall mortality (SMR = 4.91, 95 % CI: 3.8-6.2; CMR = 2.18/1000 person-years, 95 % CI: 1.7-2.8) was significantly higher than age-gender-matched general population, particularly in females (SMR = 9.55; males: SMR = 4.11; RR: 2.3, 95 % CI: 1.3-4.1). SMRs were not significantly different between treatment groups (SMRs>5.5) and non-attend group (SMR = 3.7) (p = 0.359). Two-thirds of deaths involved AOD, with AOD-induced deaths comprising 42 % and AOD as contributory for 22 % deaths. Overdose, mainly opioids (including opiates), suicide, and transport accidents were major causes of deaths. Conclusion Very high mortality rates, particularly among females, and the high incidence of overdose and suicide emphasise early screening for those at high-risk, targeted and culturally appropriate interventions, and maximised continuing after-care accessible to young people.

© 2017 Background Cholera remains a threat globally, and socioeconomic factors play an important role in transmission of the disease. We assessed socioeconomic risk factors for cholera in vaccinated and non-vaccinated communities to understand whether the socioeconomic risk factors differ by transmission patterns for cholera. Methods We used data from a cluster randomized control trial conducted in Dhaka, Bangladesh. There were 90 geographic clusters; 30 in each of the three arms of the study: vaccine (VAC), vaccine plus behavioural change (VBC), and non-intervention. The data were analysed for the three populations: (1) vaccinees in the vaccinated communities (VAC and VBC arms), (2) non-vaccinated individuals in the vaccinated communities and (3) all individuals in the non-vaccinated communities (non-intervention arm). A generalized estimating equation with logit link function was used to evaluate the risk factors for cholera among these different populations adjusting for household level correlation in the data. Results A total of 528 cholera and 226 cholera with severe dehydration (CSD) in 268,896 persons were observed during the two-year follow-up. For population 1, the cholera risk was not associated with any socioeconomic factors; however CSD was less likely to occur among individuals living in a household having ≤4 members (aOR = 0.55, 95% CI = 0.32–0.96). Among population 2, younger participants and individuals reporting diarrhoea during registration were more likely to have cholera. Females and individuals reporting diarrhoea during registration were at increased risk of CSD. Among population 3, individuals living in a household without a concrete floor, in an area with high population density, closer to the study hospital, or not treating drinking water were at significantly higher risk for both cholera and CSD. Conclusion The profile of socioeconomic factors associated with cholera varies by individuals’ vaccination status as well as the transmission setting. In a vaccinated community where transmission would be expected to be lower, socioeconomic factors may not increase the risk of the disease.

OBJECTIVETo evaluate the impact of early infectious diseases (ID) antimicrobial stewardship (AMS) intervention on inpatient sepsis antibiotic management.DESIGNInterventional, nonrandomized, controlled study.SETTINGTertiary-care referral hospital, Sydney, Australia.PATIENTSConsecutive, adult, non–intensive care unit (non-ICU) inpatients triggering an institutional clinical sepsis pathway from May to August 2015.INTERVENTIONAll patients reviewed by an ID Fellow within 24 hours of sepsis pathway trigger underwent case review and clinic file documentation of recommendations. Those not reviewed by an ID Fellow were considered controls and received standard sepsis pathway care. The primary outcome was antibiotic appropriateness 48 hours after sepsis trigger.RESULTSIn total, 164 patients triggered the sepsis pathway: 6 patients were excluded (previous sepsis trigger); 158 patients were eligible; 106 had ID intervention; and 52 were control cases. Of these 158 patients, 91 (58%) had sepsis, and 15 of these 158 (9.5%) had severe sepsis. Initial antibiotic appropriateness, assessable in 152 of 158 patients, was appropriate in 80 (53%) of these 152 patients and inappropriate in 72 (47%) of these patients. In the intervention arm, 93% of ID Fellow recommendations were followed or partially followed, including 53% of cases in which antibiotics were de-escalated. ID Fellow intervention improved antibiotic appropriateness at 48 hours by 24% (adjusted risk ratio, 1.24; 95% confidence interval, 1.04–1.47; P=.035). The appropriateness agreement among 3 blinded ID staff opinions was 95%. Differences in intervention and control group mortality (13% vs 17%) and median length of stay (13 vs 17.5 days) were not statistically significant.CONCLUSIONSepsis overdiagnosis and delayed antibiotic optimization may reduce sepsis pathway effectiveness. Early ID AMS improved antibiotic management of non-ICU inpatients with suspected sepsis, predominantly by de-escalation. Further studies are needed to evaluate clinical outcomes.Infect Control Hosp Epidemiol 2017;38:1032–1038

© 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd Background: Enhancing health literacy can play a major role in improving healthcare and health across the globe. To build higher-order (communicative/critical) health literacy skills among socially disadvantaged Australians, we developed a novel shared decision making (SDM) training programme for adults with lower literacy. The programme was delivered by trained educators within an adult basic education health literacy course. Objective: To explore the experience of teaching SDM within a health literacy programme and investigate whether communicative/critical health literacy content meets learner needs and teaching and institutional objectives. Design and participants: Qualitative interview study with 11 educators who delivered the SDM programme. Transcripts were analysed using the Framework approach; a matrix-based method of thematic analysis. Results: Teachers noted congruence in SDM content and the institutional commitment to learner empowerment in adult education. The SDM programme was seen to offer learners an alternative to their usual passive approach to healthcare decision making by raising awareness of the right to ask questions and consider alternative test/treatment options. Teachers valued a structured approach to training building on foundational skills, with language reinforcement and take-home resources, but many noted the need for additional time to develop learner understanding and cover all aspects of SDM. Challenges for adult learners included SDM terminology, computational numerical risk tasks and understanding probability concepts. Discussion and conclusions: SDM programmes can be designed in a way that both supports teachers to deliver novel health literacy content and empowers learners. Collaboration between adult education and healthcare sectors can build health literacy capacity of those most in need.

This study investigated psychological distress in Iranian international students at UNSW Australia, and explored the psychosocial factors associated with high levels of distress. A total of 180 Iranian international students pursuing undergraduate and postgraduate degrees during 2012/2013 completed an email questionnaire containing socio-demographic items and five standardized and validated scales. Multivariable logistic regression was used to analyse the predictors of psychological distress. Compared to domestic and international students at two other Australian universities, a significantly smaller proportion of Iranian international students scored as distressed on the Kessler Psychological Distress Scale (K10). Greater levels of psychological distress were associated with being female, poorer physical health, less social support, less religious involvement and spirituality, and negative attitudes towards seeking professional psychological help. Findings from this growing group of international students can help inform culturally competent mental health promotion and service provision in their host countries.

Our primary purpose was to assess the clinical (predictive) validity of central retinal thickness (CRT) and best corrected visual acuity (BCVA) at 1 week and 1 month after starting treatment with ranibizumab for central retinal vein occlusion. The authors also assessed detectability of response to treatment.The authors used data from 325 participants in the CRUISE study, which included measurement of time-domain CRT and BCVA at baseline, 1 week, 1 month, and 6 months postrandomization. Analysis of covariance models were fitted to assess clinical validity, and distributions of change were constructed to assess detectability of response.There was no evidence that 1-week CRT, and very strong evidence that 1-week BCVA were associated with baseline-adjusted BCVA at 6 months (P = 0.17 and P < 0.001, respectively). There was strong evidence that both 1-month CRT and 1-month BCVA were associated with baseline-adjusted 6-month BCVA (P = 0.005 and P < 0.001, respectively), but simultaneous adjustment found evidence of independent association only for BCVA (P = 0.71 and P < 0.001 for CRT and BCVA, respectively). Detectability of response tended to be higher for CRT than BCVA at 1 week and 1 month but by 6 months these were equivalent for CRT and BCVA.In this study, BCVA monitoring of treated central retinal vein occlusion patients seemed more informative than time-domain optical coherence tomography monitoring.

In the absence of reliable data on the burden of hepatitis E virus (HEV) in high endemic countries, we established a hospital-based acute jaundice surveillance program in six tertiary hospitals in Bangladesh to estimate the burden of HEV infection among hospitalized acute jaundice patients aged ≥14 years, identify seasonal and geographic patterns in the prevalence of hepatitis E, and examine factors associated with death. We collected blood specimens from enrolled acute jaundice patients, defined as new onset of either yellow eyes or skin during the past three months of hospital admission, and tested for immunoglobulin M (IgM) antibodies against HEV, HBV and HAV. The enrolled patients were followed up three months after hospital discharge to assess their survival status; pregnant women were followed up three months after their delivery to assess pregnancy outcomes. From December’2014 to September’2017, 1925 patients with acute jaundice were enrolled; 661 (34%) had acute hepatitis E, 48 (8%) had hepatitis A, and 293 (15%) had acute hepatitis B infection. Case fatality among hepatitis E patients was 5% (28/589). Most of the hepatitis E cases were males (74%; 486/661), but case fatality was higher among females—12% (8/68) among pregnant and 8% (7/91) among non-pregnant women. Half of the patients who died with acute hepatitis E had co-infection with HAV or HBV. Of the 62 HEV infected mothers who were alive until the delivery, 9 (15%) had miscarriage/stillbirth, and of those children who were born alive, 19% (10/53) died, all within one week of birth. This study confirms that hepatitis E is the leading cause of acute jaundice, leads to hospitalizations in all regions in Bangladesh, occurs throughout the year, and is associated with considerable morbidity and mortality. Effective control measures should be taken to reduce the risk of HEV infections including improvements in water quality, sanitation and hygiene practices and the introduction of HEV vaccine to high-risk groups., Author summary In the absence of reliable surveillance data on the burden of hepatitis E in endemic countries, we conducted a hospital-based acute jaundice surveillance study over a two and a half year period in six tertiary hospitals in Bangladesh. The study confirms that HEV infections occur throughout the year, and is a major (34%) cause of acute jaundice in tertiary hospitals in Bangladesh. Three-quarters of the acute hepatitis E cases were male, and HEV infection was higher among patients residing in urban areas than patients in rural areas (41% vs 32%). The overall case fatality rate of acute HEV infections in hospitals was 5%, but was higher among pregnant women (12%). Hepatitis E patients who died were more likely to have co-infection with HAV or HBV than the HEV infected patients who did not die. Fifteen percent of HEV infected mothers had miscarriage/stillbirth. Of the children who were born alive, 19% died, all within one week of birth. Considering the high burden of hepatitis E among hospitalized acute jaundice patients, Bangladesh could take control measures to reduce this risk including improvements in water quality, sanitation and hygiene practices and the introduction of hepatitis E vaccine in high-risk areas.

Background Chronic suppurative otitis media (CSOM) causes preventable deafness and disproportionately affects children living in poverty. Our hypothesis was that health promotion in women’s groups would increase their knowledge, attitudes and practices (KAP) regarding ear disease and reduce the prevalence of CSOM in their children. Methods We did a cluster randomised trial in two village development committees (VDCs) in Jumla, Nepal. In July 2014, 30 women’s groups were randomly allocated to intervention or control, stratified by VDC and distance to the road. The intervention groups participated in three sessions of health promotion using the WHO Hearing and Ear Care Training Resource Basic Level. The primary outcome was women’s KAP score and the secondary outcome was prevalence of CSOM in their children at 12 month follow-up. Analyses were by intention to treat. Participants and the research team were not masked to allocation. Results In June and July 2014 we recruited 508 women and 937 of their children. 12 months later there was no difference in the women’s KAP score (mean difference 0.14, 95% CI − 0.1 to 0.38, P = 0.25) or the prevalence of CSOM in their children (OR 1.10, 95%CI 0.62 to 1.84, P = 0.75) between intervention and control groups. However, overall, there was a significant improvement in the KAP score (mean difference − 0.51, 95% CI − 0.71,to − 0.31, P

© 2019 Chen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Background Widespread use of antibiotics has led to the development of antibiotic resistance. However, there are limited data describing antibiotic use in the community setting, and examining factors associated with greater use. Our study aimed to quantify antibiotic dispensing in older adults in the community according to socio-demographics and health services use. Methods Prospective analysis of a population-based cohort study of 239,981 adults aged 45 years in Australia (the Sax Institute’s 45 and Up Study). Data on socio-demographics and health from a questionnaire, were linked to 2015 antibiotic dispensing data from the Pharmaceutical Benefits Scheme (PBS), as well as other administrative health databases. We estimated the Defined Daily Dose (DDD) of systemic antibiotics dispensed, defined by an Anatomic Therapeutic Classification code beginning with J01, in 2015. We also conducted Poisson regression with robust standard errors to identify factors associated with antibiotic dispensing. Results Overall, 49.3% of 45 and Up Study participants had at least one systemic antibiotic dispensed in 2015 with a total of 392,856 prescriptions dispensed and an average of 36.5 DDDs/1000-persons/day in the study population. The quantity of antibiotics dispensed increased with increasing age (25.6 DDDs/1000/day in 15 general practitioner consultations in the last year (80.5 and 88.3 DDDs/1000/day, respectively). These factors remained strongly associated with greater antibiotic dispensing after adjusting for age, sex, education, income, area of residence and co-morbidities. Conclusions Residence in aged care facilities and high GP visits are associated with greater antibiotic dispensing. This study provides important evidence regarding high use groups for antimicrobial stewardship.

ObjectivesTo quantify the risk of overdiagnosis associated with prostate cancer screening in Australia using a novel lifetime risk approach.DesignModelling and validation of the lifetime risk method using publicly available population data.SettingOpportunistic screening for prostate cancer in the Australian population.ParticipantsAustralian male population (1982–2012).InterventionsProstate-specific antigen testing for prostate cancer screening.Primary and secondary outcome measuresPrimary: lifetime risk of overdiagnosis in 2012 (excess lifetime cancer risk adjusted for changing competing mortality); Secondary: lifetime risk of prostate cancer diagnosis (unadjusted and adjusted for competing mortality); Excess lifetime risk of prostate cancer diagnosis (for all years subsequent to 1982).ResultsThe lifetime risk of being diagnosed with prostate cancer increased from 6.1% in 1982 (1 in 17) to 19.6% in 2012 (1 in 5). Using 2012 competing mortality rates, the lifetime risk in 1982 was 11.5% (95% CI 11.0% to 12.0%). The excess lifetime risk of prostate cancer in 2012 (adjusted for changing competing mortality) was 8.2% (95% CI 7.6% to 8.7%) (1 in 13). This corresponds to 41% of prostate cancers being overdiagnosed.ConclusionsOur estimated rate of overdiagnosis is in agreement with estimates using other methods. This method may be used without the need to adjust for lead times. If annual (cross-sectional) data are used, then it may give valid estimates of overdiagnosis once screening has been established long enough for the benefits from the early detection of non-overdiagnosed cancer at a younger age to be realised in older age groups.

Background: Careful assessment of the reasons for discontinuation of active surveillance (AS) is required for men with prostate cancer (PCa). Objective: Using Movember's Global Action Plan Prostate Cancer Active Surveillance initiative (GAP3) database, we report on reasons for AS discontinuation. Design, setting, and participants: We compared data from 10 296 men on AS from 21 centres across 12 countries. Outcome measurements and statistical analysis: Cumulative incidence methods were used to estimate the cumulative incidence rates of AS discontinuation. Results and limitations: During 5-yr follow-up, 27.5% (95% confidence interval [CI]: 26.4–28.6%) men showed signs of disease progression, 12.8% (95% CI: 12.0–13.6%) converted to active treatment without evidence of progression, 1.7% (95% CI: 1.5–2.0%) continued to watchful waiting, and 1.7% (95% CI: 1.4–2.1%) died from other causes. Of the 7049 men who remained on AS, 2339 had follow-up for >5 yr, 4561 had follow-up for

The aim of this study was to determine the immunogenicity and reactogenicity of HPV vaccine in immunocompromised children.A multi-centre clinical trial was conducted in three paediatric hospitals in Australia. Unvaccinated children 5-18years of age attending one of three paediatric hospitals with a range of specified conditions associated with immunosuppression were included. Quadrivalent HPV vaccine (Gardasil) was given to the participants and serum anti-HPV antibody levels were measured at baseline (before first dose), 7 and 24months after the first dose of vaccine.Fifty-nine participants were enrolled across the three paediatric hospitals and among those one was seropositive to types 6, 11 and 16 at baseline. Seven months after the first dose, seroconversion rates were 93.3%, 100%, 100% and 88.9% for type 6, 11, 16 and 18 respectively. The corresponding rates at 24month follow up were 82.2%, 91.1%, 91.1% and 68.9%. The greatest increase in geometric mean titre (GMT) was for type 16, followed by type 11. GMTs declined over the following months, but remained more than fourfold higher for all serotypes compared to baseline titres at 24months post vaccination. Injection site erythema, pain and swelling were commonly reported local adverse events and were less common after each dose. Few participants reported systemic adverse events, and minor disease flare occurred in two participants. One child developed a squamous cell oral carcinoma during follow up, but tissue was unable to be tested for HPV.Immunosuppressed children had an adequate immunogenic response to Quadrivalent HPV vaccine regardless of age and the cause of immunosuppression. HPV related cancers occur at higher frequency and earlier in immunosuppressed patients, so early vaccination and optimal scheduling should be further studied in such children.NCT02263703 (ClinicalTrials.gov).

Background People with low literacy and low health literacy have poorer health outcomes. Literacy and health literacy are distinct but overlapping constructs that impact wellbeing. Interventions that target both could improve health outcomes. Methods/design This is a cluster randomised controlled trial with a qualitative component. Participants are 300 adults enrolled in basic language, literacy and numeracy programs at adult education colleges across New South Wales, Australia. Each adult education institute (regional administrative centre) contributes (at least) two classes matched for student demographics, which may be at the same or different campuses. Classes (clusters) are randomly allocated to receive either the health literacy intervention (an 18-week program with health knowledge and skills embedded in language, literacy, and numeracy training (LLN)), or the standard Language Literacy and Numeracy (LLN) program (usual LLN classes, specifically excluding health content). The primary outcome is functional health literacy skills – knowing how to use a thermometer, and read and interpret food and medicine labels. The secondary outcomes are self-reported confidence, more advanced health literacy skills; shared decision making skills, patient activation, health knowledge and self-reported health behaviour. Data is collected at baseline, and immediately and 6 months post intervention. A sample of participating teachers, students, and community health workers will be interviewed in-depth about their experiences with the program to better understand implementation issues and to strengthen the potential for scaling up the program. Discussion Outcomes will provide evidence regarding real-world implementation of a health literacy training program with health worker involvement in an Australian adult education setting. The evaluation trial will provide insight into translating and scaling up health literacy education for vulnerable populations with low literacy. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12616000213448. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3034-9) contains supplementary material, which is available to authorized users.

ObjectiveGiven the scarcity of shared decision-making (SDM) interventions for adults with low literacy, we created a SDM training program tailored to this population to be delivered in adult education settings.MethodsFormative evaluation during program development included a review of the problem and previous efforts to address it, qualitative interviews with the target population, program planning and field testing.ResultsA comprehensive SDM training program was developed incorporating core SDM elements. The program aimed to improve students’ understanding of SDM and to provide them with the necessary skills (understanding probabilistic risks and benefits, personal values and preferences) and self-efficacy to use an existing set of questions (the AskShareKnow questions) as a means to engage in SDM during healthcare interactions.ConclusionsThere is an ethical imperative to develop SDM interventions for adults with lower literacy. Generic training programs delivered direct-to-consumers in adult education settings offer promise in a national and international environment where too few initiatives exist.Practice implicationsFormative evaluation of the program offers practical insights into developing consumer-focused SDM training. The content of the program can be used as a guide for future efforts to engage consumers in SDM.

© The Author(s) 2018. Background: Health financing and delivery reforms designed to achieve universal health coverage (UHC) need to be informed by an understanding of factors that both promote access to health care and undermine it. This study examines the level of health care utilisation in Timor-Leste and the factors that drive it. Methods: Data from a nationally representative cross-sectional survey of health care utilisation in 1712 households were used to develop multilevel models exploring how need and predisposing and enabling factors explain health care utilisation at both primary and secondary care facilities. Results: Need was found to be the key driver in seeking both primary care and hospital services. Rural households were less likely to go to hospital (odds ratio 0.7) than urban households. The poorest quintile was also less likely to use more expensive hospital services than other socio-economic groups. Conclusions: Understanding the determinants of seeking health care in Timor-Leste is of considerable policy significance, because health care is free at the point of use. Our findings indicate that the public resources for health care are subsidising the rich more than the poor. Health care reforms in Timor-Leste need to reduce the 'other' costs of health care, such as distance barriers, to address these inequities.

© 2018 Arnolda et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Introduction Neonatal jaundice is one of the most common reasons for hospital admission in low resource settings. Treatment is frequently inadequate as conventional phototherapy requires frequent bulb changes. LED phototherapy has comparable efficacy to conventional phototherapy, and the bulbs last over 40,000 hours. This observational study compares the effectiveness of three LED machines, two single-sided and one double-sided in routine use in Vietnam. Methods We included all infants weighting 1500g and with jaundice diagnosed visually or by Total Serum Bilirubin (TSB) measurement at The Da Nang Hospital for Women and Children (Da Nang, Vietnam). The primary endpoint was the average hourly change in TSB over the first six hours of treatment. The secondary endpoints were duration of treatment; average hourly change in TSB over treatment, and length of stay in the neonatal unit. Multivariable analysis and bootstrap methods was performed to compare outcomes, adjusting for potential confounders. Results All outcomes were comparable in the two single-sided machines. The double-sided machine showed 54% increase in the hourly speed of TSB reduction (1.3 μmol/L/hr, 95% CI 0.3-2.3), with a 45% increase in the speed of TSB reduction over the duration of treatment (0.9 μmol/ L/hr, 95% CI 0.6-1.3). In addition, the double-sided machine was associated with 21% reduction in the duration of treatment (14 hours, 95% CI 5-22) and 16% reduction of length of stay (14 hours, 95% CI 3-25). Conclusion The results confirm and quantify the benefits of increasing surface-area exposure during phototherapy. Adjusted for multiple potential confounders, use of double-sided phototherapy can substantially increase the speed of TSB reduction, and substantially decrease the duration of treatment and length of stay in the NCU.

Background and objectives Monitoring N-terminal pro–B-type natriuretic peptide (NT-proBNP) may be useful for assessing cardiovascular risk in dialysis patients. However, its biologic variation is unknown, hindering the accurate interpretation of serial concentrations. The aims of this prospective cohort study were to estimate the within- and between-person coefficients of variation of NT-proBNP in stable dialysis patients, and derive the critical difference between measurements needed to exclude biologic and analytic variation. Design, setting, participants, & measurements Fifty-five prevalent hemodialysis and peritoneal dialysis patients attending two hospitals were assessed weekly for 5 weeks and then monthly for 4 months between October 2010 and April 2012. Assessments were conducted at the same time in the dialysis cycle and entailed NT-proBNP testing, clinical review, electrocardiography, and bioimpedance spectroscopy. Patients were excluded if they became unstable. Results This study analyzed 136 weekly and 113 monthly NT-proBNP measurements from 40 and 41 stable patients, respectively. Results showed that 22% had ischemic heart disease; 9% and 87% had left ventricular systolic and diastolic dysfunction, respectively. Respective between- and within-person coefficients of variation were 153% and 27% for weekly measurements, and 148% and 35% for monthly measurements. Within-person variation was unaffected by dialysis modality, hydration status, inflammation, or cardiac comorbidity. NT-proBNP concentrations measured at weekly intervals needed to increase by at least 46% or decrease by 84% to exclude change due to biologic and analytic variation alone with 90% certainty, whereas monthly measurements needed to increase by at least 119% or decrease by 54%. Conclusions The between-person variation of NT-proBNP was large and markedly greater than within-person variation, indicating that NT-proBNP testing might better be applied in the dialysis population using a relative-change strategy. Serial NT-proBNP concentrations need to double or halve to confidently exclude change due to analytic and biologic variation alone.

INTRODUCTION: Notification rates of sexually transmitted infections (STIs) have increased in New South Wales as elsewhere in Australia. Understanding trends in chlamydia and gonorrhoea notifications at smaller geographical areas may assist public health efforts to deliver targeted STI interventions.METHODS: Routinely collected disease notification data from 2 local health districts within the greater Western Sydney area were analysed. De-identified notifications of gonorrhoea and chlamydia were extracted for people aged over 15 years during the period 1 January 2003 to 31 December 2013. Sex-specific and age-specific population notification rates for each infection were calculated. Incidence rate ratios were also calculated with age group, sex, year and local government area (LGA) of residence as explanatory variables.RESULTS: Rates of gonorrhoea and chlamydia increased among males and females over the period. Males had a 4-fold increased risk of gonorrhoea (P

© The Author 2017. Published by Oxford University Press. All rights reserved. Adults with low literacy are less empowered to take care of their health, have poorer health outcomes and higher healthcare costs. We facilitated partnerships between adult literacy teachers and community health providers to deliver a health literacy training program in adult basic education classrooms. Following course completion we interviewed 19 adult education teachers (15 delivering the health literacy program; 4 delivering standard literacy classes) and four community health providers (CHPs) about their experiences, and analysed transcripts using Framework analysis. Written feedback from eight teachers on specific course content was added to the Framework. Health literacy teachers reported a noticeable improvement in their student's health behaviours, confidence, vocabulary to communicate about health, understanding of the health system and language, literacy and numeracy skills. CHP participation was perceived by teachers and CHPs as very successful, with teachers and CHPs reporting they complemented each other's skills. The logistics of coordinating CHPs within the constraints of the adult education setting was a significant obstacle to CHP participation. This study adds to existing evidence that health is an engaging topic for adult learners, and health literacy can be successfully implemented in an adult basic learning curriculum to empower learners to better manage their health. Health workers can deliver targeted health messages in this environment, and introduce local health services. Investment in adult literacy programs teaching health content has potential both to meet the goals of adult language and literacy programs and deliver health benefit in vulnerable populations.

Objective The aim of the present study was to investigate the opinions and perceptions of senior allied health (AH) leaders in relation to AH leadership, governance and organisation from an Australian public health perspective. The target group was the New South Wales (NSW) Health AH directors or advisors, the most senior public AH professionals in NSW. Methods The study was conducted over a 6-month period in 2014–15 and comprised two parts: (1) data collection through a 46-question online survey that sought the views of AH leaders about the field of AH in NSW; and (2) two confirmatory focus groups with members of the NSW Health Allied Health Directors Committee. Results The online questionnaire generated novel information about the field of AH in the public sector of NSW, including the current organisation, governance and culture of AH. Focus group participants explored key findings in greater depth, including the effects of AH on and value of AH to the health system as a whole, as well as the attributes and competencies required by AH leaders. Participants identified the need to build and grow their influence, to more clearly demonstrate AH’s contribution and to realign efforts towards more strategic issues influencing governance, performance, professional standards and advocacy. This entailed broadening the vision and scope of AH Directors as well as across discipline leaders. Conclusion The results provide new information about Australian AH leadership, governance, culture and organisation, and highlight potential priorities for future leadership activities. What is known about this topic? Although leadership is considered an essential element in the provision of high-quality health care, leadership across AH remains underexamined. What does this paper add? There is a paucity of literature pertaining to AH leadership nationally and internationally. This paper describes the issues affecting AH leaders and leadership in NSW, as reported by senior AH leaders. What are the implications for practitioners? This study identifies key elements related to AH leadership and governance. Health systems and services can use this information to implement strategies that enhance AH leadership capability.

© 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd Objective: To develop and externally validate a predictive model for detection of significant prostate cancer. Patients and Methods: Development of the model was based on a prospective cohort including 393 men who underwent multiparametric magnetic resonance imaging (mpMRI) before biopsy. External validity of the model was then examined retrospectively in 198 men from a separate institution whom underwent mpMRI followed by biopsy for abnormal prostate-specific antigen (PSA) level or digital rectal examination (DRE). A model was developed with age, PSA level, DRE, prostate volume, previous biopsy, and Prostate Imaging Reporting and Data System (PIRADS) score, as predictors for significant prostate cancer (Gleason 7 with >5% grade 4, ≥20% cores positive or ≥7 mm of cancer in any core). Probability was studied via logistic regression. Discriminatory performance was quantified by concordance statistics and internally validated with bootstrap resampling. Results: In all, 393 men had complete data and 149 (37.9%) had significant prostate cancer. While the variable model had good accuracy in predicting significant prostate cancer, area under the curve (AUC) of 0.80, the advanced model (incorporating mpMRI) had a significantly higher AUC of 0.88 (P < 0.001). The model was well calibrated in internal and external validation. Decision analysis showed that use of the advanced model in practice would improve biopsy outcome predictions. Clinical application of the model would reduce 28% of biopsies, whilst missing 2.6% significant prostate cancer. Conclusions: Individualised risk assessment of significant prostate cancer using a predictive model that incorporates mpMRI PIRADS score and clinical data allows a considerable reduction in unnecessary biopsies and reduction of the risk of over-detection of insignificant prostate cancer at the cost of a very small increase in the number of significant cancers missed.

Purpose Guidelines for the screening, prognosis, diagnosis, management and prevention of glaucoma were released by the Australian National Health and Medical Research Council in 2010. Comparable guidance has been made available by respective bodies in the USA and UK at a similar time. Key to successful translation of guidelines into clinical practice includes clinicians having the necessary skills to perform required tests. Optometrists in Australia and New Zealand were invited to participate in an online survey exploring these aspects. The results provide insights for improving glaucoma diagnosis and management by optometric primary eye care practitioners. Methods An online questionnaire was developed to investigate glaucoma assessment of optometrists as a function of demographic details, educational background and experience. Key points to ascertain compliance with current guidelines were the availability of equipment, procedural confidence in techniques, and preferences in visual field tests. Chi square statistics was employed to support similarity to national averages and highlight differences between the two countries. Multivariate linear regression analysis identified variables significantly associated with individual tests being available to optometrists and their confidence in applying them. Results Thirteen per cent of all Australian and 36% of the New Zealand optometrists responded to the survey in 2013, which reflected the demographics/geography of the practising populations. Techniques considered essential or preferred for glaucoma assessment were widely available in both countries with the exception of gonioscopy and pachymetry. After correcting for availability, regression models highlighted therapeutic endorsement and knowledge of glaucoma guidelines as the main variables to maintain high diagnostic confidence. Correlations to number of years in optometric practice mirrored a changed emphasis in teaching and technology over the past 10–15 years. Conclusions Australian and New Zealand optometrists were well equipped to perform glaucoma assessments with the possible exception of gonioscopy. Advanced imaging modalities were not yet fully integrated into optometric practice, although optical coherence tomography has shown use by 23–32% of optometrists. A marked increase in use, availability and procedural confidence of gonioscopy and other techniques with therapeutically endorsed optometrists demonstrates the advantage and importance of additional training.

Background: Central compartment lymph node metastases in papillary thyroid carcinoma (PTC) are difficult to detect preoperatively, and the role of routine or prophylactic central compartment lymph node dissection (CLND) in managing PTC remains controversial. The aim of this project was to create a nomogram able to predict the occurrence of central compartment lymph node metastasis using readily available preoperative clinical characteristics. Methods: Records from patients undergoing total thyroidectomy and lymph node dissection for PTC in the period 1968-2012 were analyzed. Nodal status was based on results of serial hematoxylin and eosin (H&E) examination. Age, sex, tumor size, tumor site, and multifocality were included in a multivariable logistic regression model to predict lymph node metastasis. A coefficient-based nomogram was developed and validated using an external patient cohort. Results: The study population included 914 patients (80% females) with an average central compartment nodal yield of eight per patient. Central compartment lymph node metastases were present in 390 patients (42.7%). The variables with the strongest predictive value were age (p

© British Journal of General Practice. Background Previous research suggests that most GPs in the UK use self-monitoring of blood pressure (SMBP) to monitor the control of hypertension rather than for diagnosis. This study sought to assess current practice in the use of self-monitoring and any changes in practice following more recent guideline recommendations. Aim To survey the views and practice of UK GPs in 2015 with regard to SMBP and compare them with a previous survey carried out in 2011. Design and setting Web-based survey of a regionally representative sample of 300 UK GPs. Method GPs completed an online questionnaire concerning the use of SMBP in the management of hypertension. Analyses comprised descriptive statistics, tests for between-group differences (z, Wilcoxon signed-rank, and ÷2 tests), and multivariate logistic regression. Results Results were available for 300 GPs (94% of those who started the survey). GPs reported using self-monitoring to diagnose hypertension (169/291; 58%; 95% confidence interval (CI) = 52 to 64) and to monitor control (245/291; 84%; 95% CI = 80 to 88), the former having significantly increased since 2011 (from 37%; 95% CI = 33 to 41; P

Accurate quantification of albuminuria is important in the diagnosis and management of chronic kidney disease. The reference test, a timed urinary albumin excretion, is cumbersome and prone to collection errors. Spot urine albumin-creatinine ratio (ACR) is convenient and commonly used, but random day-to-day variability in ACR measurements has not been assessed.Prospective cohort study of day-to-day variability in spot urine ACR measurements.Clinically stable outpatients (N = 157) attending a university hospital clinic in Australia between July 2007 and April 2010.Spot urine ACR variability was assessed and repeatability limits were determined using fractional polynomials.ACRs were measured from spot urine samples collected at 9:00 am on consecutive days and 24-hour urine albuminuria was measured concurrently.Paired ACRs were obtained from 157 patients (median age, 56 years; 60% men; median daily albumin excretion, 226 [range, 2.5-14,000] mg/d). Day-to-day variability was substantial and increased in absolute terms, but decreased in relative terms, with increasing baseline ACR. For patients with normoalbuminuria (ACR 3 mg/mmol [27 mg/g]), a change greater than ±467% (0-17 mg/mmol [0-150 mg/g]) is required to indicate a significant change in albuminuria status with 95% certainty; for those with microalbuminuria (ACR of 3-30 mg/mmol [27-265 mg/g]), a change of ±170% (0-27 mg/mmol [0-239 mg/g]) is required; for those with macroalbuminuria (ACR 30 mg/mmol [265 mg/g]), a change of ±83% (5-55 mg/mmol [44-486 mg/g]) is required; and for those with nephrotic-range proteinuria (ACR 300 mg/mmol [2,652 mg/g]), a change of ±48% (158-443 mg/mmol [1,397-3,916 mg/g]) is needed to represent a significant change.These study results need to be replicated in other ethnic groups.Changes in chronic kidney disease status attributed to therapy or disease progression, when based solely on a change in ACR, may be incorrect unless the potential for day-to-day biological variation has been considered. Only relatively large changes are likely to indicate a change in disease status.

We report the week-to-week variation of the Oxford Knee and Oxford Hip Score (OKS, OHS) in individuals with severe osteoarthritis. People waitlisted for knee (n=51) or hip arthroplasty (n=52) were assessed twice, 1-week apart. There were no major week-to-week systematic biases in the scores. Limits of agreement (LOA) for both scores were wide (OKS, -9.5 to 6.6; OHS, -7.7 to 7). For most individual questions, the answers varied by ≤ 1 point in over 90% of participants. The week-to-week 95% LOA for the Oxford scores are unacceptably large, but variations within the individual questions are minimal. Consequently, reference to variation in the individual questions may be more useful for monitoring a patient's preoperative clinical change than changes in the total Oxford score. We conclude that the total scores are not suitable for monitoring the progression of OA in individual patients.

Background The relative diagnostic accuracy of interferon γ release assays (IGRAs; based on ELISA [enzyme-linked immunosorbent assay] or ELISPOT [enzyme-linked immunosorbent spot], ie, the QuantiFERON and T-SPOT.TB tests, respectively) and the tuberculin skin test (TST) for latent tuberculosis (TB) infection in people with end-stage kidney disease is uncertain and national guidelines for their use are inconsistent. Study Design Systematic review. Selection Criteria for Studies Evaluated performance of tests for latent TB with clinical risk-factor assessment. Setting & Population People with end-stage kidney disease (chronic kidney disease stage 5 [eGFR Index Tests ELISA- or ELISPOT-based IGRAs, TST, assays to detect antimycobacterial antibodies, and flow cytometry–based tests. Outcomes Odds of test positivity with clinical risk factor for latent TB, expressed as ORs and relative ORs (RORs). Results 47 studies (6,828 participants) were included, but only 30 studies (4,546 participants) contained sufficient data to contribute to meta-analysis. Studies were predominately in the dialysis population (23/30; 3,700 participants) in countries with low to moderate TB prevalence (0.0-50.0 cases/105 persons). BCG vaccination rate was variable (2.7%-100.0%). 9 studies compared IGRAs with the TST directly, 17 studies evaluated the TST only, and the other 4 studies evaluated other tests. Compared to a positive TST result, a positive ELISA-based IGRA result was associated more strongly with radiologic evidence of past TB (ROR, 4.29; 95% CI, 1.83-10.3; P = 0.001) and contact with active TB (ROR, 3.36; 95% CI, 1.61-7.01; P = 0.001). Compared to a negative TST result, a negative ELISA-based IGRA result was associated more strongly with BCG vaccination (ROR, 0.30; 95% CI, 0.14-0.63; P = 0.002). There were insufficient data to compare performance of the ELISPOT-based IGRA with the TST or ELISA-based IGRA. Limitations 17 of 47 included studies (36.2%) did not contain sufficient data to contribute to meta-analysis. Conclusions Compared to the TST, the ELISA-based IGRA was associated more strongly with risk factors for latent TB in end-stage kidney disease.

Objectives Early identification of developmental vulnerability is vital. This study aimed to estimate the prevalence of moderate or high developmental risk on the Parents9 Evaluation of Developmental Status (PEDS) at 6-month, 12-month and 18-month well-child checks; identify associated risk factors; and examine documentation of the PEDS at well-child checks. Design, participants A prospective birth cohort of 2025 children with 50% of those approached agreeing to participate. Demographic data were obtained via questionnaires and linked electronic medical records. Telephone interviews were conducted with parents to collect PEDS data. Primary and secondary outcomes Multiple logistic regression analyses identified risk factors for moderate or high developmental risk on the PEDS. A Cumulative Risk Index examined the impact of multiple risk factors on developmental risk and documentation of the PEDS at the well-child checks. Results Of the original cohort, 792 (39%) had 6-month, 649 (32%) had 12-month and 565 (28%) had 18-month PEDS data. Parental concerns indicating moderate or high developmental risk on the PEDS were 27% (95% CI 24 to 30) at 6 months, 27% (95% CI 24 to 30) at 12 months and 33% (95% CI 29 to 37) at 18 months. Factors associated with moderate or high developmental risk were perinatal risk (OR 12 months: 1.7 (95% CI 1.1 to 2.7)); maternal Middle Eastern or Asian nationality (OR 6 months: 1.6 (95% CI 1.1 to 2.4)), (OR 12 months: 1.7 (95% CI 1.1 to 2.7)); and household disadvantage (OR 6 months: 1.5 (95% CI 1.0 to 2.2). As the number of risk factors increased the odds increased for high or moderate developmental risk and no documentation of the PEDS at well-child checks. Conclusions Children with multiple risk factors are more likely to have parental concerns indicating developmental vulnerability using the PEDS and for these concerns to not be documented.

The prevalence of idiopathic pulmonary fibrosis (IPF), a fatal and progressive lung disease, is estimated at 1.25–63 out of 100 000, making large population studies difficult. Recently, the need for large longitudinal registries to study IPF has been recognised.The Australian IPF Registry (AIPFR) is a national registry collating comprehensive longitudinal data of IPF patients across Australia. We explored the characteristics of this IPF cohort and the effect of demographic and physiological parameters and specific management on mortality.Participants in the AIPFR (n=647, mean age 70.9±8.5 years, 67.7% male, median follow up 2 years, range 6 months–4.5 years) displayed a wide range of age, disease severity and co-morbidities that is not present in clinical trial cohorts. The cumulative mortality rate in year one, two, three and four was 5%, 24%, 37% and 44% respectively. Baseline lung function (forced vital capacity, diffusing capacity of the lung for carbon monoxide, composite physiological index) and GAP (gender, age, physiology) stage (hazard ratio 4.64, 95% CI 3.33–6.47, pThe AIPFR provides important insights into the understanding of the natural history and clinical management of IPF.